Oncological Dermatology and Melanoma
The oncological dermatology clinic aims to prevent, diagnose and treat dermatological neoplasms of a melanocytic (melanoma) and non-melanocytic nature (actinic keratosis, squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma, etc.).
In the context of the oncology clinic, thanks to the most modern technologies (digital epiluminescence and advanced analysis software), the control of nevi is carried out for the early diagnosis of melanoma, as well as of other skin neoplasms.
Thanks to the experience gained over the years in Italy and abroad in 1st and 2nd level non-invasive diagnostics (epiluminescence and confocal laser microscopy), in the management of immuno and target therapy and in the management of therapies with anti-SMO drugs. Patients who have undergone removal of a dermatological tumor, from the initial stages to the advanced and / or metastatic forms, can be followed up at our facility.
Melanoma, what is it?
Melanoma is a malignant tumor that originates from melanocytes. Melanoma is more frequent in young people, respectively second and third incidence cancers in males and females, under the age of 50. It can appear on any skin surface and develops through two evolutionary phases:
horizontal growth phase, in which the aggressiveness of the disease is more theoretical than practical;
vertical growth phase, in which it acquires the characteristics of aggression and the ability to generate metastasis.
Risk factors that predispose to the development of the disease have been identified:
have a light skin type (light complexion with freckles, which burns easily, which tans little or not at all; blue or green or otherwise light eyes; red or blond hair);
have more than 100 nevi;
have reported severe sunburn, especially before the age of 15;
intense and intermittent sun exposure (for short periods of time), in the first 20 years of life;
frequent exposure to tanning lamps before the age of 30;
have already had melanoma;
have one or more first degree relatives affected by this disease (about 10% of patients with melanoma have at least one first degree family member affected by this disease; of these family cases, 15-30% are carriers of mutations in genes susceptibility to melanoma).
Surgery is the first choice treatment for localized melanoma. After the removal of the melanoma, the histological examination is performed, the only investigation that allows the definitive diagnosis. After the first surgery, a second skin enlargement operation is performed around the scar of the first removal and, when indicated, the simultaneous search for the sentinel lymph node.
In cases with melanoma of greater local-regional extension and high risk of recurrence, adjuvant therapy may be proposed in order to reduce this risk and improve prognosis.
Medical treatment, such as molecularly targeted therapies and immunotherapy, represent a revolution in improving the overall survival of patients with advanced melanoma; in case of failure of all the possibilities offered by these new therapeutic approaches, chemotherapy can be used, with very limited results in terms of clinical efficacy.
We speak of integrated therapy when other treatments for the control of localized disease are associated with systemic medical therapies. In case of disease progression with few secondary lesions (oligo-metastatic disease), surgical excision, if technically feasible, is the treatment of choice. In inoperable lesions, other locoregional therapies are indicated (radiotherapy, possibly stereotaxic; electro-chemotherapy).
Treatment planning must be addressed by a team composed of various specialists, multidisciplinary team, who take care of developing the treatment plan, taking into account various factors such as the type and stage of the tumor, age and general conditions of the sick person. Information on the different options must be shared with the patient, involving the family doctor.
Prevention, when?
Thanks to awareness and education campaigns, melanoma is increasingly recognized by the person who is affected by it or by a family member in the initial stages of its development. You notice a skin spot different from the others that you are used to seeing on your skin, first of all for the color, much darker. However, this may not be the only feature. Skin melanoma is like the “ugly duckling”: a different lesion, not always clearly definable in its diversity, but certainly evident when compared with all the other spots on the skin.
There are five characteristics that help to recognize melanoma from the early stages of its development and which can be easily remembered because their names begin with the first five letters of the alphabet:
A for Asymmetry: the shape of one half does not match the shape of the other half.
B for Edge: the outline is irregular, jagged or blurred (so-called geographic map).
C for Color: the color is not uniform. There may be black, brown and dark shades; white, gray, red or blue areas can also be distinguished.
D for Diameter: the dimensions change.
And for Evolution: shape and color change in a short time (days, weeks or a few months).
So, beware of ABCDE!
Melanoma appears much more frequently on healthy skin and is associated with a mole only in a minority of cases. It is not known whether the association between mole and melanoma is the result of a malignant transformation of the benign lesion or if the simultaneous presence is only coincidental. This does not mean that if you have moles you are bound to develop melanoma, although it has been shown that those with many moles are also more likely to develop melanoma over their lifetime. Melanoma has no symptoms: it just writes its message on the skin and must be recognized. The only symptoms that may be associated with the advanced stage of the disease are itching, serum secretion or bleeding, but they are not present in all cases.
The chances of early detection of melanoma are increased if you periodically perform skin self-exams, because you are able to recognize what is normal from what is not. If your dermatologist has taken pictures, you can use them as a reference to highlight the differences.
Skin self-examination
Skin self-examination is a very simple procedure. The best time to do this is after a bath or shower. Choose a well-lit room where a full-length mirror is available and keep a hand mirror handy.
Learn where only localized "birthmarks", moles and congenital spots, what they expect and what their consistency is.
Check carefully if a mole is different in size, shape, texture or color compared to the previous time or if there is an ulcer that does not want to heal.
Carefully scrutinize yourself from head to toe, without neglecting even a square centimeter of skin, also examining the back, skull, groove between the buttocks and genitals.
Look in the mirror front and back and raise your arms to examine your armpits as well.
Bend the elbow and carefully observe the nails, palm of the hand, forearm (also the back) and upper arm. Repeat on the other arm.
Examine the legs in front, back and sideways. Also look between the buttocks and around the genitals.
Sit down and carefully examine your feet, including nails, soles, and spaces between the toes.
Carefully examine the face, neck, ears and scalp. Part the hair with a comb or a hairdryer, or even better ask for the help of a family member or friend as it is not easy to examine the scalp alone.
It may be a good idea to note the date on which the self-examination is performed and note the observations. If you find anything unusual, see your doctor immediately.
Diagnosis and strategies to be adopted
Dermatological diagnosis
It should be done by dermatoscopy of suspicious lesions. To consider a lesion worthy of excision the ABCDE system is adopted (A, asymmetry: the shape of one half does not correspond to the shape of the other half. B, edge: the outline is irregular, jagged or blurred. C, color: color is not uniform; shades of various colors may be present; white, gray, red or blue areas can also be distinguished. D, diameter: as the size increases, attention must increase. E, evolution: shape, color and size that change in a short time). Another clinical indicator used for the recognition of melanomas is the sign of the "ugly duckling", ie the search for a nevus with different characteristics compared to the other nevi of the same individual (higher possibility that it is a potential melanoma). In the case of suspected lesions (papular or nodular), the evaluation parameters are: recent onset, rapid growth, hard consistency / elevation of the lesion (English acronym EGF: elevated, growth, firm).
Pathological diagnosis
Based on the histopathological characteristics of surgically excised melanoma and its clinical presentation, melanoma is classified into different disease stages:
- Stage 0 (melanoma in situ, non-invasive) and Stage IA (invasive melanoma with thickness <0.8 mm, without ulceration; absence of lymph node and distant metastases): there is no indication to perform instrumental tests to search for any occult injuries;
- Stage IB-IIA (IB: invasive melanoma with thickness <0.8 mm / with ulceration, 0.8-1.0 mm / with or without ulceration,> 1.0-2.0 mm / without ulceration; no lymph node and distant metastases - IIA: invasive melanoma with thickness> 1.0-2.0 mm / with ulceration,> 2.0-4.0 mm / without ulceration; absence of lymph node and distant metastases): ultrasound of abdomen and of the lymph node basin;
- Stage IIB (invasive melanoma with thickness> 2.0-4.0 mm / with ulceration,> 4.0 mm / without ulceration; absence of lymph node and distant metastases): chest CT (without contrast medium), ultrasound should be performed abdomen and lymph node pelvis;
- Stage IIC-III (IIC: invasive melanoma with thickness> 4.0 mm / with ulceration; absence of lymph node and distant metastases - III: invasive melanoma of any thickness; presence of at least one metastatic lymph node or "in transit" metastasis [ multifocal metastases that are localized between the site of the primary lesion and the regional lymphatic drainage station for that site], in the absence of regional lymph nodes involved; absence of distant metastases): total body CT with contrast medium is performed (alternatively PET with MRI / brain CT);
- Stage IV (presence of distant metastases - regardless of melanoma thickness and presence of lymph nodes, satellites, and / or microsatellitosis;): CT or PET / CT is performed and LDH values are determined to define the patient's prognosis . Brain MRI is used to confirm dubious CT lesions and to define the number and size of lesions per radiotherapy treatment.
Surgical strategy
In patients with early-stage invasive melanoma, after diagnostic excisional biopsy and histopathological confirmation of melanoma, enlargement with an adequate margin for thickness should be performed. The extent of the surgical excision of enlargement is related to the characteristics of the primary melanoma. Excision with less extended margins may be justified in case of severe aesthetic-functional impairment, subjecting the patient to close post-surgical monitoring.
In patients with histologically positive sentinel lymph node, completion lymph node dissection may be considered as an option to be discussed with the patient. Complete lymph node dissection should instead be performed in case of clinically evident metastases to regional lymph nodes (physical examination / ultrasound / CT, confirmed by cytological sampling or biopsy). The extension of the dissection to the various lymph node levels is related to the anatomical region to be subjected to lymphadenectomy; the description of the extent of the dissection and the number of lymph nodes examined define the adequacy of the dissection itself and the consequent pathological evaluation. In case of clinically evident lymph node metastases, the evaluation of the mutational status of BRAF is indicated in preparation for any adjuvant biological therapies.
The time elapsed between diagnosis and definitive surgery does not seem to affect prognosis (at least for stage II and III). Primary melanoma surgery is performed on an outpatient or day surgery basis. Ordinary hospitalization is foreseen for sentinel lymph node surgery and lymph node dissection, as well as for advanced metastasectomy (as part of an integrated multidisciplinary treatment).
Follow up
Once the treatment is completed, the surgeon or dermatologist establish a periodic check-up plan including medical visits and some instrumental tests (CT / MRI / PET). This is what doctors conventionally refer to as follow-up. At the beginning the checks will have a shorter frequency (three to six months), and then thin out over time (once a year).
Follow-up visits are the right time to share your anxieties or fears with the doctor and to ask him any questions. However, if the patient has any problems or new symptoms during the interval between checkups, he should contact the doctor as soon as possible.
Many patients report feeling very agitated, at least initially, in the periods leading up to check-ups.
This is absolutely natural.
In such a situation it may be helpful to have help from family members, friends or one of the organizations that deal with cancer patients.
The source of all information is the AIMa.Me site (Italian association of melanoma and skin cancer patients) which we invite you to visit.