Skin Cancer

Treatments

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Skin cancer is a malignant lesion of the skin, and its incidence has unfortunately increased at an alarming rate in recent years.

The most common types of skin cancer are:

Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common type of skin cancer worldwide. It originates in the cells of the basal layer of the epidermis. It grows slowly and has an extremely low likelihood of distant metastasis. However, if not removed promptly, it invades and destroys the skin and surrounding tissues locally.

EPIDEMIOLOGY:
BCC is more common in people with fair skin phototypes and in men than in women. The risk increases significantly after the age of 55.

LOCATION:
It most often occurs on sun-exposed areas such as the face and neck. Sun protection therefore plays an important role in reducing the incidence of BCC.

RISK FACTORS:
Both environmental and genetic factors contribute to BCC. Exposure to ultraviolet radiation from sunlight is the most important environmental factor, particularly unusual, intense exposure during childhood and adolescence. Previous sunburn and artificial tanning methods (sunbeds) are also implicated.

DIAGNOSIS:
Diagnosis is usually based on the clinical and dermoscopic appearance of the lesion and is confirmed by histological examination.

TREATMENT:
Surgical excision is the treatment of choice, with very high cure rates (over 99%). Depending on the case, alternatives include cryotherapy, laser treatment and topical medicines such as imiquimod.

PROGNOSIS:
The prognosis for most patients is very good because lesions grow slowly and metastasis is exceptionally rare. However, the tumour can cause extensive local destruction of the skin and surrounding tissues, resulting in considerable morbidity.

FOLLOW-UP:
Reassessment is recommended every 6 months during the first year after BCC treatment, followed by annual review because of the possibility of local recurrence.

Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most common malignant skin tumour. Compared with basal cell carcinoma, it has a greater likelihood of metastasis. Metastases most often affect the regional lymph nodes, although distant organs may also be involved. It is essential to treat cSCC at an early stage, before it causes local tissue destruction and metastasis, as early treatment offers the possibility of complete cure.

LOCATION:
cSCC can develop anywhere, including the head, trunk, limbs, nail folds, oral mucosa and genital region, with a particular preference for sun-exposed areas. Tumours around the nails and in the genital region are relatively rare and are usually associated with high-risk human papillomavirus (HPV) infection. Tumours on the ear, in the preauricular area, on the lips and in the genital region are more aggressive and have a higher risk of metastasis.

DIAGNOSIS:
Diagnosis is often based on the clinical and dermoscopic appearance. Histopathological examination helps confirm the diagnosis and assess the tumour features required for staging.

TREATMENT AND FOLLOW-UP:
cSCC should be completely excised where possible. After treatment, clinical and dermoscopic skin examination and palpation of the regional lymph nodes are recommended every 3–6 months for the first two years, then once a year. Regular ultrasound examination of the regional lymph nodes is indicated for high-risk cSCC. Further imaging is performed on a case-by-case basis for locally advanced or metastatic disease.

PROGNOSIS:
The prognosis of cSCC is generally excellent, with 5-year survival >90%. If initial treatment fails, however, the disease is more likely to recur locally, in regional lymph nodes or in distant organs such as the lungs, liver, brain, skin and bones.

Melanoma

Melanoma is one of the most aggressive tumours, both of the skin and overall. It is a malignant skin tumour arising from the melanocytes of the epidermis. Although previously considered rare, its incidence in the white population has increased in recent years. Compared with other malignant skin tumours, melanoma is the most malignant because of its ability to metastasise if it is not diagnosed early.

For this reason, early diagnosis of melanoma through dermoscopy by an experienced dermatologist is a matter of survival.

LOCATION AND EPIDEMIOLOGY:
Melanoma can occur anywhere on the skin, including areas not exposed to the sun, and on the mucous membranes. In men it is more common on the back, and in women on the lower limbs. It occurs more frequently in people with large congenital nevi, numerous melanocytic nevi or dysplastic nevi, and in those with a personal or family history of melanoma.

DIAGNOSIS:
Early clinical diagnosis of melanoma is a challenge for dermatologists.
According to the ABCDE rule recommended by the American Cancer Society and the American Academy of Dermatology to identify lesions suspicious for melanoma, an existing or new lesion should raise concern if it has the following features:
A: Asymmetry
B: Border irregularity
C: Colour variation
D: Diameter (>6 mm)
E: Evolution – Changes in the size, shape or colour of the lesion, or symptoms such as itching, bleeding or ulceration

PREVENTIVE MEASURES:
A) Protection from ultraviolet radiation:
Wear suitable clothing and a hat
Avoid sun exposure from 12:00–16:00
Apply sufficient sunscreen and reapply regularly

B) Full-body examination by a dermatologist:
Early diagnosis requires assessment of all skin lesions. A dermatologist performs a clinical and dermoscopic full-body examination. Depending on the findings, checks may be needed once a year, every 6 months or more often. People with fair skin phototypes and risk factors for melanoma should be examined more frequently.

C) Self-examination:
Self-examination plays an important role in detecting suspicious skin lesions early.

TREATMENT:
Treatment comprises three components: 1) treatment of the primary melanoma, 2) removal of regional lymph nodes if metastatic disease is found in them, and 3) a decision on whether systemic treatment is required for metastatic disease. Distant metastases may occur in organs such as the lungs, liver, bones and brain, among others. The appropriate treatment is selected according to tumour stage.

PROGNOSIS:
Melanoma can be cured surgically if diagnosed and treated at an early stage. An estimated 90% of melanomas are diagnosed at the primary tumour stage without metastases. The prognosis is poor when diagnosis occurs at an advanced stage. The 5-year survival rate depends on melanoma stage, ranging from 97% for stage 0 to 10% for stage IV.