Melanoma

Sinonimi: Maligni melanom, MM, Melanoma malignum, Malignant melanoma, Malignant melanocytic lesion

Melanoma is a kind of skin carcinoma that originates from melanocytic cells which also give our skin color.

Melanoma forms by damage to the melanocytic cells on their DNA level. We don’t yet understand to the fullest extent how this happens, but the closest explanation is that there is a combination of genetical factors on one and UV radiation on the other side. When a melanocytic cell gets damaged, it looses it’s ability to control it’s growth, and melanoma fomation begins. Melanoma can develop both on healthy skin and on an existing mole in this fashion. (Fig. 3 & 4).

Melanoma is one of the most dangerous carcinomas of the human population! It’s danger is obvious in the fact that it has extraordinary large potential in giving metastases and the fact that it’s a carcinoma that has the largest increase in number of affected people over the last 50 years.

A Change of size, color or shape of an existing mole is a first sign of something happening. However, You should always bear in mind that not all skin lesions are accesible by our eyes, so other signs such as: itching, tingling, pain, swelling, bleeding or any other sign of irregularity. Second important event is an occurence of a completely new skin lesion that at first appears as a mole, but changes in size, shape or color.

Melanoma is a carcinoma that is equally frequent in both sexes. Number of young people suffering from melanoma is vastly increasing. In terms of incidence, it’s the second most frequent carcinoma in the 15 to 29 years of age period, and the most frequent in 25 to 29 years of age period. It should be specially accented that melanoma is the first or second most frequent carcinoma in the female reproductive period.Melanoma can develop on any region of the body, it’s more common on the legs in women, and more common on the back in men.

Melanoma is one of the most dangerous carcinomas with great mortality in cases with late diagnosis..

Melanoma is completely curable in case it is diagnosed and treated in time.

Anyone can get melanoma, but light skinned persons, that always burn in the sun, with large number of moles, especially atypical ones, as well as any person who has already had melanoma or other skin cancers i.e. BCC are at a special risk.

More details on all risk factors can be seen in Table 1.

Protection from all sources of increased UV radiation presents primary prevention. The principal source of UV radiation is the Sun, besides that, sun beds and different UV lamps. The elementary threat that UV radiation poses, is damaging the skin, the melanocytic cells included, which can cause melanoma to develop, but other skin lesions as well, whether they are benign or malignant.

For basic protection measures, look at Table 2.

Besides sun protection, of great importance in prevention is education of the population. It should include the following: how to do a skin selfexamination, learning the melanoma risk factors, learning what ABCDE rules of clinical examination are and how to recognize suspicios moles.

Early melanoma detection is considered as secondary prevention. Skin and mole monitoring presents an ideal secondary prevention in all applicable cases.

Melanoma screening would involve a wholesome examination of the skin, from head to toe, for any person with a high melanoma risk factor. Above all, women in their reproductive period and during pregnancy should be examined in this manner.

Digital dermoscopy provides us with very dependable early diagnostics of melanoma. By using it, even the first signs of suspicion can be spotted, signs which cannot otherwise be seen , by eye or other forms of clinical detection. Of key importance for this diagnostic method is the appropriate selection of potentially risky and atypical skin lesions which should be dermoscopically examined. A short overview of this selection is: selfexamination of moles, ABCDE rules of clinical examination i digital dermoscopy. All of these procedures apply to the general population, but even more so to persons who carry some of the high risk melanoma factors.

Early melanoma diagnostics entails making a diagnosis of a „thin“ melanoma, which includes “melanoma in situ” and all other melanomas up to 1.0 mm in thickness.

When we diagnose a melanoma in this stage, by adequately removing it, we provide COMPLETE CURING. Besides being able to diagnose early melanoma by digital dermoscopy, we are even able to diagnose the changes that precede the formation of melanoma.

Surgical removal of melanoma is still the only successful therapy. When a melanoma is detected at an early stage, complete curing is achieved by adequately surgically removing it. For melanomas detected at a later stage, the surgical removal is still the principal treatment, but in cases of a spreading disease, immunotherapy, chemotherapy and vaccine therapy is applied to lymph nodes and internal organs.

Adequate surgical removal of an early stage melanoma means that an excision is required from 5 to 20mm in width around the suspicious lesion with the whole skin and subcutaneous fat removed in depth. After a such removal, the newly made defect can be usually be directly closed. (Figure 8.).

These surgical procedures can be done under local anesthesia in most cases.

When the extensiveness of removal is greater and in all cases of late melanomas, when there is a need for regional metastasis surgery other than just removing the melanoma, the surgery is done under general anesthesia.

Everybody reacts differently to a diagnosis of melanoma. Reactions range from shock, different emotional reactions of fear all the way up to isolation. There are a few mechanisms and strategies that may be of help in the road of increasing the quality of life during and after active melanoma treatment.

Principal signs of stress are:

• Feeling of “emptiness“
• Loss of interest in regular activities
• Disturbance of sleep
• Change in appetite (loss in some, increase in others)
• Change of bodyweight (in both directions)
• Loss of focus
• Recklessness
• Chronic fatigue
• Feeling of anxiety
• Dizzyness
• Nausea
• Increased heart rate
• Chest or stomach pain

Stress managment techniques

Techniques that may help You in managing stress are numerous, but the task at hand is that You alone, or with the help of Your physician find the most appropriate one for You. Here are some usefull ideas that may be of assistance to You:

• Talk to Your doctor
• Seek advice on proper melanoma patient nutrition
• Exercise regularly
• Listen to music
• Find time to enjoy Your favorite literature
• If You can, write letters, diaries or such
• Watch comedies
• Play with Your pets
• Walk in parks and by water
• Look for pleasurable scents and aromas
• “Refresh“ family activities and friendships
• Spend time with easy going people
• Join some of the cancer patient support groups (unfortunately, there aro no such groups for melanoma patient support, but maybe You will be the one to form one)

After receiving a histopathological diagnosis of melanoma, regular follow ups for the next 5 to 10 years are required. The probability of getting metastases (local, regional or visceral), recurring melanoma (another occurence of melanoma on the same place) and developing another melanoma (new melanoma on some other place) exists, but if You regularly do follow ups and apply prevention measures, You are making sure that Your illness will not expand and endanger Your life.

Follow ups are done at 3 month intervals at first, then at 6 months, and eventually at 12 month intervals

Blood tests

There are no characteristic tests that can point to melanoma metastasis development. The only test that shows some relevance is the serum level of LDH (lactate dehydrogenase), but that only applies to advanced melanomas, that get discovered late. For general health monitoring purposes, the following tests should be monitored: LDH, blood panel, urea, creatinin, hepatogram and electrolytes. These tests should be always done, whether the melanoma in question is early or advanced.

Ultrasonic diagnostics

With every diagnosis of melanoma, utrasonic diagnostics of regional lymph nodes is advised. Because of the specificity of melanoma metastasis, US diagnostics of the neck, axillary pits, groin and abdomen are always recommended. With melanomas on the head, salivary gland ultrasonogram is advised. In rare occasions, US diagnostics of elbow and knee regions can be of assistance. Ultrasound should be done no matter if it’s an early or late diagnosis of melanoma.

Bone scan

A bone scan is advised for detection of possible melanoma metastases in the bones. This diagnostic procedure is advised to patients with advanced melanoma.

Computerised tomography (CT )

This diagnostic procedure provides a diagnosis of melanoma metastases in the internal organs: head, neck, lungs, lymph nodes, liver and intestines. This procedure is recommended to patients with advanced melanoma.

Magnetic resonance imaging (MRI)

MRI is used for detecting melanoma metastases in the brain. This procedure is advised to patients with advanced melanoma.

o PET/CT (Positron Emission Tomography)

PET scan detects, based on metabolic activity, the smallest so far detectable metastases in the body. This procedure is advised to advanced melanoma patients.

Skin and mole monitoring entails educating the patient in conducting a skin selfexamination (once a month), making a map of skin lesions on the body and regularly do comparative digital dermoscopy of all skin lesions. Skin and mole monitoring are recommended to all melanoma patients, above all to those with an early diagnosis. Skin and mole monitoring is done by patient and physician together, in such way not even the least suspicious lesion cannot be overlooked.

The aim of a healthy nutrition is to actively participate in preventing further melanoma development and preventing the formation of new skin damage that can influence the development of new melanomas. In case there are some difficulties, such as nausea, or vomiting, the nutrition should be adjusted to them. Of course, it would be best to contact Your physician and he will reffer You to a melanoma nutrition expert.

Regular physical activity, ranging from walks to doing recreational exercise and sports activities is of exteme importance. Welfare that You can expect is great, mostly:

• Improvement of sexual activity
• Better sleep
• Gaining selfesteem
• Reduction of fatigue
• Better tissue oxygenation
• Risk reduction of ostheoporosis
• Risk reduction of a thromboembolism and cardiac diseases

Number of affected melanoma patients in Serbia is constantly increasing. The last official data we have is from 2007., when there were 410 melanoma patients registered in Central Serbia, while the number was 316, 5 years before that. Melanoma patient yearly increase rate in Serbia is about 6%, which means that the number of affected people will double in 10 years. (Table 3) This kind of increase in incidence rate is known only for lung cancer in women, besides melanoma

Mortality from melanoma, by all global data, doesn’t record any significant increase. In Central Serbia, over a short tracking time frame of only 5 years, there is an increase of 5% per year. (Table 4) .

Incidence rate data for EU countries is : average incidence rate is 11.3, maximum is 24 in Switzerland, minimum is 2.9 in Greece. Mortality rate data for EU countries is: average mortality is 2.1, maximum 5.6 in Norway, minimal 1.2 in Greece (Tables 5 and 6).

5-year survivalafter melanoma diagnosis in EU countries is is averagely 79.9%, with the highest in Switzerland with 89%, and the lowest in Greece with 52% (Table 7)

Data on the number of patients with 5-year survival is at this time unavailable for Serbia. This data is important for revealing the effectiveness of the treatment, essentially with the increase in number of early diagnosed melanomas there will be a significant incrase in 5-year survival patient numbers.

Based on this data, we can assume the following characteristics of melanoma morbidity in Serbia:

• Incidence rate is below the European average, but has a tendency of constant growth
• Mortality is above average
• • We don’t have the 5-year survival melanoma patients numbers.

These indicators point to the fact that measures of primary prevention, screening and early diagnostics are of key importance to a successful fight against melanoma.

NO. Hurting a mole is not a reason for developing melanoma. Genetic predisposition and skin damage by UV radiation (Sun and sunbeds) present the principal risk factors for developing melanoma.

Change of size or color of an existing mole or the formation of a completely new mole.

Contact Your physician or the nearest skin tumor specialized facility.

Yes. In all cases of early diagnosis, melanoma is completely curable.

Dermoscopically. Dermoscopy is the most successful diagnostics of melanoma in all stages.

Surgical removal. Radical, or adequate removal of melanoma is the fundamental principle of a successful treatment.

No. All other treatments for curing melanoma are included only after the surgical removal, and only as an adjuvant therapy with metastatic melanoma.

Da. It’s the measures of primary prevention from developing skin damage by UV radiation on persons with melanoma risk factors.

Yes. Yes. All of us learned in medical school that melanoma can be operated on only under general anesthesia, but things have changed. Contemporary findings point to that a primary melanoma should be operated on unde local aneshesia. Following the global standards, we have implemented such practice, local anesthesia as a preferred method of operating all non lymph node positive melanomas.