Treatment

Symptoms, Risk and Prevention

The Siteman Cancer Center is uniquely qualified in the diagnosis, evaluation and treatment of all forms of skin cancer. Many skin cancer patients require treatment from several medical and surgical specialists, including dermatologists, dermatologic surgeons, medical and surgical oncologists, radiologists, radiation oncologists, ophthalmologists, otolaryngologists and plastic surgeons. Washington University Physicians at Siteman who specialize in these fields routinely meet to coordinate and discuss treatment options for patients. In these multidisciplinary meetings, careful consideration is given to determining the best approach to treatment.

The main goal at the Siteman Cancer Center is to get a correct diagnosis of your condition and decide on the proper treatment. Specialists here excel in using the technology and experience to make an accurate diagnosis, often down to the genetic level so the best treatment options may be identified.

Symptoms of Squamous and Basal Cell Cancers

Symptoms depend on where the cancer occurs. Early on, most of these cancers don’t have symptoms. When they do, you should bring these symptoms to your doctor’s attention:

  • A sore that does not heal.
  • Areas of the skin that are:
    • Raised, smooth, shiny, and look pearly.
    • Firm and look like a scar, and may be white, yellow, or waxy.
    • Raised, and red or reddish-brown.
    • Scaly, bleeding or crusty.

Signs of actinic keratosis (precancerous changes) include the following:

  • A rough, red, pink or brown scaly patch on the skin that may be flat or raised.
  • Cracking or peeling of the lower lip that is not helped by lip balm or petroleum jelly.

Symptoms of Melanoma, Merkel Cell or Karposi Syndrome

Melanoma tends to present as a mole. Self-awareness of changes in the skin is the biggest aid to catching the disease early. For the detection of melanoma, dermatologists teach their patients to use the ABCDE system of self-examination in looking for moles:

A: Asymmetry
The mole is asymmetrical, not round.

B: Borders
It has irregular borders.

C: Color
It has more than one color or an uneven distribution of color.

D: Diameter
Melanomas are typically greater than 6 mm in diameter (about the size of a pencil eraser).

E: Evolution
By being familiar with your skin, you will notice when a mole changes and report it immediately.

Melanoma also may occur within the eye in pigment cells that are similar to melanocytes in the skin. If it occurs on the inner surface of the eyelid, or on visible areas of the eye, melanoma may be diagnosed early. When melanoma occurs within the deeper structures of the eye, it often is not detected until later when changes in vision are noticed. An ophthalmologist, or eye doctor, is instrumental in the diagnosis and treatment of ocular melanoma.

Merkel Cell (MCC)

This rare skin cancer often looks harmless. Many people mistake it for an acne lesion, bug bite or cyst. MCC often appears on skin that has had chronic sun exposure. The MCC tumor tends to feel firm, grow quickly (in a few weeks or months) and have one color, typically either red, pink, blue or violet. It is most common on the head and neck area.

Karposi Sarcoma skin lesions

This is most common in patients with HIV or without HIV but of Mediterranean descent. Most lesions are flat and painless, aren’t itchy and don’t drain. They appear as red or purple spots on light skin and blue, brown or black on dark skin. They may grow into raised bumps or grow together.

Risk Factors for Skin Cancers

Risk factors vary with the type of skin cancer, but may include:

Non-melanoma skin cancers

  • Being exposed to natural or artificial sunlight. (While ultraviolet light damage tends to be cumulative, any exposure to tanning beds increases risk.)
  • Having a fair complexion that freckles and burns easily.
  • Blue or green or other light-colored eyes.
  • Red or blond hair.
  • Having actinic keratosis.
  • Past treatment with radiation.
  • Having a weakened immune system.
  • Although not common, having certain changes in the genes that are linked to skin cancer development.

Melanoma

In addition to the risk factors above, risk factors include: having several large or many small moles, a family history of unusual moles or melanoma or having atypical moles

Diagnosing Skin Cancers

Making a diagnosis of non-melanoma skin cancers involve:

  • Skin exam: the skin is examined for bumps or spots that look abnormal in color, size, shape or texture.
  • Skin biopsy: All or part of the abnormal-looking growth is cut from the skin and viewed under a microscope by a pathologist to check for signs of cancer. There are four main types of skin biopsies and the dermatologist will decide on the appropriate approach:
    • Shave biopsy: A sterile scalpel is used to “shave-off” the abnormal-looking growth.
    • Punch biopsy: A special punch biopsy tool is used to remove a circle of tissue from the abnormal-looking growth.
    • Incisional biopsy: A scalpel is used to remove part of a growth.
    • Excisional biopsy: A scalpel is used to remove the entire growth.

Non-melanoma cancers are usually cured with surgical removal (not biopsy), but new cancers may develop, so routine skin checks are warranted.

Stages of Melanoma Cancer

Stages are generally 1 through 4, depending on the extent of the cancer. Staging is necessary in determining the correct treatment.

Diagnosing and Staging Melanomas

For melanoma skin cancers, once the dermatologist confirms melanoma, additional tests will be done to see if the cancer has spread:

  • Physical exam and history: A total skin exam, including the scalp and genital area, should be performed. A history of the patient’s health habits, past illnesses, risk factors for skin cancer and previous treatments will also be taken.
  • Lymph node mapping (lymphoscintigraphy) and sentinel lymph node biopsy: This procedure is performed only when primary melanoma is of a certain depth or has other features that indicate a more aggressive tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows from the skin cancer site through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist views a sample of tissue under a microscope to check for cancer cells. If no cancer cells are found, it may not be necessary to remove more nodes.

For stage 3 or 4 disease:

  • CT scan (CAT scan): A series of detailed pictures of areas inside the body, which are taken from different angles and may be combined with injection or oral intake of a dye to help the organs or tissues show up more clearly.
  • PET scan (positron emission tomography scan): A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
  • MRI (magnetic resonance imaging): This procedure uses a magnet, radio waves and a computer to make a series of detailed pictures of areas inside the body.
  • Blood chemistry studies: A blood sample is checked to evaluate organ function.

Recurrent Melanoma

The cancer comes back after it is treated, sometimes in the same place and other times as metastases to the lungs, liver, brain or other organs.

Prognosis

The prognosis (chance of recovery) for melanoma depends on the following:

  • The thickness of the tumor and where it is in the body.
  • How quickly the cancer cells are dividing.
  • Whether there was bleeding or ulceration of the tumor.
  • Whether the cancer is in the lymph nodes.
  • The number of places cancer has spread to in the body.
  • The level of lactate dehydrogenase (LDH) in the blood.
  • The patient’s age and general health.

Skin cancers are best controlled when they are small and can be removed by surgery. Clinical trials are a good option for getting the latest treatment. For skin cancers that have metastasized, the standard of care is clinical trials.