Skin Cancer Melanoma - Istituto Europeo di Oncologia
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Skin Cancer Melanoma

Melanoma is a skin cancer that 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.

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IN SHORT

Melanoma is the less common but potentially more dangerous type of skin cancer. Melanoma is caused mainly by intense, occasional UV exposure (frequently leading to sunburn), especially in those who are genetically predisposed to the disease.

 

RISKS OF SKIN CANCER MELANOMA

Risk factors of developing this type of skin cancer are:

  • 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)

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 cancer lesions: in this case the specialist may advise regular periodic check-ups.

 

 

PREVENTION AND DIAGNOSIS

Prevention is the most effective instrument for reducing the incidence and mortality of skin cancer. Early diagnosis is a priority aspect based on signs of skin cancer, 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.

Early diagnosis forms the most effective instrument for reducing death associated with melanoma skin cancer. Recognising the signs of skin cancer at the initial phase means having an excellent prognosis. To make an early diagnosis of skin cancer it is essential to undergo periodic specialist consultations at centres with specific and expert professionals.

Forms of prevention for melanoma and skin cancers

Primary prevention involves appropriate behaviour for reducing the risk of onset of a skin cancer. For melanoma and skin cancer 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 looking at possible signs of skin cancer every 3 months
  • periodic dermatology visits at specialist centres

Signs of skin cancer - what does skin cancer look like?

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, paying attention to skin cancer symptoms.

For self-examination of the skin and in particular for distinguishing the skin cancer symptoms as potential malignant lesions, 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

Symptoms of skin cancer: 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 skin cancer. Where one or more lesions present the suspected characteristics of skin cancer, 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 skin cancers. 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, as possible skin cancers, 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, looking at signs of skin cancer and 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.

 

 

TREATMENT AND CLINICAL TRIALS

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 skin cancer's histology characteristics require it, wide local excision (with or without plastic repair) of the skin site of the early cancer 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.

Treatment of bone metastases from melanoma

Cutaneous melanoma is an aggressive neoplasia of melanocytes. Prognosis is dependent on tumor stage. Stage IV melanoma is characterized by the occurrence of distant metastases.

The metastases were localized in the gastrointestinal tract (20.7%), the liver (42.9%), the adrenal glands (8.5%), the pancreas (2.3%), the spleen (6.7%) and the brain.

Bone metastases occur in about 17% of melanoma patients. Multiple sites of metastases were noted in 18.8% of patients.

Response of metastases to classical chemotherapy is limited and treatment toxicity is high. In recent years, new developments in immunotherapy and targeted therapies have improved prognosis of stage IV melanoma patients with better tolerability of treatment.

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CREDITS

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