Case based Discussion of Head and Neck Melanoma: Review of Epidemiology, Risk Factors, Identification, Treatments and Prevention Jacqueline M. Doucette MS FNP-C Objectives Define and identify melanoma Identify associated risk factors Describe treatments for melanoma Identify measures to prevent melanoma Epidemiology Skin cancer is more prevalent than all other cancers combined 1 in 5 Americans will develop a skin cancer Least common but most dangerous skin cancer Melanoma 76,380 new cases of invasive melanoma 2016 10,130 deaths in US annually DNA damage from UV exposure leads to mutations skin cells rapidly reproduce forming cancerous tumors 1
Risk Factors for Melanoma Sun exposure Moles Skin type Personal history Family history Weakened immunity Genetics Melanoma Originate in melanocytes in basal layer of epidermis Can originate in a mole or resemble a mole Typically black or brown but can be pink, red, purple, blue or white Types of Melanoma Superficial spreading melanoma Most common, 70% of cases Often seen in young people Lentigo maligna (in situ melanoma) Lentigo maligna melanoma once it is invasive (10 15%) Acral lentiginous melanoma most common melanoma in African Americans and Asians Nodular melanoma Most aggressive, found in 15 30% of cases Desmoplastic melanoma DM is an uncommon variant of spindle cell melanoma (4%) 2
What to look for Warning signs ABCDE Encourage patients to know their skin More than 100 moles greater risk of melanoma New or changing moles should be evaluated ABCDEs of Melanoma Benign vs Malignant Melanoma Staging Stage I IV Factors in staging: Thickness Depth of tumor Metastasis Staging determines treatment 3
Melanoma Staging Tumor, Nodes, Metastasis (TNM) T tumor thickness, mitotic rate (T1 only) and presence of ulceration Tis Melanoma in situ is confined to the outer layer of the skin T1: <1.0mm; T2: 1 2 mm; T3: 2.01 4.0 mm; T4: Depth >4.0 mm N regional lymph nodes containing/not containing cancer cells, presence of micro/macro metastasis, in transit/satellite lesions N0: No cancer in lymph node; N1: Melanoma cells in 1 lymph node; N2: Melanoma cells in 2 3 nodes; N3: Melanoma cells in >4 lymph nodes or 2 3 matted positive nodes or in transit/satellite lesions with any positive node(s) TNM M metastasis with presence of melanoma throughout the body M0: No evidence of metastases M1a: present in other areas of the skin, under the skin or distant lymph nodes M1b: present in lungs M1c: present in any other organ with a normal LDH (Lactate dehydrogenase) level or present in any site and LDH is elevated 4
Surgery Initial Treatment Margins wide excision Can be from 0.5 to 2 cm depending on the depth of the tumor Sentinel lymph node biopsy possible Decision Dx Reconstruction Initial Treatment Sentinel node biopsy Identifies metastasis in regional lymph nodes Performed with wide excision of tumor in OR Lymphoscintigraphy tracers and intraoperative injection of dye to identify the first draining lymph nodes from the primary tumor site, node(s) at highest risk of regional metastasis American Journal of Surgery study SLNB 30 days improves survival Decision Dx Melanoma Reconstruction Treatment Immediate vs. delayed Immediate reconstruction Limit to low risk lesions and closures that can be easily resected such as primary closure and skin grafts Local tissue reconstruction vs. flap Skin graft 5
Additional Treatments Immunotherapy Interferon naturally occurring protein ligand thought to exert anti tumor effects Ipilimumab monoclonal anticytotoxic T lymphocyte antigen 4 antibody. Pembrolizumab (Keytruda ) blocks immune suppressing ligands and helps restore T cell and immune response Targeted therapy BRAF inhibitors Vemurafenib (Zelboraf ) Chemotherapy No longer first line approach Additional Treatments Radiation Phase 3 RCTs Interferon vs Ipilimumab Interferon for early stage disease Anti PD 1 BRAF and MEK inhibition Vaccines CSF 470 Treatment of Unresectable or Metastatic Melanoma Current therapies Immunotherapy with PD 1 inhibitors or targeted BRAF MEK inhibition Immunotherapy High dose interleukin 2 replaced PD 1 inhibitors Targeted therapy BRAF and MEK inhibitors 6
Case Study 58 yo male with T1a melanoma lesion right cheek Surgery Wide excision with local reconstruction Findings Margins clear No further surgical intervention required Surveillance Case Study 75 yo male with T2a melanoma lesion on the right ear Surgery Wedge excision SLNB Parotid tail Findings Margins of excision negative SLN pathology positive Parotid tissue negative PET/CT Complete right lymph node neck dissection and right parotidectomy 7
Case Study 64 yo female with Stage IV BRAF mutant metastatic melanoma Large right upper lid pigmented lesion, large left preauricular cheek lesion, right parotid gland enlargement, diffuse lymphadenopathy No surgery performed Referred to medical oncology PET/CT and MRI Radiation therapy Phase II study Pembrolizumab (Keytruda ) Case Study 68 yo male T4aN0 (Stage III) Desmoplastic melanoma left cheek Surgery Wide excision with SLNB Cervicofacial flap reconstruction Findings Margins clear SLN negative Adjuvant radiation therapy 18 months later cough, right hip pain with soft tissue lesion Soft tissue biopsy and PET/CT Metastatic melanoma Pembrolizumab (Keytruda ) 8
Prevention Seek the shade, especially between 10 AM and 4 PM Avoid sunburn Avoid tanning Avoid UV tanning beds Cover up with clothing Use a broad spectrum (UVA/UVB) sunscreen Apply sunscreen 30 minutes before going outside. Reapply every two hours or immediately after swimming or excessive sweating Keep newborns out of the sun. Examine skin head to toe every month Annual skin exam, more frequently if there is a history of skin cancer 9
Tanning 2013 National Health Interview Survey estimated 7.8 million US adult females and 1.9 million males used indoor tanning devices in 2013 Tanning beds are associated with the rise in melanoma JAMA Dermatology Melanoma In Summary Least common, most lethal Head, face and neck are prime real estate Treatment is based on staging Many new promising treatments Teach patients New/changing moles, lesions that bleed/do not heal Avoid/minimize direct sun exposure and tanning beds Use sunscreen, reapply Protective clothing References Chapman, P., Hauschild, A., Robert, C., Haanen, J., Ascierto, P., Larkin, J.,... McArthur, G. (2011, June 30). Improved Survival wiht Vemurafenib in Melanoma with BRAF V600E Mutation. The New England Journal of Medicine, 2507 2516. Fortes, C., Mastroeni, S., Ceggiati, A., Passarelli, F., Zappala, A., Capuano, M.,... Michelozzi, P. (2016, November). The Effect of Time to Sentinel Lymph Node Biopsy on Cutaneous Melanona Survival. The American Journal of Surgery, 212(5), 935 940. Gerami, P., Cook, R., Russell, M., Wilkinson, J., Amaria, R., Gonzalez, R.,... Lawson, D. (2015, May). Gene expression profiling for molecular staging of cutaneous melanoma in patients undergoing sentinel lymph node biopsy. Journal of American Academy of Dermatology, 72, 780 785. Gershenwald, J., Halpern, A., & Sondak, V. (2016, November 8). Melanoma Prevention Avoiding Indoor Tanning and Minimizing Overexposure to the Sun. JAMA, 316(18), 1913 1914. Jaimes, N., & Marghoob, A. (2012). Improved Diagnostic and Prognostic Strategies for Desmoplastic Melanoma. Retrieved from Skin Cancer: http://www.skincancer.org/publications/the melanoma letter/fall 2012 vol 30 no 3/melanoma Melanoma Research Foundation. (216, December). Stages of Melanoma Diagnosis. Retrieved from Melanoma Research Foundation: https://www.melanoma.org/understand melanoma/diagnosing melanoma/stages ofdiagnosis?gclid=ckkhxom449acfcspswod owhea National Council on Skin Cancer Prevention. (2016, October 21). Risk Factors for Skin Cancer. Retrieved from National Council on Skin Cancer Prevention: www.skincancerprevention.org/skin cancer/risk factors Rosko, A., Vankoevering, K., McLean, S., Johnson, T., & Moyer, J. (2017, January 19). Contemporary Management of Early Stage Melanoma: A Systematic Review. JAMA Facial Plastic Surgery, E1 E7. Skin Cancer Foundation. (2016, December 7). Melanoma. Retrieved from Skin Cancer Foundation: http://www.skincancer.org/skin cancer information/melanoma Skin Cancer Foundation. (2016, November 15). Skin Cancer Facts & Statistics. Retrieved from Skin Cancer Foundation: http://www.skincancer.org/skin cancer information/skin cancer facts#general Thorne, C. H. (2017). Ear Reconstruction. Retrieved from Plastic Surgery Key: https://plasticsurgerykey.com/earreconstruction/ Zenga, J., Nussenbaum, B., Cornelius, L., Linette, G., & Desai, S. (2017, January/February). Management Controversies in Head and Neck Melanoma. JAMA Facial Plastic Surgery, 19, 53 63. 10