HUIDTUMOREN Huidcarcinoom in beeld

1
HUIDTUMOREN Huidcarcinoom
in beeld

• Nascholing oncologische neurologie,
  endocrinologie, dermatologie en sarcomen

Leslie Sabajo, dermatoloog Thorarica, zaterdag
17 maart 2007
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De huid
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Ze bestaat uit drie delen.

• Het bovenste (buitenste) gedeelte wordt gevormd
  door de opperhuid de epidermis
• Daaronder ligt de lederhuid het corium of de
  dermis. Deze lagen vormen de huid in engere zin
• Het onderste gedeelte is het onderhuidse
  bindweefsel de zogenaamde subcutis (bindweefsel
  is weefsel dat dient tot verbinding en steun van
  andere weefsels en organen).

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Epidermis
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Functies

• Scheidt (omhulsel)
• Beschermt (verdedigingslinie)
• Reguleert (oververhitting, onderkoeling of
  uitdroging)
• Verbindt (gevoel-tast)
• Identificeert (herkenbaar)
• Steunt (structuren)
• Produceert (vitamine D3 uit previtamine D3 ofwel
  precholecalciferol )
• Zonder huid is leven en bestaan niet mogelijk

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Opmerkingen

• De huid is het grootste orgaan van het menselijk
  lichaam
• Bij de volwassene is het oppervlak 1.5 - 2.0 m2
• Het gewicht van de huid, inclusief het onderhuids
  bindweefsel is 15-20 kg
• In de huid bevinden zich ook huidaanhangsels
  talgklieren, zweetklieren, haarwortels en het
  nagelbed plaatsen waar nagels worden aangemaakt
  worden.

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een gezwel of tumor of neoplasma

• is een min of meer omschreven, abnormale
  weefselmassa die in vergelijking met normaal
  weefsel een overmatige, zelfstandige en
  ongecoördineerde groeiwijze toont , die blijft
  voortduren ook wanneer de prikkel die aanleiding
  gaf tot die versterkte groei is verdwenen.
• onderscheid wordt gemaakt in
• Goedaardige niet infiltrerend en geen
  metastasen
• en
• Kwaadaardige infiltrerend en wel metastasen

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indeling van huidtumoren

• Huidtumoren kunnen op verschillende manieren
  ingedeeld worden.
• Histologisch
• Leeftijdscategorie
• Klinisch beeld
• De meest gangbare indeling gaat uit van de
  histologische (weefsels) waaruit de tumor
  ontstaat.Terwille van de eenvoud kan men een
  aantal groepen huidtumoren onderscheiden-
  epitheliale tumoren- melanocytentumoren-
  mesenchymale tumoren- neurogene
  tumoren.Epitheliale tumorenDe epitheliale
  tumoren kunnen nog worden onderverdeeld in-
  gezwellen van de oppervlakkige opperhuid waarbij
  vaak verhoorning optreedt- gezwellen van de
  diepere gedeelten van de opperhuid, van de
  kiemlaag en van de cellen die klierstructuren
  vormen.MelanocytentumorenSamenhangend met de
  melanocyten kunnen zich afwijkingen voordoen
  als- sproeten- lentigo senilis toename van
  melanocyten bij oudere mensen- premaligne
  dermatosen- maligne melanomen.Mesenchymale en
  neurogene huidtumorenMesenchymale en neurogene
  huidtumoren kunnen in principe ontstaan uit alle
  weefselcomponenten van de huid- bindweefsel-
  glad spierweefsel- bloedvaten- zenuwcellen.

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Precancers
A number of abnormal but relatively harmless skin
growths constitute the early warning signs of
skin cancer.  These may be precancerous lesions,
benign tumors that mask or mimic more serious
ones, or malignant tumors that are at the moment
just on the topmost layer of the skin.  They are
important to recognize, because they are a
warning sign of potential skin cancer.
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Actinic keratosis of keratosis solaris

• the result of prolonged exposure to sunlight. 
• It is a small crusty, scaly or crumbly bump or
  horn that arises on the skin surface. 
• The base may be light or dark, tan, pink, red, or
  a combination of these... or the same color as
  your skin.
• The scale or crust is horny, dry, and rough, and
  is often recognized by touch rather than sight.
• Occasionally it itches or produces a pricking or
  tender sensation.
• It can also become inflamed and surrounded by
  redness.
• In rare instances, actinic keratoses can bleed.
• lesion develops slowly
• usually reaches a size from 2mm to 4mm but can
  sometimes be as large as one inch.
• most likely  appear on the face, lips, ears,
  scalp, neck, backs of the hands and forearms,
  shoulders and back the parts of the body most
  often exposed to sunshine.
• The growths may be flat and pink or raised and
  rough.

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Actinic cheilitis

• Actinic cheilitis is a type of actinic keratosis
  occurring on the lips. 
• It  causes them to become dry, cracked, scaly and
  pale or white. 
• It mainly affects the lower lip, which typically
  receives more sun exposure than the upper lip. 

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Leukoplakia

• Leukoplakia is a disease of the mucous membrane. 
  
• White patches or plaques develop on the tongue or
  inside of the mouth, and have the ability to
  develop into SCC. 
• It is caused by sources of continuous irritation,
  including smoking or other tobacco use, rough
  teeth or rough edges on dentures and fillings. 
• Leukoplakia on the lips are mainly caused by sun
  damage.

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Bowen's Disease

• This is generally considered to be a superficial
  SCC that has not yet spread.
• It appears as a persistent redbrown, scaly patch
  which may resemble psoriasis or eczema.
• If untreated, it may invade deeper structures.

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Actinic Keratosis
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Tip

• Regardless of appearance, any change in a
  preexisting skin growth, or the development of a
  new growth or open sore that fails to heal,
  should prompt an immediate visit to a physician.
• If it is a precursor condition, early treatment
  will prevent it from developing into SCC.
• Often, all that is needed is a simple surgical
  procedure or application of a topical
  chemotherapeutic agent.

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Treatment

• There is no one best method to treat all skin
  cancers and precancers. 
• The choice is determined by many factors,
  including the location, type, size, whether it is
  a primary tumor or a recurrent one, and also
  health and preference of the patient. 
• Almost all treatments can be performed in the
  physicians office or in a special surgical
  facilities. 
• Most skin cancer removal can be done using a
  local anesthetic. 
• Rarely, extensive tumors may require general
  anesthesia and hospital admission.
• There are many effective methods

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Treatment

• Cryosurgery
• (Liquid nitrogen Critical Temperature -232.5F
  (-146.9C) ) condenses (liquifies) at 77 K
  (-195.8C) and freezes at 63 K (-210.0C) cooled
  down to minus 196 degrees Celsius
• Curettage and Desiccation
• Bleeding is stopped with an electrocautery
  needle, and local anesthesia is required.
• Topical Medications
• 5-fluorouracil (5-FU) cream or solution, in
  concentrations from 0.5 to 5 percent(cytostaticum-
  Efudix)
• Kan met tretinoine worden gecombineerd
• Another preparation, imiquimod cream, is used for
  multiple keratoses. It causes cells to produce
  interferon, a chemical that destroys cancerous
  and precancerous cells.
• An alternative treatment, a gel combining,
  hyaluronic acid and the anti-inflammatory drug
  diclofenac, also may prove effective.
• Chemical Peeling
• This method makes use of trichloroacetic acid
  (TCA) or a similar agent applied directly to the
  skin.
• Laser Surgery
• A carbon dioxide or erbium YAG laser is focused
  onto the lesion, removing epidermis and different
  amounts of deeper skin

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Behandeling na Tri Chloorazijn Zuur
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Basal Cell Carcinoma/Basal Cell
Epithelioma/Basalioma

• Basal cell carcinoma (BCC) is the most common
  form of cancer,
• With more than 800,000 new cases estimated in the
  US each year.
• Basal cells are cells that line the deepest layer
  of the epidermis.
• An abnormal growth a tumor of this layer is
  known as basal cell carcinoma.
• Basal cell carcinoma can usually be diagnosed
  with a simple biopsy
• is fairly easy to treat when detected early. 
• However, 5 to 10 percent of BCCs can be resistant
  to treatment or locally aggressive, eating away
  at the skin around then, sometimes even into bone
  and cartilage.
• When not treated quickly, they can be difficult
  to eliminate.
• Fortunately, however, this is a cancer that has
  an extremely low rate of metastasis,
• Although it can result in scars and
  disfigurement, it is not usually
  life-threatening.
• Cause
• The sun is responsible for over 90 percent of all
  skin cancers, including BCC, and chronic
  overexposure to the sun is the cause for most
  cases of basal cell carcinoma.  
• BCCs the tumors themselves occur most
  frequently on the face, ears, neck, scalp,
  shoulders, and back. 

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Types of Basal Cell Carcinomas

• Nodular basal cell carcinoma is the most common
  type. These tumors are often depressed in the
  middle and show ulceration.  
• Superficial.  This is a less common type of BCC. 
  
• Sclerosing or Fibrosing.  Fibrosing basal cell
  carcinoma is also called morphea-like carcinoma. 
  
• Pigmented.  Pigmented basal cell carcinoma is
  similar to nodular basal cell carcinoma, but is
  more likely to appear in people with dark hair or
  dark eyes.  As its name implies, this growth is
  almost black and can easily be mistaken for the
  more aggressive malignant melanoma.
• Fibroepithelioma.  This is a rare type of basal
  cell carcinoma
• Basosquamous carcinoma.  Squamous and basal cell
  carcinoma can coexist as one tumor growth at the
  same time.  Clinically, it can appear as a basal
  cell or a squamous cell carcinoma.  Basosquamous
  cell carcinomas are believed by some researchers
  to have a greater tendency to metastasize.  These
  tumors have to be treated immediately and
  aggressively.
• Basal cell nevus syndrome.  Rarely, basal cell
  carcinoma may develop as part of an inherited
  condition, commonly referred to as nevoid basal
  cell carcinoma syndrome or Gorlin syndrome. 
  Unlike other skin cancer conditions, this
  syndrome may develop during childhood or
  adolescence, and as many as 50-100 cancers may be
  involved.  Sometimes, the skin cancers increase
  in number as the person reaches adulthood. 
  Clinically, they have the same appearance as
  basal cell carcinomas.

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Warning SignsThe typical characteristics of
basal cell carcinoma are shown in the pictures
below. Frequently, two or more features are
present in one tumor. In addition, BCC sometimes
resembles non-cancerous skin conditions such as
psoriasis or eczema.
A Reddish Patch or irritated area, frequently
occurring on the chest, shoulders, arms, or legs.
Sometimes the patch crusts. It may also itch or
hurt. At other times, it persists with no
noticeable discomfort.
An Open Sore that bleeds, oozes, or crusts and
remains open for three or more weeks. A
persistent, non-healing sore is a very common
sign of an early basal cell carcinoma.
A Pink Growth with a slightly elevated rolled
border and a crusted indentation in the center.
As the growth slowly enlarges, tiny blood vessels
may develop on the surface.
A Shiny Bump or nodule that is pearly or
translucent and is often pink, red, or white. The
bump can also be tan, black, or brown, especially
in dark-haired people, and can be confused with a
mole
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Basalioom
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Who is At Risk?

• Anyone with a history of frequent sun exposure
  can develop BCC. 
• But risk can increase with certain genetic or
  environmental factors.
• Time Spent Outdoors
• People who work outdoors construction workers,
  groundskeepers, farmers, lifeguards, etc. are
  at greater risk than people who work indoors.
• Skin Type
• Fair-skinned individuals who sunburn easily have
  a higher incidence of skin cancer than
  dark-skinned individuals.  Check our skin type
  chart to see how at risk you are.
• Hours of sunlight
• The more hours of sunlight in the day, the
  greater the incidence of skin cancer.   

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Skin Types and At-Risk Groups
Type I  Is very fair, burns easily and severely
and does not tan.  Eyes are blue or green and
hair is blond or red.
Type III  Is somewhat darker and sometimes burns
then tans.
Type II  Is also fair and burns easily, but does
get a minimal tan.  Eyes are blue, hazel or
brown, and hair is blond, red or brown.
Type IV  Is darker still, never burns, and
always tans rapidly
Types V  Is brown
Type VI  Is black.
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After Treatment

• Treatment does not end when your skin cancer has
  been removed. 
• Cancerous and precancerous conditions can recur
  even when they appear to have been adequately
  treated.  No fail-safe method of treatment yet
  exists.  A patient should continue to see the
  physician for regular follow-up visits for
  several years to make sure that the growth has
  not recurred, patients who have had one skin
  tumor have a 40 percent greater risk of
  developing new tumors in the next five years.
• The program recommended for most patients is a
  visit to the doctor one month after the treatment
  has been completed, with follow-up visits at
  three-month intervals for one year.  After that,
  if all is well, the patient will be asked to
  visit the doctor on a semiannual and then annual
  basis.  The minimum recommended follow-up period
  is five years.

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Squamous Cell Carcinoma/Carcinoma
Spinocellulare/Plaveiselcelca

• Squamous cell carcinoma (SCC) is the second most
  common form of skin cancer. 
• Squamous cells are cells that compose most of the
  epidermis(keratinocyten). 
• An abnormal growth of these cells is known as a
  squamous cell carcinoma.
• Most SCCs are not serious. 
• When identified early and treated promptly, the
  future is bright. 
• However, if overlooked, they are harder to treat
  and can cause disfigurement. 
• While 96 to 97 percent of SCCs are localized, the
  small percentage of remaining cases can spread to
  other parts of the body, and the results are
  often fatal.

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Who is at Risk?

• Anyone with a substantial history of sun exposure
  can develop squamous cell carcinoma but certain
  environmental and genetic factors can increase
  the potential for this disease.
• Sun Exposure
• Sunlight is responsible for over 90 percent of
  all skin cancers.  Working primarily outdoors,
  living in an area that gets a lot of high
  intensity sunlight (like Australia), spending
  time in tanning booths all increase your exposure
  to UV rays and thus increase your risk for
  developing skin cancer, including squamous cell
  carcinoma.
• Skin Type
• People who have fair skin, light hair, and blue,
  green, or gray eyes are at highest risk.
  Dark-skinned individuals of African descent are
  far less likely than fair-skinned individuals to
  develop skin cancer.  Check out your skin type
  and how it affects your skin cancer risk. More
  than two thirds of the skin cancers that
  individuals of African descent develop are SCCs,
  usually arising on the sites of preexisting
  inflammatory skin conditions or burn injuries.
  Although dark-skinned individuals of any
  background are less likely than fair-skinned
  individuals to develop skin cancer, it is still
  essential for them to practice sun protection.
• Previous Skin Cancer
• If you have had a skin cancer of any type, it
  increases your risk of developing another one.
• Reduced Immunity
• People with weakened immune systems due
  to excessive unprotected sun exposure,
  chemotherapy, or those with certain illnesses
  such as HIV are more likely to develop squamous
  cell carcinoma.
• Precancers and Early Cancers
• There are some precursor conditions,  called preca
  ncers and early cancers (also called cancer in
  situ)  that are sometimes associated with the
  later development of SCC.  They include actinic
  keratosis, actinic chelitis, leukoplakia, and Bowe
  n's disease, although most dermatologists believe
  that Bowen's disease is just another name for a
  type of superficial SCC that hasn't spread yet. 
  It appears as a persistent, scaly red-brown,
  scaly patch.  It may resemble eczema or
  psoriasis. 

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Plaveiselcelca
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Warning Signs
An elevated growth with a central depression that
occasionally bleeds. A growth of this type may
rapidly increase in size.
A wart-like growth that crusts and occasionally
bleeds
A persistent, scaly red patch with irregular
borders that sometimes crusts or bleeds.
An open sore that bleeds and crusts and persists
for weeks.
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Tips

• Seek the shade, especially between 10 A.M. and 4
  P.M.
• Do not burn.
• Avoid tanning and UV tanning booths.
• Use a sunscreen with an SPF of 15 or higher every
  day.
• Apply 1 ounce (2 tablespoons) of sunscreen to
  your entire body 30  minutes before going
  outside. Reapply every two hours.
• Cover up with clothing, including a broad-brimmed
  hat and UV-blocking sunglasses, umbrella
• Keep newborns out of the sun. Sunscreens should
  be used on babies over the age of six months.
• Examine your skin head-to-toe every month.

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What Is SPF?

• Most sunscreens with an SPF of 15 or higher do an
  excellent job of protecting against UVB. SPF or
  Sun Protection Factor is a measure of a
  sunscreen's ability to prevent UVB from damaging
  the skin. Here's how it works  If it takes 20
  minutes for your unprotected skin to start
  turning red, using an SPF 15 sunscreen
  theoretically prevents reddening 15 times longer
  about five hours.
• Another way to look at it is in terms of
  percentages  SPF 15 blocks approximately 93
  percent of all incoming UVB rays.  SPF 30 blocks
  97 percent and SPF 50 blocks 99 percent.  They
  may seem like negligible differences, but if you
  are light-sensitive, or have a history of skin
  cancer, those extra percentages will make a
  difference. And as you can see, no sunscreen can
  block all UV rays.
• But there are problems with the SPF model 
  First, no sunscreen, regardless of strength,
  should be expected to stay effective longer than
  two hours without reapplication.  Second,
  "reddening" of the skin is a reaction to UVB rays
  alone and tells you little about what UVA damage
  you may be getting.  Plenty of damage can be done
  without the red flag of sunburn being raised.
• Many of the sunscreens available in the US today
  combine several different active chemical
  sunscreen ingredients in order to provide
  broad-spectrum protection.   Usually, at least
  three active ingredients are called for. These
  generally include PABA derivatives, salicylates,
  and/or cinnamates (octylmethoxycinnamate and
  cinoxate) for UVB absorption(kortgolvig
  290-315nm) benzophenones (such as oxybenzone and
  sulisobenzone) for shorter-wavelength
  UVA(langgolvig 315-400nm) protection and
  avobenzone (Parsol 1789), ecamsule (Mexoryl),
  titanium dioxide, or zinc oxide for the remaining
  UVA spectrum.

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Melanoma

• Melanoma is the most serious form of skin
  cancer.  
• However, if it is recognized and treated early,
  it is nearly 100 percent curable. 
• But if it is not, the cancer can advance and
  spread to other parts of the body, where it
  becomes hard to treat and can be fatal.  
• While it is not the most common of the skin
  cancers, it causes the most deaths. 
• Melanoma is a malignant tumor that originates in
  melanocytes, the cells which produce the pigment
  melanin that colors our skin, hair, and eyes and
  is heavily concentrated in most
  moles(naevusbeauty spot).
• The majority of melanomas, therefore, are black
  or brown.
• However, melanomas occasionally stop producing
  pigment. When that happens, the melanomas may no
  longer be dark, but are skin-colored, pink, red
  or purple.

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Who is at Risk?

• Everyone is at some risk for melanoma, but
  increased risk depends on several factors sun
  exposure, number of moles on the skin, skin type
  and family history (genetics). 
• Sun exposure
• Both UVA and UVB rays are dangerous to the skin,
  and can induce skin cancer, including melanoma.
  Blistering sunburns in early childhood increase
  risk, but cumulative exposure also is a factor.
• Moles
• There are two kinds of moles that a person can
  have normal moles the small brown blemishes,
  growths, or "beauty marks" that appear in the
  first few decades of life in almost everyone
  and atypical moles, known as dysplastic nevi. 
  Regardless of type, the more moles you have, the
  greater your risk for melanoma.
• Skin Type
• As with all skin cancers, people with fairer skin
  are at increased risk. 
• Family History
• About one in every ten patients diagnosed with
  the disease has a family member with a history of
  melanoma. 
• Personal History
• Once you have had melanoma, you run an increased
  chance of recurrence. Also, people who have or
  had basal cell carcinoma and squamous cell
  carcinoma are at increased risk for developing
  melanoma.
• Weakened Immune System
• Compromised immune systems as the result of
  chemotherapy, excessive sun exposure, and
  diseases such as HIV or lymphoma can increase
  your risk of melanoma.

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Statistics

• BCC with more than 800,000 new cases estimated in
  the US each year
• SCC with over 200,000 new cases per year
  estimated in the United States
• The American Cancer Society estimates that in
  2007, there will be 59,940 new cases of melanoma
  in the United States.
• In Nederland wordt per jaar bij ongeveer 2.850
  mensen een melanoom ontdekt.Het melanoom komt op
  alle leeftijden voor, maar meestal bij mensen van
  30-60 jaar. Melanomen komen iets vaker voor bij
  vrouwen dan bij mannen.

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Warning Signs The ABCDs of Melanoma
Border The borders of an early melanoma tend to
be uneven. The edges may be scalloped or notched.
Asymmetry If you draw a line through this mole,
the two halves will not match, meaning it is
asymmetrical, a warning sign for melanoma.
Color Having a variety of colors is another
warning signal. A number of different shades of
brown, tan or black could appear. A melanoma may
also become red, white or blue.
Diameter Melanomas usually are larger in diameter
than the size of the eraser on your pencil (1/4
inch or 6 mm), but they may sometimes be smaller
when first detected.
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BENIGNE
MALIGNE
Asymmetrical
Symmetrical
Borders are uneven
Borders are even
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BENIGNE
MALIGNE
One shade
Two or more shades
Smaller than 1/4 inch(6mm)
Larger than 1/4(6mm)
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Types of Melanoma

• The Four Basic TypesMelanomas fall into four
  basic categories. Three of them begin in situ
  meaning they occupy only the top layers of the
  skin and sometimes become invasive the fourth
  is invasive from the start. 
• Superficial spreading melanoma is by far the most
  common type, accounting for about 70 percent of
  all cases. As the name suggests, this melanoma
  travels along the top layer of the skin for a
  fairly long time before penetrating more deeply.
• The first sign is the appearance of a flat or
  slightly raised discolored patch that has
  irregular borders and is somewhat geometrical in
  form. The color varies, and you may see areas of
  tan, brown, black, red, blue or white. This type
  of melanoma can occur in a previously benign
  mole.  The melanoma can be found almost anywhere
  on the body, but is most likely to occur on the
  trunk in men, the legs in women, and the upper
  back in both. Young people who have melanoma
  usually have this type. 
• Lentigo maligna is similar to the superficial
  spreading type, as it also remains close to the
  skin surface for quite a while, and usually
  appears as a flat or mildly elevated mottled tan,
  brown or dark brown discoloration.
• This type of in situ melanoma is found most often
  in the elderly, arising on chronically
  sun-exposed, damaged skin on the face, ears,
  arms, and upper trunk. Lentigo maligna is the
  most common form of melanoma in Hawaii.  When
  this cancer becomes invasive, it is referred to
  as lentigo maligna melanoma. 
• Acral lentiginous melanoma also spreads
  superficially before penetrating more deeply.
• It is quite different from the others, though, as
  it usually appears as a black or brown
  discoloration under the nails or on the soles of
  the feet or palms of the hands. It is the most
  common melanoma in African-Americans and Asians,
  and the least common among Caucasians. 
• Nodular melanoma is usually invasive at the time
  it is first diagnosed.
• The malignancy is recognized when it becomes a
  bump. It is usually black, but occasionally is
  blue, gray, white, brown, tan, red or skin tone.
• The most frequent locations are the trunk, legs,
  and arms, mainly of elderly people, as well as
  the scalp in men. This is the most aggressive of
  the melanomas, and is found in 10 to 15 percent
  of cases.

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Breslow's thickness

• Guide to StagingThe most important factors in
  the staging system are the thickness of the
  tumor, known as Breslow's thickness, and the
  appearance of microscopic ulceration, meaning
  that the skin covering the tumor is not intact.
• Breslow's thickness measures in millimeters the
  distance between the upper layer of the epidermis
  and the deepest point of the tumor's
  penetration.  The thinner the melanoma, the
  better the chance of a cure. 
• In situ melanoma remains confined to the
  epidermis
• Very thin tumors are less than 1.0 millimeter
• Thin tumors are 1.012.0 mm
• Intermediate tumors are 2.0-4.0 mm
• Thick melanomas are 4.00 mm or more.

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Clark's level of invasion

• The presence of microscopic ulceration moves the
  tumor into a later stage.  Your doctor may elect
  to treat a tumor with ulceration more
  aggressively because of this.
• Very thin tumors are classified according to
  Clark's level of invasion, which describes the
  number of layers of skin penetrated by the tumor.
  
• Clark's level I.  The melanoma occupies only the
  epidermis.
• Clark's level II.  The melanoma penetrates to the
  layer immediately under the epidermis, the
  papillary dermis.
• Clark's level III.  The melanoma fills the
  papillary dermis and impinges on the reticular
  dermis, the next layer down.
• Clark's level IV.  The melanoma penetrates into
  the reticular or deep dermis.
• Clark's level V.  The melanoma invades the
  subcutaneous fat.

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Breslow's thickness/ Clark's level of invasion
Melanoom
42

• Stage I. This category is subdivided according to
  the thickness of the primary (original) tumor.
• Stage 1a The tumor is less than 1.0 mm in
  Breslow's thickness without ulceration and is in
  Clark's level II or III.
• Stage Ib The tumor is less than 1.0 mm in
  Breslow's thickness with ulceration and/or
  Clark's level III or IV, or it is 1.01 - 2.0 mm
  in thickness without ulceration
• Stage II. This is also subdivided according to
  gradations in thickness and/or depth, and the
  presence or absence of ulceration.
• Stage IIa The tumor is 1.01 - 2.0 mm  in
  Breslow's thickness with ulceration, or is
  2.01-4.0 mm in thickness without ulceration.
• Stage IIb The tumor is 2.01-4.0 mm in Breslow's
  thickness with ulceration, or is greater than 4.0
  mm in thickness without ulceration.
• Stage IIc  The tumor is greater than 4.0 mm in
  Breslow's thickness with ulceration.
• Later Stages Stages III and IVBy the time a
  melanoma advances to Stage III or beyond,an
  important change has occurred. The Breslow's
  thickness is by then irrelevant and is no longer
  included, but the presence of microscopic
  ulceration continues to be used in staging, as it
  has an important effect on the progression of the
  disease. At this point, the tumor has either
  spread to the lymph nodes small organs located
  in various locations within the body that fight
  cancer, disease and other infections or to the
  skin between the primary tumor and the nearby
  lymph nodes.
• Stage III. A tumor is assigned to Stage III if it
  has metastasized or spread. This can be
  determined by examining a biopsy of the node
  nearest the tumor, known as the sentinel node.
  Such a biopsy is now frequently done when a tumor
  ismore than 1 mm in thickness, or when a thinner
  melanoma shows evidence of ulceration. As the
  sentinel node biopsy is not considered necessary
  in all cases, you may wish to discuss the matter
  with your physician. In-transit or satellite
  metastases are also included in Stage III. In
  this case, the spread isto skin or underlying
  tissue (subcutaneous) for a distance of more than
  2 centimeters (1 cm equals 0.4 inch) from the
  primary tumor, but not beyond the regional lymph
  nodes. In addition, the new staging system
  includes metastases so tiny they can be seen only
  through the microscope.
• Stage IV. The melanoma has metastasized to lymph
  nodes far away from the primary tumor or to
  internal organs, most often the lung, followed in
  descending order of frequency by the liver,
  brain, bone, and gastrointestinal tract.

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Treatment

• When it comes to the early stages of the disease,
  the future is bright.  Most people with thin,
  localized melanomas are cured by appropriate
  surgery.  Early detection still remains the best
  weapon in fighting skin cancer.
• For people with more advanced disease, there is
  still good news.  The cure rate continues to
  rise.  Treatments are varied and many new
  discoveries are being made to improve the chances
  of those with metastatic disease.
• Surgical Excision The first step in treatment is
  the removal of the melanoma, usually by surgical
  excision (cutting it out).  Most surgical
  excisions also called resections are done in
  a doctor's office or as an outpatient procedure
  using local anesthesia. Scars are usually small
  and improve over time.
• There is now a trend towards performing a
  sentinel lymph node biopsy and tumor removal at
  the same time, provided the tumor is 1mm or more
  thick.
• Setting the Margins
• In today's technique, much less of the normal
  skin around the tumor is removed. The borders of
  the entire area to be excised both tumor and
  healthy skin are known as the margins. Margins
  are much narrower than they ever were before.
  Most surgeons today are following the guidelines
  recommended by the National Institutes of Health
  (NIH) and the American Academy of Dermatology
  Task Force on Cutaneous Melanoma
• When there is an in situ melanoma, the surgeon
  excises 0.5 centimeter of the normal skin
  surrounding the tumor and takes off the skin
  layers down to the fat.
• In removing a melanoma that is 1 mm or less in
  thickness, the margins of surrounding skin are
  extended to 1 cm, and the excision goes through
  all skin layers and down to the fascia.
• If the melanoma is equal to or greater than 2 mm
  in Breslows thickness, a margin of 23 cm is
  taken.

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Adjuvant (Additional) Treatment

• Chemotherapy
• A number of drugs that are active in fighting
  cancercells are being used to treat melanoma,
  either one at a time or incombinations.
  Currently, Dacarbazine (DTIC), given by
  injection, is the only chemotherapy approved by
  the FDA. Another agent you may be hearing about
  is temozolomide, anoral drug which closely
  resembles DTIC.
• Isolation-Perfusion Method
• This palliative treatment is sometimes used when
  the melanoma is on an arm or leg.Isolation
  means that the chemotherapy is perfused (added
  to) theblood flowing through the affected limb,
  and no other part of the body.
• Immunotherapy/Biochemotherapy
• Gene therapy

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TipDysplastic Nevi Syndrome

• Dysplastic nevi are atypical moles, which,
  although benign, resemble melanoma and indicate
  an increased risk.  Those who have dysplastic
  nevi and a family history of melanoma have a
  200-fold increase in risk of developing
  melanoma.  Those who have dysplastic nevi but no
  family history of melanoma also have up to
  fifteen times greater risk of developing melanoma
  than the general population.
• Research has shown that the risk of melanoma in
  members of families affected by atypical mole
  (dysplastic nevus) syndrome is 49 in persons
  1-50 years old and 82 by age 72. People with
  classic atypical mole syndrome have the
  following three characteristics
• 100 or more moles
• One or more moles greater than 8mm (1/3 inch) in
  diameter
• One or more moles that look atypical
• Shape Border Color Diameter Location
  Uniformity
• Onset  most often during early childhood through
  ages 35 - 40

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EINDE

• BEDANKT