Melanoma and Other Skin Cancers: a Guide for Medical Practitioners

Melanoma and other skin cancers: a guide for medical practitioners

Australia has among the highest rates of skin cancer in Causes of melanoma and • Having fair or red hair and blue or green eyes the world: 2 in 3 Australians will develop some form of other skin cancers • Immune suppression and/or transplant skin cancer before the age of 70 years. • Unprotected exposure to UV radiation remains recipients. the single most important lifestyle risk factor for melanoma and other skin cancers. Gender Skin cancer is divided into two main types: • UVA and UVB radiation contribute to skin In NSW, males are more than 1½ times more damage, premature ageing of the skin and likely to be diagnosed with melanoma and Melanoma Non-melanocytic skin skin cancer. almost 3 times more likely to die from it than Melanoma develops in the melanocytic cancer (NMSC) • Melanoma and BCC are associated with the females (after allowing for differences in age). (pigment-producing) cells located in the amount and pattern of sun exposure, with an • Squamous cell carcinoma (SCC) Mortality from melanoma rises steeply for males epidermis. Untreated, melanoma has a high intermittent pattern carrying the highest risk. develops from the keratinocytes in the from 50 years and increases with age. The risk for metastasis. The most common clinical epidermis and is associated with risk • Premalignant actinic keratosis and SCC death rate for males aged: subtype is superficial spreading melanoma of metastasis. SCC is most commonly are associated with the total amount of sun • 50–54 years is twice that of females (SSM). SSM is most commonly found on the found on the face, particularly the lip exposure accumulated over a lifetime. head and neck (per unit area). Other common • 55–59 years is 3 times that of females region, ears, nose, cheek and eyelid, and sites are the trunk in males and lower • Other risk factors for NMSC can include • 75–79 years is 4½ times that of females. extremities in females; however, SSM can then on the neck, dorsa of hands and exposure to some chemicals (eg arsenic), develop on any part of the body, including parts forearms in both sexes. In males, SCC is radiation therapy, UVA and psoralen (PUVA) Melanoma in not heavily exposed to ultraviolet (UV) radiation. commonly found on the head and neck, treatment for psoriasis, immunosuppressive and in females, it is commonly found on therapy and some rare genetic conditions non-Caucasian patients In NSW: the upper limbs, followed by the head and predisposing to skin cancer. The incidence of melanoma in non-Caucasians • Melanoma is the 4th most common neck. It is believed that many SCCs arise is low. However, non-Caucasians are more cancer diagnosed. Every year, more than from premalignant actinic keratoses. Risk factors for melanoma likely to experience delayed diagnosis and have poorer clinical prognosis compared 3,500 new cases are diagnosed and there • Basal cell carcinoma (BCC) also • Multiple naevi to Caucasians. are almost 500 deaths from the disease. develops from keratinocytes in the • Multiple dysplastic naevi • The risk of developing melanoma epidermis and is the most frequently Non-Caucasians are more likely to develop • Personal or family history of melanoma increases with age. However, melanoma is diagnosed cancer in Australians. BCC is clinical melanoma subtypes rare in the most common cancer in males aged most commonly found on the face: the • Increasing age Caucasian populations: 25–54 years and in females aged 15–29 eyelid, lip and nasolabial fold, followed • High levels of intermittent sun exposure (ie • Acral lentiginous melanoma on the palms of years. It is the second most common by ears, nose and cheek in both sexes. during outdoor recreation or sunny holidays) the hands and soles of the feet cancer in females aged 30–54 years. In males, BCC is common on the neck, • Personal history of NMSC • Subungual melanoma within the nail matrix. back and shoulders, and in females, on • The lifetime risk of developing melanoma the neck, shoulders and outer arms. • Fair skin that burns easily, freckles and by age 75 years is 1 in 24 for males and does not tan 1 in 34 for females.

Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. www.nhmrc.gov.au Clinical Practice Guide: Basal cell carcinoma, squamous cell carcinoma (and related lesions) – a guide to clinical management in Australia. www.cancer.org.au Cancer in New South Wales: Incidence and Mortality Report 2008. www.cancerinstitute.org.au Melanoma diagnosis Superficial spreading Nodular melanoma (NM) melanoma (SSM) This is a highly dangerous form of melanoma Melanoma can develop in pre-existing moles that grows quickly. NM differs from SSM in appearance. NM has little radial growth within in the skin or, more commonly, de novo: the epidermis but penetrates vertically into the • SSM is the most common form of melanoma. dermis early. It is more likely to be symmetrical and uniform in colour (red, pink, brown or black), • SSM can appear as a new spot, or an is more frequently lighter coloured than SSM, existing spot, freckle or mole that changes and feels firm to the touch. Over time, it may size, colour or shape. develop a crusty surface that bleeds easily. • A patient diagnosed with melanoma is at • NM can become life threatening in increased risk of new primary melanomas 6–8 weeks. (relative risks ranging above 10). • Approximately 15% of total melanomas diagnosed are NM. • NM does not necessarily arise from a pre-existing mole and is commonly found on the head and neck. The ABCDE acronym can • NM develops most commonly in older help distinguish a superficial people, particularly men. spreading melanoma from a normal mole: The ABCDE acronym cannot A Asymmetry: the lesion is irregular in be used to aid diagnosis shape or pattern. of nodular melanoma; however, the following B Border: the border or outline of a features can be of help: Biopsy and excision for melanoma is usually irregular. melanoma or suspicious naevi E Elevated: the lesion can appear as C Colour: there is variation in colour a small, round and raised lump on • Complete excision biopsy with a 2 mm within the lesion. the skin. Colour may be uniform margin is recommended. throughout the lesion and may be D Diameter: the lesion is usually • Partial biopsies (ie punch biopsies and black, brown, pink or red. greater than 6 mm across. However, shave excisions) can be less accurate than suspect lesions of smaller diameter F Firm: the lesion feels firm to the touch. excisional biopsy and should be performed should also be investigated. by trained practitioners. If nodular melanoma is G Grows: a nodule that has been E Evolving: the lesion changes over suspected, diagnosis should not growing progressively for more • If a thick SSM or NM is suspected, refer time (size, shape, surface, colour, be delayed, and urgent referral than a month should be assessed patient to a dermatologist, surgeon with an symptoms eg itch). to a dermatologist or immediate as a matter of urgency. interest in melanoma or a multidisciplinary excision is recommended. melanoma unit as a matter of urgency. Treatment for melanoma Selecting appropriate primary treatment will Other treatments options Follow-up for melanoma Survival depend on the Breslow thickness (vertical depth) of the tumour. Breslow thickness is Surgery Due to the risk of tumour recurrence and In Australia, for the period 2006-2010, the measured using the following system: Sentinel lymph node biopsy (SLNB) should be new primary melanomas, all patients require 5 year survival for melanoma was 94% for discussed with patients with pT2 (and higher routine follow-up, the frequency of which will females compared with 89% for males.* • (pTis) Melanoma in situ. The abnormal risk pT1 – ie pT1b) and thicker lesions, and depend on the stage of the primary tumour cells are found only in the non-vascular In NSW, the 5-year survival for melanoma is: performed by trained practitioners. Surgical at time of diagnosis: epidermis and have not penetrated into resection of isolated metastases can be • 96% if detected when localised deeper tissue that contains blood vessels. • 6-monthly intervals for 5 years then yearly performed in both definitive and palliative for patients with stage l disease • 63% if there has been regional spread • (pT1) Melanoma cells reach the upper part treatment settings. of the dermis. The melanoma is less than • 3-monthly or 4-monthly intervals for 5 years • 43% if there has been metastatic spread. Radiation 1 mm thick. then yearly (with ultrasound examination Radiation treatment can be used to treat of regional nodes) for patients with stage ll • (pT2) Melanoma cells reach the upper part lentigo maligna when surgical approaches and lll disease. of the dermis. The melanoma is between are considered less suitable. Post-operative Clinical Practice Guidelines for the 1 mm and 2 mm thick. radiotherapy can be performed for In Australia, up to 75% of patients detect their Management of Melanoma in Australia • (pT3) Melanoma cells reach deeper into the melanomas likely to recur locally or own recurring melanomas. Patients should and New Zealand. www.nhmrc.gov.au dermis. The melanoma is between 2 mm regionally. Radiotherapy can be used for be educated on recognising changes in palliative management of cerebral and bone and 4 mm thick. their skin, have a professional full skin metastases, and for other metastases where examination as deemed appropriate, and • (pT4) Melanoma is more than 4 mm thick or temporary local control is needed. have further testing as required. it has invaded through the dermis and into the underlying fat. Chemotherapy • Chemotherapy may be offered for treatment Treatment is based on the T1–T4 classification. of metastatic disease. Commonly used The surgical removal of the tumour with agents include dacarbazine (DTIC), recommended margins of excision for each of fotemustine and carboplatin. Temozolomide the T-classification groups are: is also occasionally used. • (pTis) Melanoma in situ: 5 mm clearance • Experimental agents, either alone or in • (pT1) Melanoma <1.0 mm: 1 cm clearance combination with standard chemotherapeutic agents, may be offered as treatment of • (pT2) Melanoma 1.0–2.0 mm: metastatic disease, within the context of 1–2 cm clearance clinical trials. Recently, new agents • (pT3) Melanoma 2.0–4.0 mm: (eg BRAF inhibitors) have shown an 1–2 cm clearance improved response compared to previously low-efficacious chemotherapy agents. • (pT4) Melanoma >4.0 mm: 2 cm clearance. Immunological therapies Note: evidence for optimal excision clearance • Interferon may be offered following for melanoma 2–4 mm thick is unclear. surgical removal of melanoma that has not The Clinical Practice Guidelines recommend it progressed past lymph nodes. may be desirable to take a wider margin (2 cm) for these tumours, depending on tumour site • Vaccines remain experimental, but may be and surgeon/patient preference. offered within the context of clinical trials, either after surgical removal of early stage melanoma, or for low-volume metastatic disease.

* Australian Institute of Health and Welfare 2012. Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Cancer Series no. 69. Cat. no. CAN 65. Canberra: AIHW. Non-melanoma skincancer(NMSC)diagnosis • • • Squamous cell Squamous cell carcinoma (SCC)

Foundation Australia Skin &Cancer Newcastle Calvary Mater Australia Melanoma Institute Diagnostic Centre Sydney Melanoma Specialised melanomaandnon-melanomadiagnosis andtreatment services It grows overaperiodofsome months. It appearsasathickened,red, scalynodule SCC canspread tootherparts ofthebody that maybleedandulcerateovertime. risk ofmortality. Rapid growth isassociated withincreased if nottreated. Lesionsonthe earsandlips have ahigherriskofmetastasis. Westmead NSW2145 7 AshleyLane Darlinghurst NSW2010 277 BourkeStreet Waratah NSW2298 Cnr EdithandPlattStreets North SydneyNSW2060 40 RocklandsRoad Camperdown NSW2050 Royal PrinceAlfred Hospital 2nd FloorGloucesterHouse

• • • • Basal cellcarcinoma (BCC)

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and NMSC management ofmelanoma Diagnosis andsurgical treatment ofmelanoma management andmedical Diagnosis, surgical treatment ofmelanoma management andmedical Diagnosis, surgical pigmented lesions of melanomaand Diagnosis andmanagement Treatment forNMSC • • • • • • • • • • • • Treatment optionsfornon-melanoma The choiceoftreatment willdependon: Follow-up forNMSC Clinical Practice Guide:Basalcell (and related lesions)–aguideto clinical managementinAustralia. carcinoma, squamouscellcarcinoma draining lymph nodes for patients with SCC), have draining lymphnodesforpatientswithSCC),have changes in their skin (including examination of changes intheirskin(includingexaminationof on histologicalclearanceandriskleveloftumour. appropriate, andhavefurthertestingasrequired. a professional fullskinexaminationasdeemed and/or anynewprimaryskincancerswilldepend skin cancerinclude: www.cancer.org.au Patients should be educated on recognising Patients shouldbeeducatedonrecognising Frequency offollow-uppatientstreated for NMSC forevidenceofrecurrence, metastasis

Radiotherapy Surgical excisionofthetumourand Application oftopicalagents(imiquimod Diathermy/electrodesiccation Curettage Cryotherapy Patient preference. Anatomic site Histological features Aetiology Thickness andgrade Tumour size cream, diclofenacgel,fluorouracil cream, surrounding tissue photodynamic therapy). Images are supplied courtesyofthe Sydney Melanoma DiagnosticCentre. www.melanoma.net.au Cancer Council Helpline1311 20

• • • • There isnoevidencedemonstratingthat 4 timesayearorasoften recommended (SSE) formelanoma Skin self-examination Australasian CollegeofDermatologists Approximately 50%ofmelanomas are and NMSC melanoma andNMSC Screening for detected bythepatient.There isnospecific of detectingskincanceratanearlyand examination mayincrease theprobability of self-examinationthathasshownto or mortality, and itisnotrecommended. and NMSCiseffective inreducing morbidity with aprevious diagnosis of melanoma. treatable stage. SSE techniqueorrecommended frequency Skin surveillance recommends thatpeopleexaminetheirskin reduce morbidity;however, regular skin melanoma andNMSC,includingpatients patients identifiedtobeathighriskof population-based screening formelanoma For thegeneralpopulation, Patients athighriskformelanomashould: Patients treated forNMSCshould: by theirmedicalpractitioner.

Have afullbodyexaminationwith Be taughttoself-screen andrecognise Have afullbodyexaminationwith Be taughttoself-screen (including clinician every12months. changes totheirskin clinician every6to12months. examination ofdraininglymphnodes)and recognise suspiciouslesions is recommended for

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