RUSSIAN PEOPLES FRIENDSHIP UNIVERSITY

MEDICAL SCHOOL

Department of Oncology and Radiology

Russian Scientific Center for Radiology and Russian Ministry of Health

VP Kharchenko, TA Lyutfaliev, NV Kharchenko,

MA Kunda, GI Isayev

"Skin cancer. MELANOMA "

IN QUESTIONS AND ANSWERS

(Training manuals)

Moscow

2001

SKIN CANCER

Skin cancer accounts for 90% of all malignant tumors of the skin.

The skin consists of epidermis, dermis and subcutaneous tissue.

The epidermis consists of five layers: basal, spinous, granular, clear/translucent and cornified layers. In the
basal and spinous layers division of cells occur, so these layers are called the germinating layers. Of the
epithelial cells of the germinating layer takes place development of two forms of skin cancer, basal cell and
squamous cell.

In the basal layer of the epidermis are cells which produce the dark coloured pigment called melanin.
Mature cells that produce melanin are called melanocytes. Immature cells - melanoblasts. From
melanoblasts arise pigmented tumors - melanoma.

Skin cancer is one of the most common tumors and occurs in 20-40 patients per 100000 population. The
incidence increases directly proportional to age of the patients. The most frequently skin cancers occur in
people older than 70 years. Women and men are affected equally. Skin cancer is more common among
residents of southern regions, people with fair skin, working outdoors.

Risk factors for skin cancer:

1. Increased insolation ultraviolet spectrum
2. Radioactive radiation
3. Thermal injury.
4. Occupational hazard (textiles, petroleum, chemical industry).
5. Preceding skin changes:

a) obligate (xeroderma pigmentosum, Bowen's disease, erythroplakia Keira)

Xeroderma pigmentosum - thinning, red, warty growths and spots that occur immediately after birth on
the face and exposed parts of the body. Under the influence of ultraviolet irradiation in 100% of young
people squamous cell skin cancer develops.
Bowen's disease - yellowish plaques with eczematous or papillary surface of the trunk or the genitalia at
the age of 45-60 years. Histologically - dyskeratosis with the presence of atypical cells is seen.
Erythroplasia Keira- dark red damp painful knot of small size on the glans penis. Rare in old age.

b) Optional pre-cancerous (chronic dermatitis, wounds and ulcers, cutaneous horn, senile keratosis,
keratoacanthoma)

Keratoacanthoma - benign tumor of epidermal hair follicles. Has the form of spherical knot with crater-like
hollow in the center.

There are two histological forms of skin cancer:

1. Basal cell carcinoma arising from cells of the basal layer of epidermis. Upto 70-75% of all skin cancers.
Localized mainly on the face. Has a slow local growth. Virtually not metastasizing
2. Squamous cell carcinoma - usually occurs against a background of precancerous conditions. Has a
rapid infiltrative growth and has potential for regional metastasis. Distant metastases are rare (lung, bone).

Localization
Skin cancer most often occurs on exposed parts of the body-70%
On body tumor occurs in 5-10% of patients
On the extremities - 5-10%

Classification TNM:

T1 - Tumor upto 2 cm
T2 - 2 to 5 cm with a slight infiltration of the dermis
T3 - more than 5 cm or tumor with deep infiltration of the dermis
T4 - tumor infiltrating other structures (cartilage, muscle, bone).

N1-metastases in regional lymph nodes

M1 - distant hematogenous metastases.

Stages:

Stage I - T1N0M0
Stage II - T2-3N0M0
Stage III-T4N0M0, T1-3N1M0
Stage IV - T1-4N0-1M1

Clinically, there are three forms of skin cancer:

1. Surface form - the most common variant. In the form of a small nodule yellowish or grayish in color.
Often at the center of the plaque retraction and erosion is seen. Most frequently encountered in the basal
cell carcinoma.
2. Infiltrative form - deep ulceration with a bumpy, uneven bottom and edge. Most often, this form
corresponds to squamous cancer.
3. Papillary form rarely seen as a solid nodule on a broad base.Nodular surface often resembles a
cauliflower ,mostly seen with squamous cell carcinoma.

Morphologic Diagnosis:

1. Cytological examination of prints from the eroded surface

or after scarification
3. Histological examination - a biopsy of the tumor.

Treatment for skin cancer:

1. Radiation therapy - radiotherapy SOD - 50-7 - Gr.

2. Surgery - is used mainly for skin cancer of the trunk and extremities.
3. Cryotherapy - treatment with low temperatures.
4. Laser therapy - the use of laser beams
5. Drug therapy in stage I -topical 5-fluorouracil ointment.
6. Combined treatment, with tumors of large size.

Results: The basal cell carcinoma

I, II stage - 100% recovery.
III, IV stage - 65-70%

Squamous cell carcinoma:

I, II stage -85-90% recovery.
III, IV stage -45-50%
 MELANOMA

Melanoma is about 1% of all malignant diseases. Occurs in 2-4 persons per 100000 population.
In women, melanoma occurs most often by 3 times.
Most often arises in the age group 30-39 years.
Most often found in southern countries.

Melanoma usually develops from congenital and acquired nevi.

Pigmented nevi are found in 90% of the people.

Depending on the layer of skin, where the nevus growns ,they are differentiated into:
1. Epidermal-dermal (epidermal nevus, nevus sebaceous)
2.Dermal
3. Mixed nevi
The most frequently malignising is the epidermal-dermal nevi. Mixed and dermal - in isolated cases.

Factors contributing to malignant transformation of nevi and melanoma:

1. Trauma (40%)
2. Ultra violate radiation (UV)
3. Hormonal changes. (Puberty, pregnancy)

Localization of melanoma:

1. Lower limb - 50% (tibia and the plantar part of foot)

2. Trunk 20-30%
3. Upper limbs of 10-15%
4. 10-20% - head and neck

Locally growth of melanoma occurs in three ways: over the skin, on the surface and depth. The deeper the
invasion into the skin worse the prognosis.

5 levels of invasion of melanoma are differentiated in the skin are:

I - lesion without invasion of the epidermis basal layer.
II growth into the basal layer and transition into the squamous layer
III -deep invasion into the dermis without invading the gland and blood vessels of the dermis
IV - invasion of dermis and its blood vessels
V-invasion into the subcutaneous tissue and deeper

Exophytic growth of melanoma is considered as IIIrd degree of invasion.

Metastasis:
1. Lymphogenic metastases in regional lymph nodes is occurs early and vigorously.
2. Metastases in the skin as "satellite" or diffuse infiltration of the skin.
3. Hematogenous most often in the lungs, liver, brain, skeleton.

The clinical picture

Signs of malignant transformation of pigmented nevus:
1. Increase in size
2. Discoloration
3. Shiny smooth surface
4. Disappearance of the skin pattern
5. Loss of hair
6. Tendency to decay
7. Itching or burning
8. Appearance of satellites

Signs of melanoma:
1. Dark color
2. Shiny smooth surface
3. Disappearance of the skin pattern
4. Tendency to ulceration and decay (in the later stages)

Morphological verification:
Because of the risk of dissemination ,biopsy is not done. Sample can be taken for cytological examination
from the eroded surface.

TREATMENT OF MELANOMA

Surgical treatment:
Wide excision with restrain from edge of not less than 5 cm (on the face 3 cm). Flap should be removed
deeply. Skin is removed along with subcutaneous tissue and fascia.

Often, after removal of melanoma, plastic surgery is performed. Usually the plastic is taken from any free
skin graft. If the location of the tumor is in the fingers or toes, disarticulation is done.

Lymphadenectomy is performed only with a confirmed metastasis to regional lymph nodes. (Prophylactic
lymphadenectomy does not improve the results.)

Chemotherapy is used in the presence of regional metastasis or progression of the process.

Most often used drugs are: nitrosourea, vincristine, dactinomycin, imidazolecarboxamide.
It should be noted that the melanoma is insensitive to chemotherapy and gives poor results of
chemotherapy.

Immunotherapy - BCG vaccine - used in treatment of relapse and cutaneous metastases. The vaccine is
injected into the tumor sites.

Results of treatment:
In Ist and IInd degree of invasion 5 year survival rate reaches 50%

In IIIrd degree, and more - 15-20%

The presence of regional lymph nodes worsens the long-term results.