Skin Cancer – Symptoms, Causes, Treatment

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Melanoma is a form of skin cancer that originates in the pigment-producing cells called melanocytes. These cells become abnormal, grow uncontrollably and  invade the surrounding tissues aggressively. Even though melanoma is less common than other types of skin cancer, it is the worst.

Fortunately, melanoma can be cured if it is detected and treated in early stages when it is located only at the level of the skin. In more advanced stages, it can spread or metastasize by a hematogenous (  through blood) or lymphatic (  through the lymph) way to other organs or bones, in these cases healing being less likely.

 

Article Contents

1.Causes

2.Symptoms

3.Physiopathogenic mechanism

4.Risk Factors

5.Professional medical consultation

6.Watchful waiting

7.Recommended doctors

8.Investigations

9.Early diagnosis

10.Stages

11.Initial treatment

12.Maintenance treatment

13.Treatment if the disease advances

14.Prophylaxis

15.Outpatient Treatment

16.Medication

17.Surgical treatment

18.Other treatments

Causes

 

The most frequent causes of melanoma are:

- Exposure to ultraviolet (UV) between 10:00 a.m. to 15:00 p.m. and exposure to high altitudes

- the damage of the DNA from the melanocytes as a result of  exposure to sunlight and UV radiation with short wavelength is the most important factor that causes melanoma

- when going to the solarium the body is also exposed to UV which increase the risk of developing melanoma

- the reduction of the ozone layer can significantly affect the incidence of melanoma. It is estimated that there is a 1% increase in the incidence of melanoma with each percent of thinning of the ozone layer

- family aggregation of melanoma (more cases of melanoma in the same family)

- Atypical moles

- Weakened immune system, especially in the case of people with organ transplants, leukemia or lymphoma.

Symptoms

 

Early symptoms

The most important warning sign for melanoma is the change in size, shape or color of moles or other skin growths, such as birthmarks. Watch the  changes that occur after a period of one month to 1-2 years.

 

Use the ABCD rules of the American skin Cancer Society to evaluate skin changes and consult your family doctor if any of the following changes occur:

- A is for asymmetry. Half a mole or skin tumor does not overlap with the other half

- B is for irregular borders. The edges are ragged, notched or spotted

- C is for colour. Pigmentation is not uniform. Shades of tan, brown and black are present. Red, white and blue dashes are added to the appearance of coloured spots. The change in the distribution of colours, especially the spread of the colour from the the edge of the mole on the skin around it, is also an early sign of melanoma

- D is for diameter. The mole or skin tumor is larger than 6 mm (0.2 in) or of the size of a pencil eraser. Any increase of the mole should be a signal of concern.

 

Signs of melanoma, if a mole exists, include changes in:

- Height – such as depth invasion or the elevation of a mole which was previously flat

- Surface – as redness, swelling or the appearance of new small coloured spots around the larger lesion (pigmented satellite)

- Itching, tingling or burning at the level of the lesion

- Soft, brittle consistency with small pieces that break easily.

 

Melanoma can develop on an existing mole or other skin sign, but it can sometimes grow and stretch on a portion of skin which is intact and has no sign. Although melanoma can develop anywhere on the skin, it appears more frequently on the chest of both men and women and on the legs of women. Less frequently it may develop on the soles, palms, nail beds or  at the level of the mucous membranes that line the body cavities such as mouth, rectum and vagina.

Many other diseases (such as seborrheic keratoses, warts and basal cell carcinoma) have similar features of melanoma.

 

Late symptoms

Late symptoms of melanoma include:

- An ulcerative skin lesion or bleeding from a mole or other coloured skin lesion

- Pain at the level of a mole or lesion.

 

The symptoms of metastatic melanoma may be vague and include:

- Lymphadenitis (swollen lymph nodes), especially the glands in the armpit or stomach

- A more discoloured or dense portion below the skin

- Unexplained weight loss

- Gray skin (melanosis).

 

Physiopathogenic mechanism

 

Melanoma develops when the pigment-producing cells called melanocytes become abnormal, grow uncontrollably and invade the surrounding tissues. Usually only one melanoma develops at a time. Although melanoma can occur on the surface of an existing mole or other skin tumor, most are located on unmarked skin. Melanoma is classified as primary or metastatic.

 

Primary melanoma

Primary melanoma usually follows a kind of proliferation in the skin layers. Early detection and surgery to remove melanoma cure most cases of primary melanoma. If left untreated, most melanomas spread to other parts of the body. Melanomas are unlikely to  disappear without treatment once they developed.

 

Long-term survival or the prognosis of primary melanoma depends on:

- How deeply the melanoma invades the skin ( infiltrated melanoma)

- If a painful ulcerated lesion is present on the surface of primary tumor (ulceration).

 

Metastatic melanoma

Metastatic melanoma spreads through the lymphatic system of the skin near the tumor, lymph nodes or by hematogenous (through blood) way to other organs such as brain or liver. Metastatic melanoma can not usually be cured. Early detection and the removal of primary melanoma before metastasis offers the best chance of healing.

 

Risk Factors

 

Risk factors for melanoma include:

- anterior exposure to ultraviolet (UV)

- exposure to sunlight is the most important risk factor for melanoma. Unexpected exposure to sunlight may occur during childhood, in the trades in which the person must work out and during outdoor activities

- UV exposure in tanning salons (solarium) is as risky as exposure to sunlight

- anterior sunburn, especially in childhood

- Personal history of melanoma or other skin tumor

- family aggregation of melanoma (FAM syndrome – M)

- Atypical moles (dysplastic nevi)

- More than 50 moles on the body

- Whites, especially people with light skin who burn rather than tan, with red hair or blue eyes

- Many freckles (spread) on the upper portion of the back

- Other forms of cancer like leukemia or lymphoma

- Weakened immune system

- Moles present since birth, especially if the moles are larger than 20 cm (7.9 in) (congenital melanocytic nevi)

- A rare inherited disease called xeroderma pigmentosum. This is a disease where the body can not restore the cells damaged by solar UV

- Treatment with UV A (PUVA), used to treat dermatological diseases like psoriasis (chronic skin disease, inflammation characterized by erythematous lesions covered by silvery white squamas).

Professional medical consultation

 

The most important warning signs of melanoma are the changes in size, shape or colour of moles or other skin growths (as birthmarks).

It is recommended to call your doctor if you see any of the following:

- Any change in the mole, including size, shape, colour, sensitivity or pain

- Bleeding mole

- A discoloured area beneath the nail of the hand or foot which is not injured

- A darkening of the skin in general, uncorrelated with sun exposure.

 

Immediately call your family doctor if the melanoma was diagnosed and the patient has:

- Dyspnea (difficult breathing) or dysphagia (difficulty when swallowing)

- Hemoptysis (cough which contains blood or hemoptoic sputum)

- Blood in vomit or faeces

- black urine and faeces, in which case the colour is not influenced by administration of tablets or products containing iron.

Watchful Waiting

 

Watchful waiting or  the survival period is a time when patient and doctor observe symptoms without having recourse to medical treatment. Watchful waiting does not correspond to melanoma. Consult your doctor if you suspect any change in the mole or other skin tumors. Melanoma is curable if diagnosed early, before the tumor to grow and to metastasize

 

Recommended specialist doctors

- GP

- Doctor of internal medicine

- Dermatologist.

If melanoma is suspected, a biopsy is needed to settle the diagnosis. The doctor will take a tissue sample that the pathologist can examine under a microscope to check if there are cancerous cells.

If additional treatments are necessary or excision, melanoma can be treated by a dermatologist, surgeon, plastic and reconstructive surgeons or by the oncologist.

Investigation

 

The evaluation of skin lesions

An objective skin exam is used to check melanoma skin. If melanoma is suspected, a skin biopsy will be performed. For this, the doctor will take a tissue sample cutatnat and will send it to the pathologist to examine it under a microscope. If the biopsy reveals melanoma, the pathologist will measure the melanoma invasion so as to determine how advanced the cancer is. Other investigations, including photography can be used to monitor the changes in skin lesions. A series of photographs of the suspected lesions are taken as the reference for further comparisons with the following photos.

The evaluation of lymph nodes

Testing the lymph nodes may not be necessary if the melanoma is less than 1 mm (0.04 in), because the risk of cancer invasion is low. There should be performed several laboratory tests if melanoma is invasive or of a big size. If the size of melanoma is thicker than 1 mm, the doctor will perform a physical exam of  the superficial lymph nodal system to verify which of the lymph nodes are enlarged in size. This examination may be followed by the lymph nodes biopsy to assess how spread the melanoma is in the lymph system. Biopsy of the sentinel lymph nodes is a relatively new technique that can be used as an alternative to the conventional lymph node biopsy.

Like the classic lymph node biopsy, sentinel lymph node biopsy is performed to identify the lymph nodes invaded by melanoma. Before the sentinel node biopsy, there is a technique of nuclear scanning called lymfoscintigraphy through which drainage “maps” of the lymphatic network from the place where melanoma was found are made. A radioactive substance is injected into the skin around the melanoma and the lymph nodes are photographed with a special camera.

The first nodes in the network of lymphatic drainage that absorb the radioactive substance are called sentinel nodes. They most likely contain cancerous cells. If cancer is dealt with in the sentinel nodes, a procedure to remove more lymph nodes (lymphadenectomy) is made in this case.

Evaluation for possible metastases (cancer has spread)

A complete history and a physical exam are needed in order to determine whether the cancer has metastasized (spread) to other parts of the body. Imaging tests, including computed tomography (CT scan) or magnetic resonance imaging (MRI), can be used to detect metastases in other parts of the body such as lungs, brain, liver and other organs.

Early diagnosis

 

Personal examination of the skin is the best way to detect early the skin changes that may indicate the onset of melanoma. Approximately 93% of primary melanomas may be easily identified on the skin. A personal examination of the skin is used to identify the suspected tumors which can be malignant or the proliferative lesions that can develop into cancerous lesions (precancerous lesions). Adults should examine their skin once a month. They should look for any abnormal proliferation of the skin or any change in color, shape, size or the appearance of skin tumors. They should check any lesion that does not heal.

There are other steps that should be followed in order to prevent skin cancer or to detect it in an early stage:

- avoid skin cancer risk factors and obey to the rules of prevention, including the use of sunscreen creams, wearing protective clothing and non-exposure to midday sun

- any suspicious changes in the skin should be examined by the doctor.The screening guidelines of the American Cancer Society and other international expert companies recommend that adults older than 40 years should seek medical skin examination at least once a year, as well as for other medical examinations. This can lead to early treatment and prevent the possible invasion of cancer. It is necessary the beginning of early screening, especially if the person has:

- Familial atypical nevi and melanoma (FAM-M syndrome), which is an inherited tendency to develop melanoma.

Own examination of the skin and the examination by a doctor every 4-6 months, preferably by the same doctor every time:

- Increased occupational or recreational exposure to ultraviolet radiation (UV)

- Abnormal moles are called atypical moles (dysplastic nevi). These moles are not cancerous, but their presence is a sign of alarm for the inherited trait of developing melanoma.

Stages

 

Staging is a descriptive method of cancer progression. It is performed after the excision of melanoma and the examination of the lymph nodes and other parts of the body so as to determine the extent of cancer. Staging helps doctors to indicate the best method of treatment available.

Staging evaluates:

-  the hickness and depth of the tumor

- the ulceration of the skin at the level of the melanoma

Initial treatment

 

Melanoma is curable if detected and treated in early stages when only the skin tissue is affected. If melanoma is confined to the skin (primary melanoma), the solution is to resort to surgery to remove damaged area of skin. If melanoma is thin and has not invaded the surrounding tissues, excision may cure the melanoma.

In advanced stages, melanoma can spread or metastasize to other organs and at the level of bones, in these situations melanoma being less curable:

- Melanoma that invades only the outer layer of skin – called stage 0 of melanoma or melanoma in situ – is an indication for surgery to remove the lesion or the nevus, together with 0, 5 cm (0.2 in) margin of safety of normal skin tissue.

- first stage of melanoma – surgery that removes the lesion and 1 cm (0.39 in) margin of healthy tissue around and below the lesion is indicated.

- second stage of melanoma – surgical removal of tumor with 3 cm (1.18 in) of healthy tissue around and below the lesion. Plastic surgery procedures may be necessary to fix the residual scar remained after surgery, especially if it is located on the face or hands

- third stage of primary melanoma – in which lymph nodes are invaded- surgery to remove the primary melanoma and all the lymph nodes and lymph tissue from primary melanoma region is indicated. Even if melanoma has already spread (metastases) through the agency of the lymph nodes at distance from the primary tumor

- Adjunctive therapy (extra) is commonly used after surgery in oder to overcome the symptoms. Adjuvant therapy is the treatment performed before and after surgery so as to increase the chance of healing and destruction of residual cancerous cells

- the use of interferon may increase the survival rate of people with third stage of melanoma.

 

 

Treatment of melanoma that develops in other parts of the body depends on its location.

The localizations of melanoma include:

- the eye (ocular melanoma) – In the past, ocular melanoma required the removal of the eye (enucleation), but nowadays radiotherapy is an alternative for the treatment of some of these cases

-the skin on the fingers of the hand or foot or under the nail. Melanoma localized in these places is treated by removing the affected tissue (excision). Sometimes it is necessary the removal of the hand finger or toe in full.

Maintenance treatment

 

Repeated checkups are important once the melanoma diagnosis was given. After the surgery of removing melanoma controls are recommended every 3-6 months for 5 years, then annually.

Regular checks every 3-6 months are indicated if the patient has:

- Abnormal moles called atypical moles (dysplastic nevi). These moles are not cancerous, but their presence means a warning sign for the inherited tendency to develop melanoma

- Atypical melanocytic nevi associated with the presence of melanoma (FAM-M syndrome) is an inherited disease predisposed to the development of melanoma.

 

Treatment in case the disease worsens

 

The swelling or the sensitivity of lymph nodes may be a sign of melanoma extension. Any lymph node increased in size should be removed and investigated for melanoma.

 

The fourth stage (metastatic) of melanoma responds poorly to most forms of treatment. 5-year survival in the fourth stage of melanoma is less than 50%. Metastatic melanoma treatment goals are to control symptoms, reduce complications and increase patient’s comfort in this stage of disease (palliative treatment). Treating the disease is not intended.

 

Metastatic melanoma can be treated by:

- Radiotherapy – chemotherapy with dacarbazine. The main side effects of chemotherapy with dacarbazine are nausea and vomiting, which can usually be controlled by antiemetic medicines ( which prevent vomiting).

People with metastatic melanoma may be included in clinical trials. Talk to your doctor about clinical trials available in the area.

To be retained!
After the removal of primary melanoma, a skin graft may be necessary for cosmetic reasons or to restore the functionality of the area. This is probably necessary if the melanoma was removed from the face, hands, feet, forearms or legs or in the case of large melanomas.

The relapse of melanomas is frequent. Perform a self examination skin monthly and report to the doctor any changes.

 

Terminal problems

In the case of advanced melanomas (metastatic) curative treatmen may be stopped in oder to focus on the patient’s comfort (palliative treatment). The decision of when you should stop medical treatment intent to prolong life and change the aim towards a palliative treatment is difficult.

Prophylaxis

 

The main risk factor for developing melanoma is represented by the (excessive) unexpected exposure to sun ultraviolet rays (UV). Some experts appreciate that 65% or more of cases of melanoma are caused by exposure to the sun, especially during childhood. One study estimated that using a sunscreen with sun protection factor greater than 15 in the first 18 years of life would reduce the risk of developing melanoma by 78%.

 

The following are recommended in order to prevent skin cancer:

- Daily use of a solar filter with a protection factor of at least 15

- Wear protective clothing

- avoid sun exposure between 10:00 a.m. to 3:00 p.m..

- Use an SPF (sun protection factor) as high as possible

- imposing a good example to children by always using sunscreen or wearing protective clothing.

- Avoid sun exposure on the beach or in the solarium salons. UV from artificial sources are as dangerous as those from the sun

- Examining the skin regularly and in the routine clinic visits at least once a year.

 

People who live in areas with hot, sunny climate or have jobs that require them to spend  more time outdoors present an increased risk for developing melanoma. People who burn rather than tan, especially those with red hair or blue eyes, are at increased risk of developing melanoma and they should take additional precautions in order to prevent melanoma.

Some people find that a dark skin may protect against sunburn and this is why they protect skin against lesions and the appearance of skin carcinoma. However, if you do not tan gradually, the amount of exposures to the sun to get a tan will cause excessive skin damage and exclude any possible benefit of dark skin.

 

Outpatient treatment

 

Outpatient treatment after the removal of melanoma includes the protection of the skin from prolonged exposure to ultraviolet (UV) and periodical examination of the skin in case of suspicious changes:

- use sunscreen of at least 15 daily. Use a higher SPF in high altitude areas ( at heights)

- wear protective clothing for outdoor activities, including wide-brimmed hat, long sleeve shirts and pants

- do not expose to the sun between 10 am – 3 pm

- avoid the sun on the beach or solarium salons.

- make a self examination of the skin once a month. Check the skin and the skin tumors for any change in color, shape, size or appearance

- look for any skin lesion that has not healed after an injury.

- bring to the attention of the family doctor any suspicious skin changes.

 

If you have recently undergone chemotherapy or radiotherapy for advanced forms of melanoma, outpatient treatment is recommended in order to control the adverse effects that may accompany these types of treatment. The outpatient treatment may be the only one necessary to face the following problems. If your family doctor gave appropriate instructions or medicines to treat these symptoms, make sure you respect them.

Generally, healthy habits like a balanced diet or adequate sleep programs and exercises can help control symptoms:

- Outpatient treatment for nausea or vomiting, including monitoring the treatment of early signs of dehydration such as dry mouth, viscous saliva, reduced production of urine, the urine becomes dark yellow.

- Outpatient treatment for diarrhea includes putting the stomach at an alimentary rest and carefully monitoring the appearance of signs of dehydration. Consult your GP before using antidiarrheal medicines.

- Outpatient treatment of constipation includes gentle exercise along with consuming the right amount of fluids and a diet containing large amounts of fruit, vegetables and fibers. Consult your doctor before using laxative tratment to combat constipation

- Outpatient treatment of fatigue includes ensuring a prolonged period of rest in the case of undergoing chemotherapy or radiotherapy. The patient should be guided by the symptoms. The patient may be able to persevere in the daily routine and enjoy an additional period of sleep.

 

Other problems that can occur are:

- Alopecia (hair loss). This can be emotionally distressing. Not all chemotherapies cause hair loss, some persons showing only a slight thinning of the hair which is observed only individually. Consult your doctor when alopecia is an expected side effect of the received cure of chemotherapy

- Insomnia. If sleep disturbances occur, you might sleep easier if you establish a regular sleep schedule,  you may do exercises during the day, avoid dozes and try other methods to combat impaired sleep.

 

Many people with melanoma face emotional problems as a result of disease or treatment:

- Melanoma diagnosis and the need for treatment can be very stressful. You can try to reduce stress by sharing feelings with other people. Learning relaxation techniques may also be useful in reducing stress

- Opinions about your body may change as a consequence of the diagnosis and the need for treatment. The adaptation to the body image may involve an open discussion with the partner concerning the preoccupation for this and the sharing of the feelings with the doctor. The doctor may guide patients towards organizations that offer support and additional information.

Not all forms of cancer or all treatments for this pathology cause pain. If pain occurs, many treatments are available in order to combat it. If your doctor has recommended instructions or medicines to treat pain, make sure you do as you was told to. Outpatient treatment can help to alleviate pain and improve physical and mental condition. Talk to your doctor about any alternative outpatient treatment useful for pain relief.
New innovations in Melanoma treatment

Medication

 

The interferon administered before and after surgery is the preferred treatment for melanoma that has invaded the lymph nodes. The use of interferon may increase the survival rate of people with third stage of melanoma.

 

That melanoma that metastasized at distance is rarely curable  using standard treatment, even if different classes of drugs have been studied in clinical trials.

 

Chemotherapy generally does not increase the survival rate for metastatic melanoma. However, chemotherapy with dacarbazine can be used for the palliative treatment of the fourth stage of melanoma.

 

Medication Choices

 

Drug treatment for metastatic melanoma may include:

- Interferon – can be used in the case of melanoma that has invaded the lymph nodes

- Dacarbazine (DTIC) – can be used to treat the fourth stage of melanoma (metastatic melanoma).

 

The main adverse effects of dacarbazine are the nausea and vomiting, which can normally be controlled by antiemetic medicines. The family doctor will prescribe these drugs to be taken together with the background and outpatient treatment so as to combat any nausea that may occur.

 

These medication options include:

- Serotonin antagonists – such as ondansetron (Zofran), granisetron (Kytril), or dolasetron (Anzemet). These drugs can be more effective in preventing nausea and vomiting caused by chemotherapy when combined with corticosteroids, such as dexometazona (Hexadrol)

- Aprepiant (Emend) – which is used in combination with ondasetron and dexamethasone starting with the third day of treatment

- Phenothiazines – such as the Compazine and Phenergan – Metoclopramide (Reglan).

 

To be retained!

New forms of chemotherapy are constantly being tested. The success of new drugs and new combinations of drugs is determined by clinical trials.

Surgical Treatment

 

Complete surgical removal (excision) is the most effective treatment and most commonly used to treat melanoma. Lymph nodes must also be removed (by lymphadenectomy) in the case of the second and third stage of melanoma.

Metastatic melanoma is also treated by surgical removal of the primary melanoma and of the neoplastic tissue near the tumor or lymph nodes.

Surgical treatment options

 

The most common surgical procedures used to treat melanoma include:

- Surgical excision – the excision removes the entire melanoma along with a margin of normal looking tissue (safety margin)

- Lymphadenectomy – surgical procedure in which the lymph nodes that are invaded by melanoma are removed.

 

To be retained!

 

Other treatment options are used for melanomas that develop in areas with rare localization of melanoma, such as the eye, a finger of the hand or foot or underneath the nail.

Other treatments

 

Radiotherapy may be used for treating advanced forms of melanoma or metastatic melanoma. Radiotherapy uses high doses of radiation which destroy or shrink melanoma, with little damage to a portion of healthy tissue near the tumor. Radiation affects the genetic material of cells that are localized in the area where the treatment takes place,having as a result the stoppage of cell growth.

Other forms of treatment, including therapy with monoclonal antibodies or vaccines have been studied in clinical trials. No vaccine is currently approved by the international organizations in order to treat melanoma.

 

Adjuvant therapy methods

Additional to the conventional treatment, adjuvant treatment may improve the patient’s quality of life by helping to control stress and adverse effects of the treatment for melanoma.

 

However, these adjuvant therapies should not replace standard therapy:

- acupuncture

- Homeopathic treatment – herbal extracts

- Biofeedback

- meditation

- Yoga – Hypnosis

- Vitamin and nutritional supplements.

Before using any of these therapies consider together with your doctor  the possible benefits and side effects. Announce your doctor if you are already using any of these therapies.

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