Cutaneous melanoma

Content

Introduction

Skin melanoma is a type of skin cancer that can spread to other organs in the body (Video).

It originates from the malignant transformation of melanocytes, cells distributed in the deep layers of the skin that produce melanin, a substance produced in abundance after exposure to the sun and responsible for the color of the skin and the phenomenon known as "tanning". In fact, its function is to protect the skin from the harmful action of the sun's rays (read LaBufala). Under normal conditions, melanocytes can grow on the surface of the skin in the form of agglomerates, with variable color ranging from reddish to dark brown , and are commonly known as moles (medical term snows).

Until a few years ago, melanoma was considered a rare tumor, even very rare until adolescence, while in the last 20 years the number of new cases (incidence) has increased by over 4% with an increase among men in the last few years , and a reduction among women. It is estimated that in Italy in 2019 about 12,400 cases of cutaneous melanoma were ascertained (diagnosed), of which 6,700 among men and 5,700 among women. origin to metastases, a better response to therapies and in general a longer survival.

This type of melanoma ranks third in the number of new cases in the age group from 0 to 44 years.

Skin melanoma can develop anywhere on the body. In most cases, melanomas have an irregular shape and an uneven color. We must therefore pay attention to changes in skin moles and report them to the attending physician who, after a thorough examination, if he deems it necessary, may advise you to consult a specialist, dermatologist or oncologist, for further investigations.

Symptoms

The first sign of skin melanoma growth is the appearance of a new mole on the skin or the change of an existing mole. Since melanoma can develop in any part of the body, even in areas not directly visible such as, for example, the back, it is important to periodically get help in the observation of the entire surface of the body, including the mucous membranes (Video).

It is possible to keep moles and suspicious formations present on the skin under control, paying attention to 5 characteristics that have the first five letters of the alphabet as initials:

  • A, as an asymmetry. The shape of one half is different from the other
  • B, as an edge. The outline is irregular, jagged or blurred
  • C, like color. The color is not uniform
  • D, like dimensions. The dimensions change
  • And, as an evolution. Shape and color change in a short time

Other warning signs are bleeding and itching of a mole or the appearance of a lump or red area around a mole.

Causes

It is now established that most skin cancers are caused by ultraviolet (UV) light as it can damage the DNA of cells (DNA is deoxyribonucleic acid, a structure that contains all the information for the synthesis of molecules necessary for development and to the functioning of the organism such as RNA, ribonucleic acid, and proteins) inducing their transformation into cancer cells.

The main source of UV rays is sunlight. There are three types of UV rays: UVA, UVB and UVC. While UVC rays are filtered out of the atmosphere, UVA and UVB rays cause damage to the skin over time, making it more likely to develop a tumor. In particular, UVB rays are considered to be the most dangerous. However, artificial sources of rays are also considered. UVA, such as sunlamps and tanning beds, can increase the risk of developing skin cancer, especially when exposure is frequent and intense. Repeated burns caused by sunlight or artificial sources increase the risk of melanoma occurring in people of all ages but, above all, in children.

People with many moles have a higher risk of getting melanoma, especially if the moles are larger than 5mm or unusually shaped.

For this reason, it is important to monitor both the appearance of new moles and any changes in existing moles and avoid exposing them to the sun. Having one or more cases of melanoma among family members also increases the risk of getting the same disease.

Other risk factors are represented by some individual characteristics and living conditions including:

  • have a fair complexion, especially rich in freckles and prone to sunburn
  • have red or blond hair
  • have blue eyes
  • being in old age
  • have a poorly functioning immune system (for example in cases of HIV infection or for immunosuppressive therapies commonly used after organ transplantation)
  • be exposed to some chemicals such as creosote and arsenic

Diagnosis

It is good that every adult person undergoes, at least once, a medical examination for the examination of moles to "photograph" the present situation and be able to notice any changes that may occur over time.In the event that, with the passage of time, changes in the skin are found, it is advisable to quickly consult the treating doctor who will carefully evaluate the case and, if he deems it necessary, will prescribe a visit to a specialist doctor. The specialist (dermatologist / oncologist) will be able to advise the removal of the suspicious mole (biopsy, under local anesthesia) and the execution of the histological examination to establish whether or not it is a melanoma.

There are 4 types of cutaneous melanoma:

  • superficial spreading melanoma, (the most common, accounting for about 70% of all skin melanomas)
  • lentigo maligna
  • acral freckled melanoma
  • nodular melanoma

Unlike the first three types, which initially have superficial growth, nodular melanoma invades deep tissue from its earliest stages of development and is the most aggressive but least frequent (it accounts for about 10-15% of all melanomas ).

If the presence of melanoma is ascertained (diagnosed) and, after removal, the thickness of the lesion (Breslow index) exceeds 0.5 mm, a new surgery will be performed to remove a larger part of tissue around the lesion of origin and any lymph nodes neighbors (sentinel lymph nodes). Sentinel lymph node biopsy is usually done by the plastic surgeon under general anesthesia.

If there are no melanoma cells (node ​​negative) in the sentinel lymph node, it is extremely unlikely that all other lymph nodes could be affected by the disease. Otherwise, since there is a risk that other lymph nodes of the same group may contain cancer cells (positive lymph nodes), the surgeon will evaluate whether to proceed with a complete removal of the lymph nodes in the affected area for both diagnostic and therapeutic (teranostic) purposes. .

Other exams that may be required are:

  • a computed tomography (TC)
  • an MRI (RM)
  • a positron emission tomography (PET)
  • blood analysis

Therapy

Surgery is the initial treatment of melanoma. If the melanoma recurs (relapse), new therapies are available to the doctor.

Choice and planning of care

People who have been diagnosed with melanoma are usually looked after by a team of specialists that includes a dermatologist, a plastic surgeon, an oncologist, a pathologist and a trained nurse. The elements taken into consideration in deciding which is the most suitable treatment for each patient are:

  • the type of cancer
  • the stage of the tumor (how big and how widespread is it)
  • the general state of health

The team of specialists will propose a type of treatment but, in the end, the decision will be up to the patient who must, therefore, be informed about the advantages and disadvantages of each treatment. Before making the decision, it is useful for the patient to expose to the specialists all doubts about both the disease and the therapy.

Staging of melanoma

Staging (Video) is a classification system used by doctors to indicate the degree of advancement of the tumor and refers to characteristics such as the thickness, the speed of reproduction of the tumor cells, the presence of ulceration, the involvement of the lymph nodes and the spread distant tumor (metastasis). The type of treatment that will be indicated will depend on the stage reached by the melanoma.

Normally, melanoma is classified into 4 stages:

  • stage I and II, there are no metastases
  • stage III, regional lymph node metastases are present
  • stage IV, distant metastases are present

Active surveillance

This term means the choice not to carry out any treatment after surgery (for the early stages I and II), but to subject the patient to a specific program of checks and examinations.

Relapse surgery and / or treatment with new generation drugs (stages III and IV)

In the event that melanoma spreads to the lymph nodes or other organs in the body (any organ can be the site of metastases) the surgeon will take care of removing the tumor tissue again.

New drugs have recently been approved to treat advanced-stage melanoma. In particular, BRAF and MEK inhibitors (when these are mutated) and immunotherapy drugs such as CTLA-4 or PD-1 inhibitors are used.

These are very powerful drugs that are changing the evolution of the disease but can have serious undesirable effects (side effects) and must therefore be administered under strict medical supervision.

Living with

If diagnosed early, melanoma is unlikely to return, and after a period of regular check-ups, the affected person may forget that they have had this tumor.

In some cases, the removal of the lymph nodes can cause a defect in the circulation of the lymph and increase the risk that the lymph can accumulate in the tissues (lymphedema). To prevent this from happening, it is necessary to observe specific behaviors that the doctor will be able to recommend. But even if lymphedema occurs it is possible to reduce it with appropriate physiotherapeutic treatments.

In the case of advanced cancer, the new treatments can give concrete hopes of recovery but it is necessary to carefully evaluate the onset of any side effects in close collaboration with the doctor, to minimize their consequences and lead a normal life.

In-depth link

Italian Association of Cancer Patients, Relatives and Friends (AIMaC). Melanoma

NHS. Skin cancer (melanoma) (English)

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