Skin Cancers. Malignant Melanoma.

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  меlanoма “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 dermatologist-oncologist
(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
6 mm;
Evolving (surface
changes [raised,
bleeding, crusting] or
symptomatic [itchiness
or tenderness]).
Melanoma can vary in appearance
Dermatoscopy:
Dermatoscopy: ABCD

ЕЛМ
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
(Breslow’s thickness,
Clark’ levels)
 Thickness of melanoma

TNM:

T1 < 1 mm Radial growth phase

T2 1-2 mm
T3 2-4 mm
T4 > 4 mm

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 Т3bN1аМ0:
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 Hutchinson’s freckle)

1 year after Radiation Therapy

Melanoma: scars, recurrence, in transit Mts

1 2

3 4
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 ≤1 mm: 91%–95% at 5 years; 83%–88% at
10 years
Lesions 1.01–2 mm: 77%–89% at 5 years; 64%–79% at
10 years
Lesions 2.01–4 mm: 63%–79% at 5 years; 51%–64% at
10 years
Lesions >4 mm: 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 non–sun-exposed 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
(Breslow’s 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 non–hair-
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 fair-skinned 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-to-treat
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:

Тis – carcinoma in situ

Т1 –  2 cm
Т2 – 2 - 5 cm
Т3 – > 5 см
Т4 – 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
gamma-
therapy, 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:

Postoperative wound is temporary

T4NxM0 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
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