All right. So melanoma, what I think is the funniest thing about melanoma, maybe not ha ha funny, is that they're not they don't always contain melanin. So this is a great slide example of the various amounts of pigment you can have in a melanoma and it can be absent and they're called amelanotic melanomas. So something to keep in mind. All right. But and then it was actually funny because when Steve asked the question about the mast cells being cutaneous, we're going to focus on oral melanomas. Can you get them elsewhere? Yes. In the dog, by far the most common form of melanoma is going to be oral. So I'll touch on a couple others. But remember that these are really heavily focused, and that's because it's the most common way we see them. So in the mouth, they are malignant, they're invasive, they're highly metastatic. These are very aggressive tumors. Again, our older age population, that does not surprise us. We have predisposition of black coat color, but it's possible to have any coat color. So just because they do not have any pigment on their gums does not exclude a melanoma. And we do have some  breed dispositions. Like we have our lovely little dachshund here who's showing us his blackly pigmented gums. We see them in Chow Chows, Dobermans, Golden Retrievers again, poor Goldens, Scottish terriers, poodles. So it's a wide variety, but there are some breed disposition. The other types of presentations that are out there is you can have an ocular melanoma. They do behave differently. While they can be locally invasive, they tend to be benign. You can have a cutaneous form also tends to be benign, but they're really pretty rare. Ventral abdomen, scrotal areas is where we see those. And we can have I love this term subungual. It means toenail bed. Which, ya know, cute term, but subungual those are a little less metastatic, but they still are invasive, but they have a lower metastatic rate. So those are some of the other areas we can see. But again, we're going to focus on these orals. The ones in the mouth present as round. They're friable, they bleed really easily, they're often ulcerated, and that's because they're getting traumatized in the mouth. Again, two thirds will be pigmented. They will be black in color and one third will not be, they'll be amelanotic. So just because we're seeing a mass in the mouth and it's not pigmented does not rule out melanoma. And as far as clinical signs, they can be an incidental finding. You know, we should definitely be doing our oral exams maybe with this little dachshund, I'd actually ask the owner to lift the gums because he probably wants to bite me, But we definitely want to look in there. Not just to look at the teeth, but just, you know, looking at the gums quickly, trying to maybe look under the tongue a little bit, palate, that sort of thing. If the dog comes in for clinical signs, they're often associated with either the bacterial infection that can go along with those masses, so halitosis, might have bleeding or facial swelling. We may also have weight loss. This dog might not be eating as well if there's a mass that's in their way. So those are some of the clinical signs that can present with, again, the cutaneous solitary masses. The subungual, you have toenail swelling and loss of toenail bed. 

So diagnostically, these are ones where histopathology is really going to be your definitive. But you often want to consider an incisional biopsy rather than an excisional biopsy because that lets you plan. Again, these are aggressive tumors, so sometimes we want to know what it is and maybe potentially take a much bigger margins than in sort of doing a lumpectomy in the mouth and then having it come back as a melanoma. Cytology can be accurate with melanoma. But in general, in dogs, oral tumors don't exfoliate well. So it's not that you can't try it's that oftentimes you're not going to get good cells. This slide does show cytology of melanoma because I want to see those pigmented granules. But again, they don't all shell out very well like that. And then staging wise, we definitely want to do that. That helps us know how we're going to approach this from a treatment standpoint. These are ones you want to do lymph node aspiration in. Very, very important with these melanomas to know if the lymph nodes are involved. We want to do X-rays to check for bony involvement. This is a tumor that can invade bone like we talked about with osteosarcs. There's other tumors that will get in there. And we do want to check for thoracic Mets. That's another place it likes to go. We can consider CTE, which will help us for excisional planning with these oral ones. There is a a staging for these guys. I'll go through it really quickly. It is not used as commonly as some of our other staging, but the World Health Organization does a staging for oral tumors. And so stage one is a small less than 20 millimeter tumor. Stage two is 20 to 40mm with with no other involvement elsewhere. When we get to stage three, they're bigger, they're bigger than 40mm or it's any size with bone involvement. So it's invading into its local bone or one lymph node. And stage four is any size tumor with bilateral lymph node involvement, so metastasis to more than one lymph node or distal MET. So, so a quick staging there. It's not used as commonly with our dogs. 

Treatment wise again, does depend on how how the lymph nodes are involved. So if there's no metastases lymph node, when you've been doing that workup, then we consider radical surgical removal and chemotherapy. So when you can get all of the tumor and that might mean doing a max, maxillectomy or a mandibularectomy, even though it looks like a small tumor sitting on the side. But if you can get it all, that is ideal. When you can't get full margins, you stick it as much as you can. And in addition to chemo, we're going to add radiation. And this melanoma vaccine, which is a very interesting, awesome tool specific to melanomas currently but coming for other tumors. When you have lymph node metastasis, then you still do the surgical excision and you take the lymph nodes with you and again, continue to the rest of the treatment. Chemotherapy is used when you have these high risks of metastasis. And then again, this melanoma vaccine has been around long enough that I would say this is a valid question at this point. It's no longer completely novel therapy, but it's really cool. It's an exogenous DNA, which means DNA from another species. It's used post surgically, and it does improve survival times when you combine it with other chemotherapy. It is, though, I believe still, at least it was not too long ago, only in the hands of oncologists. So this is something that needs to be referred. And then again, we have all these new other therapies that are super exciting. This electromagnetic thermo ablation is actually sticking a needle into the tumor itself, causing necrosis. It's not widely used yet, but it is under study. Palladias come up for these guys. And then also remembering when we're dealing with anything in the mouth, we need to make sure that we're providing other support. So nutritional support, feeding tube sometimes, analgesics, and then they're really good at getting secondary bacterial infections, because it in the mouth, it's ulcerated. And we want to make sure we're covering for all of those. 

Pearl wise. Prognosis, again, sorry, it's a fairly poor prognosis. We get a two months survival time without treatment. If we add treatment with surgery, radiation, chemo, vaccine, it's really variable. And again, it depends on the stage. We can get anywhere from 5 to 12 months, sometimes even more with with an early stage. So mitotic index again, comes into play here. And I'm going to go through some of this quickly. I don't expect you guys to memorize this, but, you know, if you have a greater than three mitotic index, you have a very high risk of death within one year. So all the staging, all the grading, again, it is the fourth most common tumor. Sorry. Oral neoplasia itself is the fourth most common tumor type in the dog. And of those oral tumors, malignant melanomas are the most common, taking about 30 to 40% of that. Alright. So we see oral, oral neoplasia, very commonly in a dog, of those, we're going to see melanomas the most. I'm going to show you, I'm going to, if you haven't had a chance to look at this x ray, take a peek at this x ray, see if you can identify the METs yourself. There's more than one. I'm going to outline the two easiest to see. But again, aggressive, metastatic and not uncommon to find things like this. When we look at oral tumors, at least in the dog and besides the melanoma group, benign tumors are more common than in cats. Cats are known to have very aggressive oral tumors. So at least at least there's that for the dog.