Melanoom - WIN O · Melanoom Niet één diagnose, niet één standaardbehandeling Wolter J. Mooi VU...
Transcript of Melanoom - WIN O · Melanoom Niet één diagnose, niet één standaardbehandeling Wolter J. Mooi VU...
Melanoom Niet één diagnose, niet één
standaardbehandeling
Wolter J. Mooi
VU medisch centrum Amsterdam
Melanoomclassificatie
• Superficieel spreidend melanoom
• Nodulair melanoom
• Acrolentigineus melanoom
• Lentigo maligna melanoom
Wallace Clark
Richard Reed
Vincent McGovern
Melanoomclassificatie
• Superficieel spreidend melanoom
• Nodulair melanoom
• Acrolentigineus melanoom
• Lentigo maligna melanoom
• Subunguaal melanoom
• Spitzoïd melanoom – Kinderen
– volwassenen
• Desmoplastisch melanoom
• Poypoïd melanoom
• Kleincellig naevoïd melanoom – Verruceus naevoïd melanoom
• Lentigineus naevoïd melanoom
• Balloncelmelanoom
• Myxoïd melanoom
• Maligne blauwe naevus
• Dermaal hypermelanotisch laaggradig melanoom
Melanoomclassificatie:
relevantie
• Sterk verschillende presentaties en histologische
beelden
• Verschillende subtypen hebben verschillende
diagnostische pitfalls
• Soms verschil in klinisch gedrag.b.v.:
– Spitzoïd melanoom bij kinderen;
– Desmoplastisch melanoom;
– Dermaal hypermelanotisch laaggradig melanoom
Zoogdieren
Superficieel spreidend melanoom
Nodulair melanoom
Acraal lentigineus melanoom
Lentigo maligna melanoom
Desmoplastisch
melanoom
Melanoom met
regressie Subunguaal
melanoom Amelanotisch
melanoom
Dermal hypermelanotic
low-grade melanoma
Melanoomclassificatie:
relevantie
• Sterk verschillende presentaties en histologische
beelden
• Verschillende subtypen hebben verschillende
diagnostische pitfalls
• Soms verschil in klinisch gedrag.b.v.:
– Spitzoïd melanoom bij kinderen;
– Desmoplastisch melanoom;
– Dermaal hypermelanotisch laaggradig melanoom
• 11 cases, 1-10 years (10 years = upper limit for inclusion in study)
• All were referral cases
• Initial diagnoses:
– Spitz tumour of uncertain malignant potential (4 cases)
– Atypical Spitz naevus (2 cases)
– Spitz naevus (2 cases)
– Cellular blue naevus (2 cases)
– No diagnosis (1 case)
• All cases diagnosed as melanoma by the authors
• All cases: metastasis (inclusion criterion)
Case nr Thickness
(mm)
Site of
metastasis
Months to
metastasis
FU (months)
1 8,0 Satellite 0 14, alive
2 4,2 Regional LN 1 2, alive
3 3,5 Regional LN 11 35, alive
4 9,0 Regional LN 2 13, alive
5 8,0 Regional LN 9 23, alive
6 6,5 Regional LN 1 5, alive
7 7,0 Regional LN 13 37, alive
8 11,0 Widespread 32 33, DOD
9 7,0 Regional LN 0 37, alive
10 9,7 Regional LN 1 6, alive
11 1,9+ Regional LN 10 14, alive
Regional nodal metastasis was uncommon in patients who presented with clinically
localized pDM (1%) compared with those with mDM (10%) or CM (6%) (P <
.05,pDM vs. CM). Five-year melanoma-specific mortality was lower for patients who
presented with pDM compared with mDM (11% vs. 31%; P < .01). Patients with
pDM and CM had a similar melanoma-specific mortality despite a 3-fold difference
in median tumor depth (3.6 vs. 1.2 mm, respectively).
Conclusions: DMs can be divided into two subtypes based on a histological
quantification of desmoplasia. Tumors with prominent fibrosis (pure subtype) are
unlikely to disseminate to regional lymph nodes and are associated with a favorable
outcome when compared with those with mixed desmoplasia or CM.
Hypermelanotic low grade dermal
melanoma
• = ‘Animal type melanoma’ = ‘Pigment synthesizing
melanoma’ = ‘Pigmented epithelioid melanocytoma’
• Follow-up of 64 cases:
– Locoregional recurrence and/or spread to regional
lymph nodes: at least 22 cases
– Spread beyond region: 4 cases
– Tumour related deaths: 2 reported
• Possible relationship to epithelioid blue naevus and
deep penetrating naevus requires further study
Dermal low-grade
hypermelanotic
melanoma
Multiple melanotic tumours of p16 -/- mouse, with occasional metastasis
(Krimpenfort et al., Nature 2001)
Dadras, Arch Lab Pathol Med, 2011
• Dermal low-grade
hypermelanotic melanoma
• Animal type melanoma
• Pigment synthesizing
melanoma
• Atypical pigmented dermal
melanocytoma
Melanoom: geen graderingssysteem.
Vreemd, eigenlijk....
T Stadiëring voor melanoom
Classificatie Tumordikte
(mm)
Ulceratie/mitosen
Tis NVT NVT
T1 ≤ 1.0 a: Zonder ulceratie en
mitosen < 1/mm2
b: Met ulceratie of
mitosen > 1/mm2
T2 >1.0-2.0 a: Zonder ulceratie
b: Met ulceratie
T3 2.1-4.0 a: Zonder ulceratie
b: Met ulceratie
T4 > 4.0 a: Zonder ulceratie
b: Met ulceratie
Taylor RC, Patel A, Panageas KS, Busam KJ,
Brady MS, J Clin Oncol 2007; 25: 869-75
2005
CCND1
locus
79% van tumoren met KIT mutaties en
53% met amplificaties toonden KIT
overexpressie
0 %
28 %
36 %
39 %
Optimale melanoomclassificatie:
werk in uitvoering