Melanoma Diagnosis, Treatment in PDF

Here is the transcription of the image into a structured markdown format. # Melanoma It is a malignant tumor that derives from the neoplastic transformation of melanocytes, (the cells responsible for producing melanin). It can arise as cutaneous tumor: - Melanoma with superficial diffusion. It is...

Here is the transcription of the image into a structured markdown format. # Melanoma It is a malignant tumor that derives from the neoplastic transformation of melanocytes, (the cells responsible for producing melanin). It can arise as cutaneous tumor: - Melanoma with superficial diffusion. It is the most common form of tumor. Or in other sites where melanocytes are present. Examples: - Uveal Melanoma - Conjunctival Melanoma - Mucosal Melanoma ## How to make the diagnosis? 1. It starts with the identification of the suspected lesion (inspection) & Anamnesis: - Personal History - Family History - Solar exposure 2. With the naked eye we evaluate the ABCDE criteria: - Asymmetry - Borders - Color - Diameter - Evolution 3. Dermatoscopy (epiluminescence) with the dermatoscope is done to highlight typical patterns & architectures of a suspected melanoma lesion. In melanoma we can see: - Atypical pigmentary networks. - Uneven distribution of dark dots. - Areas of diffuse bluish pigment - Irregular/asymmetric globules (indicate chaotic proliferation of melanocytes.) - Areas of tumor regression (whitish-blueish structures indicate proliferation) 4. If the lesion is suspected, direct surgical removal is performed, making an excisional biopsy, especially if it is easily removable except in cases of large lesions or in critical sites such as: - the face - genitals. Due to the difficult closure of the post-surgical wound and high risk of margin dehiscence. For ex: Lentigo maligno on the face. It is not possible to perform an excisional biopsy (e.g. in particular sites like face), you can opt for an intra-lesional biopsy, especially in case of very large lesions. Once the histological diagnosis with confirmation of melanoma is obtained, radicalization must occur within 30 days. If the initial excision is not radical, radicalization must be carried out as soon as possible and in any case within 30 days. ## Therapy Surgical therapy represents the treatment of choice for melanoma that has not crossed the regional barriers. This is because melanoma does not respond to other therapies. Any suspected or dubious melanocytic lesion must be surgically removed. The operational process of a suspected lesion follows these steps: - Removal of the primitive lesion. - Histological confirmation (eventual). - Definitive diagnosis. - Adjuvant therapy, if necessary, which includes: - Surgical enlargement. - Selective or therapeutic lymphadenectomy. ### Removal Of The Primitive Lesion The excisional surgery of the primitive lesion represents the first step of the treatment. Objective: Remove the lesion radically and completely, with margins of macroscopic radicality which will then be confirmed by the histological examination. Depth: The removal must take place up to the subcutaneous tissue, without removing the muscle fascia. Surgical Margins: The minimum macroscopic margin must be less than 2 mm. This is a fundamental aspect, because it allows to perform an essential examination: the sentinel lymph node, which allows the staging of the patient. If the lesion has been removed in total radicality (confirmed by histological parameters), this is the excision that should follow the following protocols: - Melanoma in situ → enlargement by 0.5 cm. - Thickness < 2 mm → enlargement by 1 cm. - Thickness > 2 mm → enlargement of more than 2 cm. If the intervention is performed correctly, the risk of recurrence is less than 5%. ### Exceptions To The Surgical Technique In some anatomical districts, particular strategies should be adopted: 1. Face → Pay attention to aesthetics to obtain an acceptable result. If the eyelids are involved, they should be treated with particular caution. 2. Fingers → - Lesion to the distal phalanges → amputation of the toe. - Lesion to the proximal phalanges → carpo-metacarpal disarticulation. - Lesion in the interdigital point → sacrifice of both fingers involved - Lesion to thumb or forefinger → try to preserve the prehensile function. ## Selective Lymphadenectomy After histological diagnosis and surgical enlargement, selective lymphadenectomy is performed, which consists of biopsy of the sentinel lymph node. ### Sentinel Lymph Node It is the first lymph node that drains the cutaneous territory interested by the main lesion. - Objective: To identify micro-metastases early, before the patient manifests clinical signs of metastatic disease. - Patients without clinically evident metastases are candidates for therapeutic lymph node dissection and possible adjuvant therapy. ### Inclusion Criteria For Selective Lymphadenectomy Patients undergoing sentinel lymph node biopsy must present at least one of the following criteria: - Confirmed histological diagnosis. - Thickness ≥ 0.75 mm (Breslow > 0.75 mm). - Regressive phenomena or ulceration that prevent precise measurement of thickness. - Presence of mitosis per field. ### Exclusion Criteria From Selective Lymphadenectomy One patient may not undergo sentinel lymph node biopsy in the following cases: - Presence of clinically evident lymph node metastases. - Presence of distant metastases that are clinically detectable. - Incorrect primary surgery with excision margins ≥ 2 mm. In this case, excessively wide excision may alter the lymphatic drainage of the region, making it impossible to identify the early lymph node that drains the area. - Repair with enlargement of the edges. This technique should be avoided, as it prevents access to sentinel lymph node biopsy, which is essential to identify early lymph node metastases. ## Timing Of Selective Lymphadenectomy - It should be performed concurrently with surgery, if possible. - If it is not possible, it must be performed within 3 months. This is a fundamental concept to guarantee timely diagnosis and effective treatment. ### Implementation Methods For Sentinel Lymph Node The sentinel lymph node is the first lymph node that drains the skin region affected by melanoma and represents a fundamental parameter for the staging of the disease. Its identification and analysis allow to identify early the presence of lymph node metastases and to select the patients candidates to the lymph node. ### Administration Of Radioactive Drugs Or Vital Dyes The procedure involves the identification of the sentinel lymph node through two main methods: - Use of radioactive drugs - A radioactive tracer is injected locally into the scar site. - Through a scan, the sentinel lymph node is identified, that is, the one that first receives the lymphatic drainage from the primary lesion. - This method is only possible if the hospital has a nuclear medicine unit. - Use of vital dyes - If it is not possible to use radioactive drugs, a vital dye, such as Patent Blue , can be used . that is injected directly into the lesion site. - The dye follows lymphatic drainage, allowing the sentinel lymph node to be visually identified . ### Diagnostic Images - Lympho-scintigraphy: imaging technique that shows the path of the radioactive tracer and localizes the sentinel lymph node. - Cutaneous mapping: allows to highlight the invaded lymph nodes, which are typically located in the following areas: - Trunk: axillary, inguinal, laterocervical, supraclavicular lymph nodes. - Upper limb: axillary lymph nodes. - Lower limb: inguinal lymph nodes. ### Intraoperative Localization Of The Sentinel Lymph Node - During the surgery, an intraoperative probe is used to detect the radioactivity of the sentinel lymph node previously marked with the radioactive tracer. - The probe is equipped with a manual detector that captures the gamma rays emitted by the marked lymph node, guiding the surgeon in its removal. ### Removal Of The Sentinel Lymph Node - Once the sentinel lymph node has been located, it is removed surgically. - Its radioactivity is checked to make sure that it is the correct lymph node. - The sample is then sent for histological examination. ## Examination Results - Negative Lymph Node: - There are no metastases present. - The patient does not need further surgical interventions and enters a follow-up program. - Positive Lymph Node: - There is a metastasis. - Proceed to the second step, that is, the total therapeutic lymphadenectomy of the affected lymphatic district. ### Advantages Of Sentinel Lymph Node Identification - Reduces surgical invasiveness: avoids immediate lymphadenectomy when not necessary. - Selective approach: allows to perform only a lymph node dissection in patients with confirmed metastasis. - Allows early lymph node dissection in appropriate patients, improving therapeutic management. - Does not cause disadvantages in terms of survival compared to immediate total lymph node dissection. - Offers crucial information for the staging of the disease. - Identifies early the patients indicated for adjuvant therapy, allowing a more timely and effective treatment. ## By-Pass of the sentinel lymph node In some cases, a skip lesion may occur, i.e., lymphatic drainage bypasses the first lymph node and metastasizes directly to more distant lymph nodes. This phenomenon is rare, with an incidence of about 2% of cases. Despite the possibility of error, the technique of identifying the sentinel lymph node is considered epidemiologically successful. ## Therapeutic Lymph-Node Dissection The therapeutic lymph node dissection is indicated in the following cases: 1. Presence of evident lymph-node metastasis - If the lymph nodes clinically palpable or evident to imaging are metastatic, the technique of the sentinel lymph node has no utility anymore. 2. Positive sentinel lymph node - If the histological examination of the sentinel lymph node confirms the presence of metastases, it follows the complete therapeutic lymphadenectomy of the affected district. ### Importance of the sentinel node in the choice of lymphadenectomy - Thanks to the use of the sentinel lymph node, therapeutic lymphadenectomy is reserved only for patients with real lymph node metastasis. - Thisapproach has allowedus to select patients more accurately,avoiding unnecessarilyinvasiveintervention in cases wherewedo not havemetastases. This organization allows to understand in a clear and detailed way eachpassage of theidentification of thesentinel lymph node, itsanalysis and thetherapeuticimplications,guaranteeingan organized and completetraining. #Integration ## Melanoma: Diagnosis, Surgical Therapy and Sentinel Lymph Node Melanoma is a well-known cutaneous tumor, and its main treatment is surgery. Each lesion suspected of melanoma must be removed surgically with a precise and methodical approach to ensure correct staging and the best possible treatment. ### 1. Excision Of The Suspected Lesion The surgical removal of the lesion must follow rigorous criteria to avoid errors that could compromise the subsequent diagnostic and therapeutic process. #### 1.1. Margins Of Resection - The lesion must be excised with minimal macroscopic resection margins. - The margin must never exceed 2 mm in distance. - Margins larger than 2 mm can alter lymphatic drainage, making evaluation of the sentinel lymph node impossible. #### 1.2. Biopsy of the Lesion - A complete excisional biopsy is preferable. - Intralesional biopsy should be avoided, except in cases of very extensive lesions, such as the malignant lentigo of the face. - After the excision, the histological confirmation is awaited before proceeding with the therapeutic protocol. ## II Sentinel Lymph Node ### 2.1. Definition The sentinel lymph node is the first draining lymph node in the district where the lesion is located. Its analysis allows to identify any micro-metastases, providing fundamental information on tumor spread. ### 2.2. Risks of an overly large Excision An early excision with overly wide margins can: - Alter the profile of lymphatic drainage. - Make it impossible to recognize the draining lymph node correctly. - Interfere with the staging of melanoma. ### 2.3. Lymphadenectomy In patients with melanoma, local lymphadenectomy is a very important procedure. However, in some cases, jump phenomena of the sentinel lymph node have been described, where metastases bypass the first draining lymph node. ## Amplification of the Resection after Histological Confirmation After histological confirmation of melanoma, it is necessary to widen the excision of the scar with precise criteria: - Melanoma in situ → Enlargement of 0.5 cm per side. - Thickness < 2 mm → Enlargement of 1 cm. - Thickness ≥ 2 mm → Enlargement of 2 cm. ### 3.1. Timing of the Expansion The expansion must be carried out within 30 days from the primary surgery. Beyond this limit, the intervention loses effectiveness, since it is no longer able to exclude any satellites in the surrounding tissue spared. ### 3.2. Importance of Conservative Surgery The primary excision must be extremely conservative, avoiding exceeding 2 mm of margin, to preserve lymphatic drainage and guarantee the reliability of the sentinel lymph node analysis. ## 4. Criteria Inclusion and Exclusion of the Sentinel Node ### 4.1. Inclusion Criteria To be able to perform the technique of the sentinel lymph node, the following criteria must be met: - Histological confirmation of melanoma. - Breslow thickness > 0.75 mm (in the past the limit was 0.8 mm). - Presence of ulceration or tumor regression, which make an accurate assessment of thickness impossible. - More than 2 mitoses per microscopic field. ### 4.2. Exclusion Criteria The technique of the sentinel lymph node cannot be applied in the presence of: - Locoregional, distant or lymph node metastases already confirmed. - Incorrect primary surgery, with margins over 2 mm. - Use of rotation flaps for reconstruction after enlargement, as they alter the lymphatic drainage, compromising the reliability of the technique. ## 5. Application of the Sentinel Lymph Node to Other Tumors The sentinel lymph node is not an exclusive technique of melanoma. It is also used in other tumors with lymphatic spread, such as: - Squamous cell carcinoma. - Breast carcinoma. In these cases, it allows an accurate staging thanks to the visualization of micrometastases. ## Conclusion The surgical approach to melanoma must be extremely precise to ensure correct diagnosis and staging. The early excision must respect minimal margins to preserve the sentinel lymph node and allow a subsequent adequate expansion. The technique of the sentinel lymph node is crucial for the prognosis of the patient and also applies to other tumors with lymphatic spread.