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Signs/Symptoms:
According to the American Cancer Society, ABCDE rule is a guide that warrants you to
notify your doctor for check up.
o Self-examination for ABCDE rule for mole.
A Difference in matching of some of the moles (Asymmetry).
B The border edges are irregular, notched, or blurred.
C Non uniform color which may include shades of brown or black, patches of pink.
D The spot is larger than 6 millimeters diameter across or smaller.
E Evolving mole size, shape, or color.
o Unusual sores that does not heal
o
lumps,
Clinical Presentation:
Most malignant melanoma grow slowly at first and it is confined to the epidermis (radial
growth phase) with good prognostics if treated. Left untreated, it proceeds to the vertical growth
phase which invades the dermis, subcutaneous layer and other tissues. The prognostic at this
level is poor with distant metastases on the skin, gastrointestinal tract, lungs, liver, and other soft
tissues. Malignant melanoma spreads to the brain more often than any other form of cancer
(ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
Diagnosis, staging and Work-up.
Diagnosis is based on physical examination following the sign and symptoms brought to the
doctors attention couple with medical history. Biopsies are done within suspected areas as
demanded by the doctor. If there is a possible spread, sentinel lymph node biopsy is done or
imaging modalities such as CT, MRI and PET may also be used. The National Comprehensive
Cancer Network, pathology report considers factors such as breslow thickness, ulceration status,
mitotic rate, Clark level, microsatellite status and histologic subtype during diagnosis, staging
and diagnostic work-up. Breslow thickness (expressed in mm) is determined by the extend of the
tumor penetration beneath the skin. American Joint Commission on Cancer (AJCC) uses the
TNM system to stage melanoma.
American Cancer society estimate the 5 year survival rate based on the stage of the disease,
age of the person, genetic changes in the cancer cells and the response to treatment. The 5year
survival rate is listed below as follows: Stage IA: 5-year survival rate = 97%, and 10 year = 95%.
Stage IB: 5-year survival rate = 92%, and 10-year survival = 86%.
Stage IIA: 5-year survival rate = 81%, and 10-year survival = 67%.
Stage IIB: 5-year survival rate = 70%, and 10-year survival = 57%.
Stage IIC: 5-year survival rate = 53%, and 10-year survival = 40%.
Stage IIIA: 5-year survival rate = 78%, and 10-year survival = 68%.*
Stage IIIB: 5-year survival rate = 59%, and 10-year survival = 43%.
Stage IIIC: 5-year survival rate = 40%, and 10-year survival = 24%.
Stage IV: 5-year survival rate = 15% - 20%, and 10-year survival = 10% - 15%
The Principle and Practice of Radiation Therapy, 3rd ed. described the TNM system as
follows: TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor
Tis Melanoma in-situ
T1 (a & b) Tumor is 1 mm thick, without or with ulceration.
i. Radiation:
Radiation is recommended when lymph nodes are involved and it has been surgically removed,
or when the surgical margins test positive. Also use to relieve symptoms caused by the spread of
melanoma. Mixed beam technique is usually used following the involvement of lymph nodes and
the energies ranges from 6-22MeV and 18MV. Lower energy electrons fields are used to treat
superficial nodes and the entire extend of the scar, while high energy photons use for deep nodes
such as the iliac nodes (ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
The Dose to melanoma depends on the area being treated. For example skin and mucosal
melanoma in the oral cavity, vagina and the anus can be treated with doses of 60 70cGy with
200-300cGy per fraction. Also, lentigo maligna can be treated with 45cGy with 300cGy per
fraction or 5000-6000cGy in 200cGy per fraction (Radiation Oncology-Management Decisions).
Treatment Borders:
The target volume for adjuvant radiation following lymph node dissection typically includes
the primary site scar with a 3- to 4-cm margin. In an event of surgery in the axillary region,
radiation fields will include the axillary lymph nodes, the supraclavicular fossa, and the low
cervical nodes.
Radiation Side Effects:
According to ASRT-Radiation Therapist, 2014 Vol. 23 No.1, radiation side effects depends
on the area being treated and some effects includes:
Fatigue
Nausea
Late adverse effects include hyper and hypo pigmentation, not leaving out lymph-edema.
ii. Surgery:
a. Small low risk tumors are removed using cryosurgery with the use of liquid nitrogen or
carbon dioxide. Within weeks the form scab falls off.
b. Mohs micrographic surgery is the surgical method with the highest cure rate and best
cosmetic effects. It is performed with the use of anesthesia around critical structures such
as the eye, nose, lips, and ears. It is the surgical removal of very thin layer of tissue and it
is immediately examined under the microscope to determine whether cancerous cells are
present; and if present, another thin layer is removed and examined until no malignant
cells found (ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
iii. Immunotherapy/chemotherapy
The US Food and Drug Administration (FDA) has approved an immunotherapy drug
(pembrolizumab) to treat advance cases of melanoma which cannot be treated using surgery or
other drugs. This drug is a type of anti PD-1 drug. Melanoma cells often have a protein called
PD-L1 on their surface that helps them avoid being found and destroyed by the bodys immune
system. Drugs that block the PD-L1 protein, or the corresponding PD-1 protein on immune cells,
can help the immune system recognize the melanoma cells and attack them. Surgery still remains
the treatment of choice for melanomas (American Cancer Society, 2014).
Chemotherapy is usually not as effective in melanoma as it is in some other types of cancer, but
it may relieve symptoms or extend survival for some patients. If use, Temozolomide, paclitaxel.
Carmustine, Cisplatin to name a few.
Work Cited
Punch biopsy. During a punch biopsy, your doctor uses a tool with a circular blade. The
blade is pressed into the skin around a suspicious mole, and a round piece of skin is removed.
Excisional biopsy. In this procedure, the entire mole or growth is removed along with a
small border of normal-appearing skin.
Incisional biopsy. With an incisional biopsy, only the most irregular part of a mole or
growth is taken for laboratory analysis.
The type of skin biopsy procedure you undergo will depend on your situation. Doctors prefer to
use punch biopsy or excisional biopsy to remove the entire growth whenever possible. Incisional
biopsy may be used when other techniques can't easily be completed.
Sentinel Node Biopsy: This procedure involves
intradermal injection of a radiopharmaceutical such as technetium Tc 99m sulfur colloid at
multiple sites around the primary lesion to help visualize lymphatic drainage patterns.
The status of the sentinel lymph node is crucial, as it
provides important prognostic information, helps physicians
make subsequent treatment decisions, and can help
identify patients who are candidates for clinical trials.
Keratoses
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