A presentation created by Dr. Henry N. Ho, Medical Director, Head and Neck Program, Florida Hospital Cancer Institute, discussing everything you need to know about head and neck melanoma.

1. Head and Neck Melanoma
Henry Ho, M.D.

2. Head and Neck Melanoma
 Overview
 Diagnosis and Evaluation
 Staging
 Treatment

3. Head and Neck Overview
 In 2010, estimated 68,130 new cases and 8,700
died of disease in the U.S. (under estimate as
many are unreported)
 Incidence is increasing in men more rapidly than
any other malignancy, and in women, second to
lung cancer.
 Median age at diagnosis is 59 and ranks second
to adult leukemia in loss of years of life per
death.

4. Overview
 Since 1950 increase of > 600% in annual
incidence and 165% increase in annual
mortality
 Seventh most common cancer in women
and fifth most common in men.
 Head and neck melanoma accounts for
30% of all cases, due to sun exposure and
melanocyte density.

5. Overview: Etiology
 Ultraviolet exposure
 Positive family history
 Prior Melanoma carries a 10x greater risk
of second primary
 Multiple atypical moles or dysplastic nevi
 Fair skin (although any ethnic group and
non-exposed skin can develop melanoma)

6. Overview: Outcomes
 80% present with localized disease
 15% present with regional disease
 5% present with distant disease
 Localized disease, <1.0mm thick, 90% 5
yr survival
 Nodal disease reduces survival by half
 Distant disease, survival less than 10%

7. Lentigo Maligna
 Atypical proliferation of melanocytes
 Precursor to melanoma?
 Typically sun exposed cheek of the elderly
 Although non-invasive, 20% exhibit
features of lentigo maligna melanoma

8. Lentigo Maligna Melanoma
 5-10% of melanomas but 50% of head
and neck melanomas are lentigo maligna
melanoma.
 Hallmark is invasion into papillary dermis
 Radial growth phase is prolonged.

9. Superficial Spreading
Melanoma
 Most common melanoma variant
 Radial growth phase followed by a vertical
growth phase
 Homogeneous neoplastic cells are
distributed in all layers of the epidermis

10. Desmoplastic Melanoma
 Least common melanoma variant
 Often atypical appearance, may be
nonpigmented, often occur in the head
and neck
 Local recurrence, distant mets, perineural
invasion and decreased survival

11. Melanoma History
 Fair skin
 Early or severe sunburns
 Ultraviolet light exposure
 Family history
 Prior skin cancer
 Prior radiation exposure
 Immunosuppression

12. Melanoma Physical Exam
 “ABCD”
 Assymetry
 Border irregularities
 Color variegation
 Diameter > 6mm
 Woods lamp black light
highlights borders
 Palpation of cervical
nodes and parotid glands

15. Melanoma: Biopsy
 Excisional biopsy with 1-3 mm margin preferred.
(avoid wider margin to permit subsequent SLNB)
 Orient the biopsy with ultimate excision in mind
 Full thickness incisional or punch of thickest part
of lesion acceptable
 Shave biopsy may compromise assessment of
Breslow thickness but is acceptable if index of
suspicion is low

16.  Clark Levels:
 I: in-situ, epidermis
 II: papillary dermis
 III: to reticular derm
 IV: into reticular
 V: into subcu. Tissue
 Breslow Thickness:
 Stage I: <0.75mm
 Stage II: 0.76-1.50
 StageIII: 1.51-4.0
 StageIV: >4.0mm

19. Melanoma Workup
 Lentigo maligna melanoma and thin
lesions (no ulceration or spread to reticular
dermis), stage 0 or stage 1A do not
require additional testing
 Early stage melanoma: LDH and CXR
 More advanced stage: CT, MRI, PET/CT

20. Melanoma: Treatment of the
Primary Lesion
 Surgical excision with margin (frozen
sections not reliable)
 Moh’s micrographic excision by
experienced dermatologists and
dermatopathologists, with rapid
immunohistochemical stains

31. Melanoma Treatment: Radiation
Therapy
 Melanoma historically deemed “radio-
resistant”
 Currently used as primary treatment for
unresectable disease or medically unfit for
surgery
 Adjuvant for adverse features of primary,
regional disease and mets.

33. Melanoma: Risk of Occult Regional
Disease
 Tumor thickness: 0.75 - 1.5mm, 5% risk
 Tumor thickness: 1.50 – 4.0mm, 20% risk
 Tumor thickness: >4.0mm, 35% risk
 Overall 15-20% of clinically Stage I and
Stage II lesions have occult Stage III
disease and are at risk for recurrence

34. Melanoma: Sentinel Node Biopsy
 Introduced by Morton, et al, 1992
 “Identification of a positive sentinel lymph
node has emerged as the most important
prognostic factor for recurrence and
survival in cutaneous melanoma.”
 SLNB can be augmented by injection of
iso-sulfan blue dye

35. Melanoma and Sentinel Node
Biopsy
 Allows detection of occult regional mets,
promotes accurate staging and decision making
for adjuvant therapies
 Spares unnecessary elective neck dissection for
80% of patients with intermediate-thickness who
do not have regional mets
 Indicated for 0.8-4.0mm thick or ulcerated
lesions of any thickness.
 Due to high rate of presumed regional mets in
those >4.0mm, no added benefit to SLNB

36. Melanoma: SLNB
 False negative rate up to 10%
 Limit false negatives: remove all blue
nodes, suspicious nodes and those with
>10% of ex-vivo radioactive count of the
most radioactive sentinel node.

37. Melanoma: Neck Dissection
Indications
 Clinically N+ disease
 Positive sentinel lymph node
 No role for elective node dissection (N0 or SLNB
negative)
 “The staging of intermediate thickness (1.2-
3.5mm) primary melanomas according to the
results of sentinel node biopsy provides
important prognostic information and identifies
patients with nodal mets. whose survival can be
prolonged by immediate lymphadenectomy.”
Morton, NEJM 355:1307, 2006

38. Melanoma: Neck Dissection for
Intermediate Thickness Lesions
 Multicenter Selective Lymphadenectomy Trial
(MSLT-1), Morton, NEJM 2006
 1339 patients with 1.2-3.5mm melanomas
 Randomized to wide excision with observation
and possible delayed neck dissection vs wide
excision with SLNB and immediated neck
dissection for SLNB +.
 Delayed TLND had 52.4% 5 yr. survival
 Immediate TLND had 72.3% 5 yr. survival
 SLNB negative had 90.2% 5 yr. survival

39. Melanoma: Cutaneous Lymphatic
Drainage Patterns

40. Neck Dissection for Stage III
Melanoma
 Include involved lymph nodes and nodes
at greatest risk according to drainage
patterns
 For microscopic disease: functional neck
dissection preserving SCM, XI, and IJV
 For macroscopic disease: sacrifice of non-
lymphatic structures should be based on
clinical invasion

41. Nodal Basins to Dissect in
TLND
 Anterior scalp, temple, anterior auricle,
pre-auricular skin, forehead: dissect
superficial parotid, SND I-IV
 Midline chin, nose, cheek medial to lateral
canthus, anterior neck skin: SND I-IV
(consider bilateral drainage)

42. Nodal Basins to Dissect in
TLND
 Posterior scalp, posterior auricle, posterior
neck skin: postero-lateral SND II-V plus
post-auricular and occipital nodes
 Lateral neck skin, scalp and ear that
overlap plane of external auditory canal:
SND I-V, superficial parotidectomy for
scalp/ear

43. Neck Levels of Lymph Node
Dissection

47. Adjuvant Systemic Therapy for
Advanced Melanoma

48. Systemic Therapy for Advanced
Melanoma
 High-dose interferon (IFN@-2b) is ( the only
adjuvant treatment approved by the FDA to
minimize recurrence and mets in stage IIB to III
melanoma (Moore et al, Head and Neck Cancer,
2008)
 Combinations of interferon with melanoma
vaccines, other biologic response modifiers such
as interleukin-2, gene therapy and chemo. such
as dacarbazine, cisplatin and vinblastine are the
subject of clinical trials.

49. Melanoma of the Head and Neck:
References
 NCCN Guidelines Version 3.2012
 Head and Neck Cancer An Evidence-Based
Team Approach, Moore et al, ch.9, Carcinoma of
the Skin of the Head, Face, and Neck, 152-179,
2008
 Melanoma of the Head and Neck, Conley, 1990
 Role of Neck Dissection in Melanoma
(presentation), Bradford, Update in Head and
Neck Cancer (course), April 27-29,2012,
Harvard Medical School.