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Melanoma staging offers patients key information through common criteria about skin cancer prognosis and likely

disease outcomes. There are two main melanoma staging systems: Clark's level Melanoma Staging System Breslow's thickness of invasion

Staging systems help patients and specialists communicate more effectively through the use of key stage to better understand prognosis and likely outcomes with or without treatment. Basically, the higher the cancer stage, the more serious the related health consequences and greater risk of mortality as a result. Clark's Level Melanoma Staging System

Clark's level is a staging system where the skin's natural anatomy is used which
measures the depth of tumors. Developed in the late 1960s by Dr. Wallace Clark, this microstaging method consists of five different levels which include: Level 1 lesions (no risk to life) Level 2 lesions (low risk) Level 3 lesions (greater risk of spreading) Level 4 lesions (very high risk of spreading) Level 5 lesions (invaded directly into subcutaneous tissue) Clark's levels describe at each stage which layer of the skin has been penetrated by the melanoma with survival rates decreasing as levels of invasion increase. It is possible for Clark's levels to result in a different prognosis than using Breslow thickness due to individual variations in terms of skin thickness.

Breslow Thickness for Micro-staging Melanoma Breslow thickness, which was first used in the early 1970s, groups melanomas by their thickness. The Breslow thickness measures melanomas in millimeters from top to bottom and highlights the fact that even fractions of a millimeter may have an impact upon survival rates. This method does not require determining the skin's different layers and uses a special measurement device which is incorporated into the eyepiece of the microscope. Though the use of a specialist measurement device, a pathologist can directly measure the thickness of a melanoma. After having carried out this procedure, the pathologist then reports key findings to one's doctor. This report uses a classification of invasion known as the T staging system: T0 Melanoma in situ (no invasion)

T1 T2 T3 T4

Tumor which is one millimeter or less in thickness Tumor between one and two millimeters Tumor is one which is between two and four millimeters Tumor thicker than four millimeters

Breslow thickness focuses on the thickness of the tumor, Clark's level relates to the depth of the tumor within the patient's skin. Curettage and Electrodesiccation (Scraping and burning of the skin cancer) Skin cancer cells do not have the regular cell-to-cell attachments of healthy skin cells. This allows them to be removed by scraping the skin where the cancer is with a curette (scraping device), leaving the surrounding non-cancerous skin intact. The area is then treated with an electric current to seal over blood vessels. The area may be treated with liquid nitrogen instead of the electric current. This is generally used for early skin cancers, especially superficial basal cell carcinoma and superficial squamous cell carcinoma. Melanoma would never be treated this way.

Mohs procedure involves surgically removing skin cancer layer by layer and examining the tissue under a microscope until healthy, cancer-free tissue around the tumor is reached (called clear margins). Advantages of Mohs Surgery: Mohs surgery is unique and so effective because of the way the removed tissue is microscopically examined, evaluating 100% of the surgical margins. The pathologic interpretation of the tissue margins is done on site by the Mohs surgeon, who is specially trained in the reading of these slides and is best able to correlate any microscopic findings with the surgical site on the patient. Advantages of Mohs surgery include: Ensuring complete cancer removal during surgery, virtually eliminating the chance of Minimizing the amount of healthy tissue lost Maximizing the functional and cosmetic outcome resulting from surgery Repairing the site of the cancer the same day the cancer is removed, in most cases Curing skin cancer when other methods have failed the cancer growing back

Surgeons usually perform Mohs surgery as an outpatient procedure in their office, which will have an on-site surgical suite and a laboratory for immediate preparation and microscopic examination of tissue. Typically, surgery starts early in the morning and is completed the same day, depending on the extent of the tumor and the amount of reconstruction necessary.

Local anesthesia is administered around the area of the tumor as the patient is awake during the entire procedure. The use of local anesthesia in Mohs surgery versus general anesthesia provides numerous benefits, including the prevention of lengthy recovery and possible side effects from general anesthesia. After the area has been numbed, the surgeon removes the visible tumor along with a thin layer of surrounding tissue. This tissue is prepared and put on slides by a technician and examined under a microscope by the surgeon. If there is evidence of cancer, another layer of tissue is taken from the area where the cancer was detected. This ensures that only cancerous tissue is removed during the procedure, minimizing the loss of healthy tissue. These steps are repeated until all samples are free of cancer. While there are always exceptions to the rule, most tumors require 1 to 3 stages for complete removal. When the surgery is complete, the surgeon will assess the wound and discuss options for ideal functional and cosmetic reconstruction. If reconstruction is necessary, the surgeon will usually perform reconstructive surgery to repair the area the same day as the tumor removal. The Mohs Surgery Process Step 1 The roots of a skin cancer may extend beyond the visible portion of the tumor. If these roots are not removed, the cancer will recur.

Step 2 The visible tumor is surgically removed.

Step 3 A layer of skin is removed and divided into sections. The ACMS surgeon then color codes each of these sections with dyes and makes reference marks on the skin to show the source of these sections. A map of the surgical site is then drawn.

Step 4 The undersurface and edges of each section are microscopically examined for evidence of remaining cancer.

Step 5 If cancer cells are found under the microscope, the ACMS surgeon marks their location onto the "map" and returns to the patient to remove another layer of skin - but only from precisely where the cancer cells remain. Step 6 The removal process stops when there is no longer any evidence of cancer remaining in the surgical site. Because Mohs surgey removes only tissue containing cancer, it ensures that the maximum amount of healthy tissue is kept intact. Radiation therapy (or radiotherapy)

It is the treatment of cancer using radiation. During radiation treatment, radiation is


directed to the target tissue and transmits energy that damages and destroys the cancer cells. It does this by damaging the genetic material of the cells which triggers cell death. The radiation damages genetic material in both normal and malignant cells and does not discriminate between them.

Normal cells are able to recover from the damage, while the cancer cells do not.
Radiation therapy aims to maximize the number of cancer cells destroyed, while minimizing the damage to nearby normal cells. X-rays The main type of radiation used for the treatment of skin cancers. X-rays can be generated with different energy levels: o High energy x-rays are able to penetrate deep into the body, and are used to Low energy x-rays (superficial or orthovoltage x-rays) do not penetrate very treat internal cancers.

deep into the body and transmit most of their energy into the skin and are therefore used for the treatment of skin cancers.

Electron beams and gamma rays are other forms of radiation that are

sometimes used to treat skin cancers.

When is radiation therapy used? Radiation therapy is not suitable for all types of skin cancers. Some of the factors affecting whether radiation therapy can be used include: Type of cancer Site of the cancer Previous use of radiation therapy Suitability of other treatments Patient preference Type of cancer Different cancers vary in their sensitivities to radiation induced damage, which influences how successful the radiation therapy will be. For example, melanomas are less sensitive to radiation, and are rarely treated with radiation therapy. Skin cancers which are relatively sensitive to radiation and commonly treated with radiation therapy include: Basal cell carcinoma Squamous cell carcinoma Cutaneous lymphomas Kaposi sarcoma Merkel cell carcinoma Site of the cancer Radiation therapy is often used in sites in which surgery may be difficult, eg. eyelids. Some areas of the body are more likely to develop side effects from radiation therapy, such as the lower legs, and in these areas other treatments may be preferred. Previous use of radiation therapy If a site has previously been treated with radiation, then further radiation therapy cannot be used. If a skin recurs after radiation treatment then other treatments, such as surgical excision are usually preferred. Suitability of radiation therapy The dermatologist will be able to advise whether the skin cancer is suitable for radiation therapy. Fluorouracil cream (Medication Class: Antimetabolites) Fluorouracil cream and topical solution are used to treat a type of skin cancer called superficial basal cell carcinoma if usual types of treatment cannot be used. It works by killing fast-growing cells such as the abnormal cells in

actinic keratoses

basal cell carcinoma

Photoradiation therapy (PRT) / Photodynamic therapy Treatment for skin cancer that combines a light source and a photosensitizing agent (a drug that is activated by light) to destroy cancer cells. Useful when there are several lesions on the skin or scalp.

Photosensitizing agents:

Hematoporphyrin derivative (Hpd)


. Photosensitizing agent collects more readily in cancer cells than in normal cells. Exposing the agent to light makes it react with oxygen to create chemicals that can kill a skin cancer cell. The approved light sources can only penetrate a limited depth of tissue; therefore doctors mainly use PDT to treat areas on or just under the skin. It is less effective for treating large tumors because the light cannot pass deeply into the tumors. Because it is a localized treatment, doctors dont use PDT to treat skin cancer that has metastasized. Doctors sometimes use PDT in precancerous treatments. Considerations for PDT Patients age, if the patient is over 60 years old. Identify if multiple lesions are seen on the skin or scalp, usually three or more. fluorouracil

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