Skin cancers may originate from the outer cells – keratinocytes – or from the cells responsible for the production of melanin – melanocytes.

Prevention is the most effective instrument for reducing the incidence and mortality of skin cancers. Early diagnosis is a priority aspect, as it allows you to diagnose skin cancers at an early stage, reducing the weight of therapies and assuring the best prognosis.

Enlisting medical experts from a cancer reference centre allows adequate and prompt screening of the population.  For patients who have already received a diagnosis of skin cancer, a centre of excellence enables correct description of the disease and planning of therapy.

Skin neoplasms included two main families of tumour:

a)            Melanoma

b)           Skin neoplasm of epithelial origin

Melanoma

Melanoma originates in the majority of cases from the melanocytes found in the epidermis. Melanocytes are located in the deepest layer of the epidermis and produce melanin, the pigment responsible for skin colouration.

Over the last 10 years new cases of melanoma in the Caucasian population have increased by around 5% a year. In Italy more than 7000 new cases of melanoma are diagnosed every year. Melanoma can appear at any age, and it is one of the most frequent cancers in adults aged between 30 and 40 years.

Those most at risk of developing melanoma have one or more of the following characteristics:

– fair complexion, blue eyes and blond or red hair

– often clinically atypical

– history of repeated sunburn, especially in adolescence and young age

– personal history of melanoma

– nearest relatives suffering from melanoma

– alterations of immune defences (for example subject undergoing organ transplant or in immunosuppressive therapy)

Early diagnosis forms the most effective instrument for reducing death associated with melanoma. Recognising a melanoma at the initial phase means having an excellent prognosis.

To make an early diagnosis it is essential to undergo periodic specialist consultations at centres with specific and expert professionals.

 
Skin neoplasms of epithelial origin (non-melanoma skin cancer)

These are the most frequent skin cancers in adult and later age, especially in the areas most exposed to ultraviolet rays, such as the face and back of the hands.

Subjects most at risk are those with fair complexion and hair, a long history of sun exposure and sunburn. Risk increasing factors can be chronic immunosuppressive therapies.

There are two main types of cancer of epithelial origin:

a)            Squamous cell or spinocellular carcinoma

b)           Basal cell carcinoma or basalioma

These are the most frequent cancers in the general population, especially in those older than 50 years.

Squamous cell carcinoma originates from the keratinocytes in the epidermis and represents around 20% of epithelial origin cancers.

The behaviour of squamous cell carcinoma can be aggressive, therefore early diagnosis is important.

Surgical removal is the treatment of choice in the majority of cases.

Basal cell carcinoma is a very frequent epithelial origin cancer in the general population.

Basal cell carcinoma can be locally aggressive, therefore early diagnosis is also fundamental for this type.

The treatment options can be many and include surgical removal and, for certain cases, a series of therapies such as immunomodulators by topical use or photodynamic therapy for example.

Forms of prevention for melanoma and skin neoplasms

Primary prevention involves appropriate behaviour for reducing the risk of onset of a tumour. For melanoma and skin tumours it is important to limit exposure to sunlight, find areas of shade if remaining in sunlit places for long periods and avoiding exposure to the sun during the middle part of the day.

Sun protection cream can be helpful for avoiding erythema (sunburn, for instance) and should be applied every 2 hours, in adults and in children.

Secondary prevention has the goal of reducing mortality through melanoma and other skin cancers by anticipating diagnosis and early treatment of the high-risk forms.

For melanoma and the main skin cancers, secondary prevention is based on the following:

– periodic self-examination of the skin, every 3 months

– periodic dermatology visits at specialist centres

When self-examining the skin it is essential to look carefully. A relative, friend or partner can help to inspect the less visible regions of the body, such as the back and the rear surface of the thighs.

For self-examination of the skin and in particular for distinguishing a potential malignant lesion, it can be helpful to remember the ABCDEF rule:

A for Asymmetry: the shape of a benign neo is generally circular or at least regular, while a melanoma is irregular

B for Borders: in melanoma, irregular and indistinct

C for Colour: variable in melanoma (or with different shades within the neo itself)

D for Dimensions: increasing in melanoma, both in width and thickness

E for Evolution: in melanoma, the characteristics of the neo (symmetry, borders, colour, dimensions) change over time

F for Firmness

What happens at the visit to the day Hospital for diagnosis of skin lesions at IEO?
 

During the first visit the specialist will evaluate your risk factors for skin cancer by considering a series of variables such as: personal and family history of melanoma and other skin cancers, previous sunburns, patient's tendency to tan, inclination to use artificial sun beds or lamps, tendency to use sun protection, history of interventions for removal of moles (naevi) or other skin lesions.

The collection of this information will be followed by a clinical exam of the entire body surface manually using a dermatoscope. This allows the specialist to evaluate the neo and any other lesions, such as the presence of actinic keratosis (precancerous lesions, expression of actinic damage to the skin) or non-melanocytic skin lesions (non-melanoma skin cancer).

Based on all information collected and the subject's clinical evaluation, the patient will be separated into one of different categories.

Low-risk patients (risk comparable with that of the general population) without suspected skin lesions: in this case the specialist may advise regular periodic check-ups.

Patient with one or more clinically atypical or suspected lesions:

Regardless of the risk attributable to the subject based on the information collected, if one or more suspected skin lesions are found the patient will be offered the option of undergoing more thorough diagnosis using a digital videodermatoscope and confocal laser microscopy.

Digital videodermatoscopy allows magnified, high-resolution images of the skin lesions to be obtained to be able to examine the characteristics that cannot be appreciated with the naked eye or by manual dermatoscopy alone.

Confocal laser microscopy is a non-invasive technology which can obtain live images of the skin lesions at variable depth and with a very high resolution (virtual biopsy).

The combination of videodermatoscopy and confocal laser microscopy will, in many cases, enable avoiding surgical removal of the lesion. Where one or more lesions present the suspected characteristics, surgical exeresis will be carried out for histopathological investigation.

Patients who have risk factors for the development of melanoma (high-risk patient), especially if they have numerous moles or naevi, will be offered digital mapping.

Digital mapping is carried out in two phases. The first takes high resolution photographs of various areas of the body (face, trunk, limbs, extremities). The second phase involves acquiring a series of high-resolution images and neos and any other skin lesions by digital videodermatoscopy. This will provide a digital archive of the representative lesions of a subject in order potentially to follow the evolution of these lesions. In addition, by comparing the images of the various areas of the body it will be possible to identify any new recently onset lesions.

In each case the consultation for the skin lesions will be followed by a brief explanation of the best strategies for reducing the risk of melanoma and non-melanoma skin cancer. Specifically, each subject will be explained how to avoid excessive exposure to ultraviolet rays and the appropriate sun protection will be indicated. Furthermore, it will be explained to each subject how to perform a self-examination of skin lesions, following simple and understandable rules.

We believe that the moment of diagnosis must always be accompanied by a moment of education for both children and adults on how to provide correct prevention of the skin cancer risk.

Surgical removal is the best therapy available for skin cancers, and it is curative in the majority of cases. For basal cell epitheliomas and for non-invasive and well differentiated spinocellular epitheliomas, complete surgical removal is therapeutic. At IEO, for lesions in difficult surgical sites, extemporaneous histology exam at the margins of surgical resection is in use in clinical practice. This method allows verifying, during the intervention, that the removal has been performed completely.

For melanoma and for squamous cell carcinoma, when the tumour's histology characteristics require it, wide local excision (with or without plastic repair) of the skin site of the early tumour is performed with potential biopsy of the sentinel lymph node. This surgical procedure also allows early diagnosis of any lymph node metastases.

In the presence of one or more microscopic (if diagnosed by the sentinel lymph node biopsy) or macroscopic (if visible, found during the clinic visit or via follow-up ultrasound) locoregional lymph node metastases, radical lymph nodal dissection of all lymph nodes in the same lymphatic basin is indicated (the most frequent sites are axillary, inguinal or supraclavicular). In cases selected for palliative purposes or in the absence of other treatment strategies, electrochemotherapy can be offered.

IEO offers its patients a dedicated psychology service, with the presence of a psychotherapist specifically for patients of the Melanoma and Sarcoma Division.

The individuality and value of the service is given by the specific experience that psychotherapists have developed over the years with this population of patients. This is achieved through the continuity of service and systematic integration of this work within the team, and allows an approach and support for patients at all levels of disease and sharing of the best way of caring for the patient.

Patients may benefit from:

A psychological and emotional assessment, integrated with the medical/nursing work and giving the patient an idea of the mechanisms;

Psychological and educational meetings on the emotional impact of diagnosis, the interventions, and the treatment pathways;

Psychological support to help the patient in understanding, accepting and adapting to the medical condition, to the interventions and/or the treatments, and at the same time, integration of this time into the context of life.