SUMMARY

Anatomy of the Skin

Largest and heaviest organ.
3 layers
- Epidermis (Stratified Squamous Epithelium)
- Dermis (Connective Tissue Layer)
- Hypodermis (Subcutaneous Tissue)

Thickness of skin
varies from 0.5mm to 6mm. Difference due mainly to variation in the thickness of the dermis.
- Thick skin covers palms, soles and surfaces of fingers/toes. has sweat glands but no hair follicles or sebaceous glands.
- Thin skin covers the rest of the body. Has hair follicles, sebaceous glands and sweat glands

Epidermis
Keratinized stratified squamous epithelium.

Layers of epidermis from the top
-stratum corneum
-stratum lucidum
-stratum granulosum-keratohyalin granules
-stratum spinosum-desmosomes attaches keratinocyte
-stratum basale

Cells of epidermis
-Stem cells
-Keratinocytes
-Melanocytes
-Tactile Cells
-Dendritic Cells/Langerhans cells

Dermis
-2 zones of dermis
- Papillary Layer
- Reticular layer

Hypodermis
-binds skin to underlying tissue

Subcutaneous fat
-energy reservoir and thermal insulation

Benign and Malignant Tumour

Benign tumours are not cancer:
• rarely life-threatening, can be removed, usually do not grow back.
• do not invade the tissues around them.
• do not spread to other parts of the body.

Malignant tumours are cancer:
• more serious. May be life-threatening, often can be removed, but sometimes they grow back.
• Cells can invade and damage nearby tissues and organs and metastasize to other parts of the body.

The two important differences between benign and malignant tumours are invasion and spread.

Confirmatory test
• By examining a small sample of cells under a microscope. This is called a biopsy.
• First, Imaging
• Then, Biopsy (removal of a small piece of tissue for lab exmination) / Tissue sampling

How to know whether the tumour is malignant or benign

• size and shape of the nucleus of a cancer cell is often abnormal and the nucleus appears darker
  
• overall size and shape of cancer cells are often abnormal
  
• 
  Cancer cells do not relate to each other normally
  

Incidence and prevalence

• Highest incidence in Australia and New Zealand.
  
• 2002, prevalence of 37.7 cases per 100,000 men and 29.4 cases per 100,000 women in Australia and New Zealand.
  
• America, Prevalence of 6.4 cases per 100,000 men and 11.7 cases per 100,000 women in North America.
  
• European countries, highest incidence rates in northern and western countries and the lowest in southern countries, with rates from three to eight times lower for men and women, respectively.
  

Aetiology and Pathophysiology.

Aetiology

• Can be acquired:
  
  • Through (sporadic) somatic mutations of certain genes
    
  • DNA can be damaged caused by chemicals or carcinogens (In melanoma is associated with DNA damage by UV radiation)
    
• Can be hereditary: Caused by mutated genes passed down from the parents. In this case, it requires a germ line mutation that occurs in either one of the parents.
  

Pathophysiology

• Mutation in certain genes: Tumor suppressor genes, oncogenes (proto-oncogenes), apoptosis-regulating genes and mismatch repair genes.
  
• Mutation in these genes causes loss of function or gain in function that will predispose to cancer.
  

Spreading of cancer cells locally or distant (Metastasis)

Differential Diagnosis for Melanoma

Seborrheic keratosis

Diagnosis is based primarily on the appearance of the growths. A skin lesion biopsy may be used to confirm the diagnosis.

Traumatized or irritated nevus

The history of trauma or biopsy along with review of the original biopsy helps exclude a diagnosis of melanoma.

Basal cell carcinoma

grows by direct extension and appears to rely on the surrounding supportive tissue to grow – thus does not metastasize through blood vessels or lymphatics.

Lentigo

Lentigines profusa (ie, generalized lentigines) is characterized by numerous lentigines without signs of associated abnormalities or triggering factors.

Angiokeratoma

A harmless, discolored, raised skin lesion involving damaged blood capillaries.

Venous lake

Vascular thrombosis play a role in development

Hemangioma

Hemangiomas are diagnosed by a physical examination. In the case of deep or mixed lesions, a CT or MRI scan may be performed.

Dermatofibromas

Diagnosis is clinical; lesions typically dimple when grasped between the fingers

Pigmented actinic keratosis

The health care provider makes the diagnosis based on the appearance of the skin growth. A skin biopsy may reveal any cancerous changes, if they occur.

Signs and Symptoms of Melanoma

Usually detected using the ABCDE method or Glasgow 7-point checklist.

ABCDE'S of Melanoma (Asymmetry, Border, Colour, Diameter,
Elevation or Evolving)

Glasgow 7-point checklist (1985), (Change in size, Irregular shape, Irregular colour, Diameter greater than 7mm, Inflammation, Oozing, Change in sensation)

Diagnosis

Biopsy

• Types of biopsy:
  
  • excisional biopsy
    
  • incisional biopsy, or core biopsy
    
  • punch biopsy
    
  • saucerization biopsy
    
  • fine-needle aspiration
    

Staging

• Staging of primary melanoma is based on the histological features of the lesion.
  

• The current staging is based on measurement of the invasive component of the tumour and the presence or absence of microscopic ulceration.
  

Life expectancy

• 1A: 95% > 5yrs, 88%>10yrs
  
• 1B: 89-91% >5yrs, 79-83%>10yrs
  
• 2A: 77-79% >5yrs, 64%>10yrs
  
• 2B: 63-67%>5yrs, 51-54%>10yrs
  
• 2C: 45%>5yrs, 32%>10yrs
  
• 3A: 63-69%>5yrs, 57-63%>10yrs
  
• 3B: 46-53%>5yrs, 39-48%>10yrs
  
• 3C: 24-29%>5yrs, 15-24%>10yrs
  
• 4: 7-19%>5yrs
  

Treatment & management

Stage 1 (Wide Local Excision)
Stage II and III (Lymph Node Dissection, Adjuvant treatment, Drug – Interferon)
Stage IV (Surgery, Biological therapy, Chemotherapy, Radiotherapy)

complementary treatment :
-Nutrition therapy
-Naturopathic Medicine
-Mind-body medicine
-Oncology Rehabilitation
-Spiritual Support
-Image enhancement

Palliative care:
-improves the quality of life of patients
-can improve symptom control
-dependent on the need for intervention for physical or psychological symptoms, not the stage of the illness
-Can be given in the form of complementary medicine.

Prevention

1. Primary prevention
   
   1. Limiting sun exposure
      
   2. Using sunscreens
      

• Seeking medical attention for a suspicious and changing nevus
  

1. Secondary prevention
   
   1. Routinely performing a total skin examination
      

Psychosocial issues on melanoma

Impact of melanoma on lifestyle of patient

• practical, emotional, psychological and physical effects of the disease & treatment
  
• subjected to different degrees of psychosocial distress
  
• depression, anxiety and deterioration in quality of life
  
• women have greater distress than man
  

Denial Patient

• The main step to cope with the emotional impact of melanoma is to:
  
  • Talk openly about their feelings and concerns
    
  • Ask questions they have about melanoma
    
  • Ask about their own particular condition
    
  • Gather as much information as possible
    

    
    

• Patient can promote recovery by:
  
• Maintaining a positive outlook
  
• Identifying beneficial activities
  
• Making changes in diet and exercise
  
• Reducing stress in daily life
  

What Physician Should Do?

• Physician should adopt a stance that neither minimizes nor exaggerates the threat of a patient's diagnosis