Malignant Melanoma and Skin Cancer

Igor Y. Galaychuk, MD, DSc,

Professor, Head of Oncology and Radiology Department,

Ternopil State Medical University

Statistical data:

More than 1 million cases of skin cancer will be diagnosed in the United States every year. About 80 % of these new skin cancer cases will be basal cell carcinoma, 16 % will be squamous cell carcinoma, and only 4 % will be malignant melanoma.

Definition:

Cutaneous malignant melanoma is a neoplasm arising from the melanocytes that can occur de novo or from a preexisting lesion such as a congenital, acquired, or atypical (dysplastic) nevus.

Biologic progression of melanoma

Melanocyte nevus dysplastic nevus меlanoма “in

situ” superficial spreading melanoma

nodular melanoma metastatic melanoma

Professional education:

students family doctors dermatologists surgeons cosmetologists morphologists oncologists ! nurses

ABCD-test

Screening:

Self-Examination for Melanoma:

examine your body front and back in the mirror, arms and palms, legs and feet, neck and scalp – If you have any doubt about a mole, see a dermatologist-oncologist

(American Academy of Dermatology)

Malignant Melanoma: Risk Factors

Age > 40 yr. Race: whiteSun exposure: UVA, UVB Hereditary factors: “melanoma families“, atypical mole syndrome or dysplastic nevus syndrome Trauma of moles, Giant congenital neviOncogene mutations

Dysplastic Nevi (Atypical Moles)

Atypical moles are not melanoma, but they can become melanoma. They can be found in sun-exposed or sun-protected areas of the body. Atypical moles are larger and more irregular in shape, with notched or fading borders. They may be flat or raised or the surface smooth or rough. They are typically of mixed color, including pink, red, tan, and brown.Precursor Lesions

ABCDE rules:

'A' is Asymmetry

Asymmetry means one half of a mole does not match the other half. Normal moles are symmetrical. When checking your moles or freckles, draw an imaginary line through the middle and compare the two halves. If they do not look the same on both sides, have it checked by a dermatologist.

'B' is for Border

If the border or edges of the mole are ragged, blurred, or irregular, have it checked by a dermatologist. Melanoma lesions often have uneven borders.

'C' is for Colour

A mole that does not have the same color throughout or that has shades of tan, brown, black, blue, white, or red is suspicious. Normal moles are usually a single shade of color. A mole of many shades or that has lightened or darkened should be checked by a doctor.

'D' is for Diameter

A mole is suspicious if the diameter is larger than 6 mm. Benign moles are usually less than 6 millimeters in diameter.

'E' is for Evolving

A mole that is evolving – shrinking, growing larger, changing color, begins to itch or bleed – should also be checked. If a portion of the mole appears elevated, or raised from the skin, have it looked at by a doctor. Melanoma lesions often grow in size or change in height rapidly.

ABCDE: summary

Asymmetry of lesion; Border irregularity; Color change; Diameter larger than 6 mm; Evolving (surface changes [raised, bleeding, crusting] or symptomatic [itchiness or tenderness]).

Melanoma can vary in appearance

Dermatoscopy:

Dermatoscopy: ABCD

ЕЛМ

Diagnostics system MoleMax:

Growth patterns of melanoma:

superficial spreading melanoma – 70% nodular melanoma – 15-20% lentigo maligna melanoma – 4 -10% acral lentigo-melanoma – 2-8% amelanotic melanoma – 5%

Biopsy techniques

For cytological exam:- fine-needle aspiration,- superficial scraping.

For histological exam:- complete excision

(Breslow’s thickness, Clark’ levels)

Thickness of melanoma

TNM:

T1 < 1 mmT2 1-2 mmT3 2-4 mmT4 > 4 mm

Radial growth phase

Vertical growth phase

Evaluation for Metastasis: N0-3, M0-1

Regional Lymph Nodes: N0 – no metastasis,N1 – one lymph node with metastasis,N2 – 2-3 lymph nodes with Mts.,

N3 – 4 and > metastatic lymph nodes. Distant Metastasis: M0 – no metastasis,M1a: Mts in subcutaneous tissue, M1b: Mts in lung,M1c: Mts in other visceral organs (brain, liver, etc)

Surgical treatment of primary melanoma Т3bN1аМ0: wide local excision with wound plasty.

Postoperative wound closed by flaps’ transposition.

melanoma  Wide local excision

Sentinel node biopsy,or regional lymph node

dissection

 

Metastatic cells

Surgical approach to lymphogenous metastases of melanoma

 

 

 

Surgery of regional lymph nodes

Elective lymph node dissection is defined as removing regional lymph nodes that drain the site of the primary melanoma in the absence of any clinical evidence of nodal metastases. Elective lymph node dissection is a much-debated topic in the management of melanoma. Sentinel lymph node biopsy, a staging and possibly therapeutic procedure, is the most powerful predictor of melanoma recurrence and survival. Initially, lymphoscintigraphy is used to precisely map the draining nodal basin. Therapeutic regional lymph node dissection carried out when clinically present metastatic lymph nodes.

Lentigo maligna melanoma (arise from Hutchinson’s freckle)

1 year after Radiation Therapy

Melanoma: scars, recurrence, in transit Mts

1

3

2

4

Metastatic melanoma

Palliative - therapyHormonotherapySupportive care

Survival rates:

J Clin Oncol 2001;19:3635-3648.

Melanoma in situ: 100% survival at 5 years and 10 years.Lesions ≤1 mm: 91%–95% at 5 years; 83%–88% at 10 yearsLesions 1.01–2 mm: 77%–89% at 5 years; 64%–79% at 10 yearsLesions 2.01–4 mm: 63%–79% at 5 years; 51%–64% at 10 yearsLesions >4 mm: 45%–67% at 5 years; 32%–54% at 10 years

Skin cancers

More than 1 million estimated new nonmelanoma skin cancers were diagnosed in the United States in 2005, a number that was nearly equivalent to the number of all other cancers diagnosed in the US the same year. Of these cases, approximately 80% are basal cell carcinoma (BCC) and 20% are squamous cell carcinoma (SCC), making cutaneous SCC the second most common skin cancer and one of the most common cancers overall in the US.

BCC, T1

The following are exposure-related risk factors in the development of cutaneous cancers:

UV radiation exposure (high cumulative dose of sunshine, tanning beds, or medical UV treatments)Immunosuppression (eg, HIV), including iatrogenic immunosuppression (eg, transplant recipients)Ionizing radiation (eg, medical treatments, occupational or accidental radiation exposure)Infections (eg, HPV, osteomyelitis, acne conglobata, hidradenitis suppurativa, dissecting cellulitis of scalp, lupus vulgaris, lymphogranuloma venereum, granuloma inguinale, and chronic deep fungal infection) Chemical carcinogens (eg, arsenic, tar, polyaromatic hydrocarbons)

Host responses that influence cutaneous SCC development include the following:

Genetic susceptibility and dermatoses (eg, xeroderma pigmentosum, dystrophic epidermolysis bullosa, epidermodysplasia verruciformis, xeroderma pigmentosum, oculocutaneous albinism, dyskeratosis congenita, porokeratosis [Mibelli type, disseminated superficial actinic type, linear type], nevus sebaceous, and KID syndrome [keratitis, ichthyosis, deafness]) Susceptibility to UV radiation (eg, fair skin [Fitzpatrick skin types I and II], blond or red hair, light-colored eyes)Chronic inflammation, such as nonhealing burns or scars (eg, Marjolin ulcer, burn scar or thermal injury, venous ulcer, lymphedema, discoid lupus erythematosus, erosive oral lichen planus, lichen sclerosis et atrophicus, mutilating keratoderma, and necrobiotic lipoidica)

The biggest cause of skin cancer is sun exposure

SCC in situ:

Clinically, lesions of SCC in situ (SCCIS) range from a scaly pink patch to a thin keratotic papule or plaque similar to an actinic keratosis. Bowen disease is a subtype of SCCIS characterized by a sharply demarcated pink plaque arising on non–sun-exposed skin (see the first image below). Erythroplasia of Queyrat refers to Bowen disease of the glans penis, which manifests as one or more velvety red plaques

Every patient with suspected skin carcinoma should undergo a comprehensive examination,

including the following:

Location of lesion Size of lesionCharacter of lesion (smooth/nodular, vascularity, color) – SCC may appear as plaques or nodules with variable degrees of scale, crust, or ulceration Presence of ulcerationEvaluation of subcutaneous tissues (depth of lesion, bony involvement)Palpation of regional lymph nodes

Methods of morphological confirmation of skin cancer:

For cytological exam: - superficial scraping - fine-needle aspiration

For histological exam: complete excision (Breslow’s thickness, Clark’ levels)

High-risk tumor features include the following:

Greater than 2 mm thickness or Clark level IV or higherPerineural invasionPrimary anatomic location on the ear or non–hair-bearing lipPoorly differentiated or undifferentiated cellular histology

Precancerous lesions: Actinic (Solar) Keratosis)

These small, scaly patches are caused by too much sun, and commonly occur on the head, neck, or hands, but can be found elsewhere. They can be an early warning sign of skin cancer, but it's hard to tell whether a particular patch will continue to change over time and become cancerous. Most do not, but we recommend early treatment to prevent the development of squamous cell skin cancer. Fair-skinned, blond, or red-haired people with blue or green eyes are most at risk.

Cutaneous Horns

The cutaneous horn appears as a funnel-shaped growth that extends from a red base on the skin. It is composed of compacted keratin. The size and shape of the growth can vary considerably, but most are a few millimeters in length. Squamous cell carcinoma can be found at the base. It usually occurs in fair-skinned elderly adults with a history of significant sun exposure.

Skin cancer

Clinical case:Basal Cell Carcinoma,

T1N0M0(ulcer pattern)

Basal Cell Carcinoma

Basal cell carcinoma is the most common and easiest-to-treat skin cancer. Because basal cell carcinoma spreads slowly, it occurs mostly in adults. Basal cell tumors can take on many forms, including a pearly white or waxy bump, often with visible blood vessels, on the ears, neck, or face. Tumors can also appear as a flat, scaly, flesh-colored or brown patch on the back or chest, or more rarely, a white, waxy scar.

Skin cancer

Clinical case:Ear Squamous Cell Carcinoma,

T4N0M0

TNM-Classification of Skin Cancer:

Тis – carcinoma in situ Т1 – 2 cm Т2 – 2 - 5 cm Т3 – > 5 см Т4 – t-r invades cartilage, muscle, or bone. N0, N1 M0, M1

Skin Cancer

Squamous Cell Carcinoma of lower eyelid with invasion in bulbar conjunctiva,

T4N0M0

Skin Cancer

Squamous Cell Carcinoma of Cheek,

T4N0M0

Skin Cancer

Results after half course of gamma-therapy, 45 Gy

SCC of back: scheme of surgery

Surgery of skin cancer: flap plasty of wound after complete excision of cancer

Skin Squamous Cell Cancer of Neck:

Postoperative wound is temporary covered with Pig skin xenografts T4NxM0

Skin Cancer:granulation wound (1), skin autografting (2)

14 day: wound after removing of xenografts

Skin Cancer: complete recovery12 months later

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