Which of the following prognostic features of melanoma is not included in the AJCC staging system?
Mitotic rate. The American Joint Committee for Cancer staging system has undergone several revisions; however, it uses the TNM staging system. T (tumour) staging includes Clark’s level and ulceration as prognostic factors. N (node) staging includes micro-metastases, and M (metastases) includes LDH as a prognostic factor. Mitotic rate is not used.
References: 1. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, Fleming ID, Gershenwald JE, Houghton A Jr, Kirkwood JM, McMasters KM, Mihm MF, Morton DL, Reintgen DS, Ross MI, Sober A, Thompson JA, Thompson JF. Final version of the American Joint Committee on Cancer Staging system for cutaneous melanoma. J Clin Oncol 2001; 19(16): 3635-48.
Which of the following are risk factors for cutaneous melanoma?
Childhood UV exposure. Cutaneous melanoma has an increased risk with light hair colour, lower Fitzpatrick skin Type (1 and 2), and dysplastic naevi (no benign naevi). Radiotherapy is related to an increased risk of sarcomas. A history of blistering sunburn in childhood is a risk factor. Melasma (chloasma) is hormonal-related pigmentation of the skin commonly seen in women, especially during pregnancy and when taking hormone-replacement therapy or oral contraception. It does not have a risk of malignant transformation.
Dysplastic naevus syndrome is characterised by:
>100 naevi with at least one clinically atypical naevus. Atypical moles can be inherited or sporadic. Formal genetic analysis has suggested an autosomal dominant mode of inheritance (not X-linked). The risk of developing malignant melanoma approaches 100%. Naevi begin to develop in childhood.
With respect to sentinel lymph node biopsy in melanoma, which is the best answer?
All of the above. While there is still debate as to the role of sentinel lymph node biopsy in melanoma staging, the results of a sentinel node biopsy do provide prognostic and staging information. This information guides adjuvant therapy and certainly mandates completion nodal dissection, if nodal metastases are found.
In relation to axillary lymphadenectomy:
Division of pectoralis minor is commonly undertaken for improved access. The axillary vein is medial to the axillary artery and the axilla usually contains 20-30 nodes.
References: 1. Stone C, Ed. The evidence for plastic surgery. Shrewsbury, UK: tfm publishing Ltd, 2008.
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