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 lano 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 dermatologistoncologist
(American Academy of Dermatology)

Malignant Melanoma: Risk Factors

Age > 40 yr.

Race: white
Sun exposure: UVA, UVB
Hereditary factors:
melanoma families,
atypical mole syndrome
or dysplastic nevus
syndrome
Trauma of moles,
Giant congenital nevi
Oncogene 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
6mm;
Evolving (surface
changes [raised,
bleeding, crusting] or
symptomatic
[itchiness or
tenderness]).

Melanoma can vary in appearance

Dermatoscopy:

Dermatoscopy: ABCD

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
(Breslows thickness,
Clark levels)

Thickness of melanoma
TNM:
T1
T2
T3
T4

< 1 mm
1-2 mm
2-4 mm
> 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 3bN10:

wide local excision with wound plasty.

Postoperative wound closed by flaps

transposition.

Sentinel node biopsy,

or regional lymph node
dissection

Metastatic cells

melanoma

Wide local
excision

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 Hutchinsons freckle)

1 year after Radiation Therapy

Melanoma: scars, recurrence, in transit Mts

Metastatic melanoma
Palliative therapy
Hormonotherapy
Supportive care

Survival rates:
J Clin Oncol 2001;19:3635-3648.
Melanoma in situ: 100% survival at 5 years and 10
years.
Lesions 1mm: 91%95% at 5 years;
83%88%
at 10 years
Lesions 1.012mm: 77%89% at 5 years; 64%79%
at 10 years
Lesions 2.014mm: 63%79% at 5 years; 51%64%
at 10 years
Lesions >4mm:
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 nonsunexposed 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 lesion
Character of lesion
(smooth/nodular, vascularity,
color) SCC may appear as
plaques or nodules with
variable degrees of scale,
crust, or ulceration
Presence of ulceration
Evaluation 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
(Breslows thickness,
Clark levels)

High-risk tumor features include the

following:
Greater than 2 mm
thickness or Clark level
IV or higher
Perineural invasion
Primary anatomic
location on the ear or
nonhair-bearing lip
Poorly 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 fairskinned 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-totreat 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:

is carcinoma in situ
1 2 cm
2 2 - 5 cm
3 > 5
4 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 gammatherapy, 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:

T4NxM0

Postoperative wound is temporary

covered with Pig skin xenografts

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

14 day: wound after removing of xenografts

Skin Cancer: complete recovery

12 months later