Definition
A.Two main types.
1.Melanoma (most aggressive).
2.Nonmelanoma.
a.Basal cell carcinoma (most common).
b.Squamous cell carcinoma (second most common).
B.Other types of less common nonmelanoma skin cancers include Merkel cell carcinoma or trabecular cancer, Kaposi sarcoma (associated with HIV), cutaneous lymphoma, and skin adnexal tumors.
Incidence
A.Skin cancer is the most common cancer in the United States.
B.Each year there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung, and colon.
C.Melanoma is one of only three cancers with an increasing mortality rate for men, along with liver cancer and esophageal cancer.
D.An estimated 76,380 new cases of melanoma were diagnosed in 2016 with 10,130 deaths.
E.Males are affected more than females, and non-Hispanic whites have higher incidence rates compared to other ethnicities.
F.The incidence and mortality rates in the United States are 19.9% and 2.7%, respectively.
G.The rates of new cases of melanoma have risen ∼1.4% each year over the past 10 years.
Pathogenesis
A.Pathophysiology of skin cancer comes from damage to the DNA base.
B.Ultraviolet (UV) radiation from sunlight is an important risk factor for skin cancer.
C.UV sunlight appears to disable a tumor suppressor gene called p53.
Predisposing Factors
A.Male with age greater than 60 years.
B.Excess sun exposure and ultraviolet-based artificial tanning.
C.Family history of skin cancer.
D.Personal history of skin cancer.
E.History of sunburns, especially early in life.
F.History of indoor tanning.
G.Patients receiving immunosuppressive drugs.
H.Individuals with dysplastic or atypical nevi, with several large nondysplastic nevi, with many small nevi, or with moderate freckles.
I.Chemical exposure to arsenic, chromium, polycyclic aromatic hydrocarbons, or benzene.
J.Associated genetic syndromes; basal cell nevus syndrome, xeroderma pigmentosum, oculocutaneous albinism, epidermolysis bullosa, and Fanconi anemia are associated with an increased risk of skin cancer.
Subjective Data
A.Common complaints/symptoms.
1.There are some general physical characteristics of malignant skin lesions but the appearance may vary with each skin cancer.
2.The most common sign of skin cancer is a change in the skin including:
a.A new growth.
b.Nonhealing sore: Basal cell carcinomas often ulcerate and have an eczematous appearance.
c.A change in appearance of a mole.
d.Scar elevation (thickening or rising of a previously flat mole).
e.Surface changes (scaling, erosion, oozing, bleeding, or crusting).
f.Surrounding skin changes (redness, swelling, or small new patches of color around a larger lesion [satellite pigmentations]).
g.Sensory changes (itching, tingling, or burning).
h.Changes in consistency (friability).
3.Metastatic melanoma signs and symptoms include:
a.Unexplained weight loss or fatigue.
b.Swollen or painful lymph nodes: This may be the first presenting sign in metastatic melanoma of unknown primary.
c.Shortness of breath or persistent cough.
d.Bone pain.
e.Headaches, numbness, weakness, or decreased sensation.
f.Seizures.
g.Anorexia, abdominal pain, dysphagia, small bowel obstruction, hematemesis, and melena.
h.Intraocular melanoma may present with altered vision.
Physical Examination
A.Integumentary system.
1.Total body skin should be examined including scalp, dorsal feet, soles, toe webs, and nails.
2.Assess the total number of nevi present on patient’s skin and differentiate between typical and atypical lesions using the ABCDE criteria.
3.Melanoma lesions are more likely to be asymmetrical, have irregular borders, appear very dark black or blue or have more variation in color than a benign mole and may be greater than 6 mm in diameter.
B.Lymphatic system.
1.Melanoma may disseminate through the lymphatics.
2.Palpate for hard and swollen lymph nodes.
C.Pulmonary system.
1.Observe for tachypnea, dyspnea, or labored breathing.
2.Auscultate all lung fields for lung sounds.
3.Melanoma metastasis to lungs may cause persistent cough, shortness of breath, pain in the chest, or pleural effusion.
D.Cardiovascular system.
1.Auscultate heart sounds for abnormal findings to evaluate the presence of a tumor that has
direct cardiac involvement.
2.Assess for signs of hypotension, jugular venous distension, or pericardial rub.
3.Cardiac symptoms, pericardial effusion, and cardiac tamponade are associated with cardiac metastasis of melanoma.
E.Gastrointestinal tract.
1.Auscultate bowel sounds in four quadrants.
2.Palpate for hepatomegaly or tenderness to palpation.
3.Liver metastases also may cause ascites.
F.Musculoskeletal system.
1.Bone metastasis of melanoma can cause bone pain and discomfort.
2.Examine for any tender area including spine.
G.Central nervous system.
1.A neurological examination is essential to evaluate for any intracranial metastases.
2.Evaluate for decreased strength, altered sensation, and/or neuropathy.
H.A complete eye examination is necessary to test the presence of intraocular melanoma.
1.Uveal melanomas can arise in the iris or in the posterior uveal tract, and initially may be asymptomatic.
2.Iris melanoma may cause distortion of the pupil; ciliary body melanoma may cause blurred vision.
3.Choroidal melanoma may result in retinal detachment and decreased visual acuity.
Diagnostic Tests
A.Biopsy.
B.Nodal basin ultrasound and/or lymphoscintigraphy.
C.Imaging (if a sentinel lymph node is positive or symptoms warrant).
1.CT of the chest/abdomen/pelvis with intravenous contrast.
2.Consider whole body PET/CT.
3.Consider brain MRI with IV contrast.
4.If clinically indicated, perform a neck CT with IV contrast.
D.Staging.
1.Staging for melanoma determines the degree of severity, treatment options, and prognosis.
2.The American Joint Commission of Cancer staging system tumor, node, metastasis (TNM) classification of melanoma is similar to any other cancers.
Differential Diagnosis
A.Basal cell carcinoma.
B.Squamous cell carcinoma.
C.Malignant melanoma.
D.Benign lesions.
Evaluation and Management Plan
A.General plan.
1.Based on staging, the treatment options include surgery, immunotherapy, targeted therapy, and chemotherapy and/or radiation therapy (e.g., stereotactic radio surgery or whole brain radiation).
2.For metastatic and unresectable disease, systemic therapy is indicated.
3.Surgery.
4.Radiation therapy.
5.Immunotherapy and targeted therapy.
B.Acute care issues in skin cancers.
1.Most of the surgical procedures are done on an outpatient basis; however, hospitalization is indicated for complex surgeries and depends on reconstructive techniques.
2.Wound care, JP drain management and pain management, and monitoring for infection are the main areas of focus during postoperative management.
Follow-Up
A.Perform physical and skin examinations every 3 to 6 months for the first 2 to 3 years, then once a year after that.
B.Follow-up scans may be recommended.
Consultation/Referral
A.Patients with suspected skin cancer should be referred to dermatology, medical oncology, radiation oncology, and surgical oncology.
Special/Geriatric Considerations
A.The white skinned elderly population represents the largest patient group at risk for developing skin cancer.
B.Treatment of skin cancer in the elderly population should be based on life expectancy, quality of life, and patient functional status, and not solely on chronological age.
Bibliography
Aerts, B., Kock, M., Kofflard, M., & Plaisier, P. (2014). Cardiac metastasis of malignant melanoma: A case report. Netherlands Heart Journal, 22(1), 39–41.
National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer