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Compact information about skin cancer


Besides general information on skin cancer that you can get from many sources, our idea is 
- to name the early signs of a starting skin cancer 
- and show representative examples of some cases 
to encourage you, the reader, to contact a physician to get a proper diagnosis. 

The information provided here is as a first step on the two most important skin cancer types: 
  -  Melanoma 
  -  Basalioma (BCC)
  -  Squamous cell carcinoma (SCC)



The malignant melanoma starts to grow from the pigment cells in the skin
It can occur on any area of the body. It is found in one of 
7000 persons per year in Europe in caucasians in the middle of their lifetime. 

In most cases melanoma is discovered as a flat, growing,
irregular shaped pigment spot often without symptoms that only later grows in thickness and in some cases perhaps might itch. Bleeding is a late sign. Not all melanomas are dark brown or black.
Half of the
early melanomas do not look typical at all in the beginning. 

mal.Melanom Typ SSM
Early SSM type melanoma

There are different types of melanomas defined : 
The superficial spreading melanoma type (SSM) is the most common type representing 75% of the cases (see above). As it grows in a thin layer first, it is mostly discovered early enough to be removed timely. 
The malignant age spot Lentigo maligna melanoma (LMM) is the second most common melanoma type. It usually starts on sunexposed body areas as the face or the arms of
elderly people. Only late it would start growing deeper into the skin. 
The type of nodular malignant melanoma (NMM) is present in about 5% of the cases. It can look misleading and from the beginning grows deeper into the skin, which makes it more dangerous than the other types. 
A melanoma type on hands or feet is called acro-lentiginous melanoma (ALM)
It can start under a nail or hide between fingers or toes and therfore is sometimes misdiagnosed as fungal infection or wart for some time and is left growing. This makes it dangerous. 
This melanoma type is rare but is the most common type in persons with dark coloured skin. 

To diagnose a melanoma is not always simple and often a dermatoscope is being used
to get deeper insight into the pigment structure of a skin tumor.
There are also some computer systems in use that offer image analysis as a second expert oppinion for correct melanoma recognition. There are several ways to find out what a pigment spot is, but some doubt is left with a precision of 95% in expert physicians.  That means an uncertanty of one case in 20.
So, if there is a doubt,
a pigment spot should better be taken out. 

Risk factors 
Known risk factors to develope melanoma are: 
- fair coloured skin with, freckles and red coloured hair,
- easy sun burn
- persons with numerous moles, adults with more than 50 moles,
- severe sun burns in childhood, 
- melanoma in first degree family members, 

Standard treatment is surgical removal of the
suspicious spot soon in local anaesthesia. For melanomas there are
safty margins around the melanoma known to be necessary, depending on
the thickness of the melanoma, which is expressed in the tissue
analysis later. This makes a second excicion necessary in case of an unexpected melanoma, 
according to the known guidelines in your country. 

For example:
if it is clear it is a melanoma and it is
assumed to be less than 2mm thick, it can be removed at once with 1cm safty margin. (valid for Germany) 
For precursor melanomas (in-situ melanomas) 0.5cm is necessary.
For melanomas up to 2mm
tumor thickness 1cm margin is needed.
For melanomas with more than 2mm thickness 2cm safety margin is recommended. 

For melanomas with more than 1mm thickness also the
removal and examination of the sentinel lymph node is recommended, to be able to give an accurate prognosis
and decide, if more treatment
options are applicable.
In more advanced cases an adjuvant treatment
with interferon or other chemotherapy modalities sometimes are considered, but this is not a gereral rule and needs an expert doctor
or clinic as a reference for the patient. 

Follow up 
As for melanomas with less than 1mm thickness metastazation is very unlikely,
follow up the full examination of the skin and of all moles is what is recommended twice a year in the first 5 years, after that once a year. 
With tumor thickness above 1mm besides sentinel lymph node removal ultrasound of local lymph nodes, chest x-ray and some blood tests are recommended:
LDH, AP and S100.

More details can be found
in the national guidelines .



Basal cell carcinoma (BCC) or Basalioma

The most common type of skin cancer is BCC or Basalioma. It occurs about five times more often than melanoma in caucasian population. 
Again the sunburn sensitive skin types are more at risk.

BCCs start from the surface of the body from the cells of the basal cell layer in the skin that is responsible for the regeneration of the skin surface, sometimes they can start deeper down e.g. from a hair bulb.

Important to understand is that cancer can spread by metastazation, but BCC does not do this. 

BCC can occur in several places on the body over time and is most often found in elderly people around their seventies. There are tendencies to develope Basaliomas running in some families. 

Basaliomas most commonly are found in the face, but can occur anywhere on the body, preferrably on sun exposed areas, like chest, arms or trunk or even on the scalp.

Most BCCs start as a skin coloured spot, sometimes scaling, sometimes as a little sore, not quite healing away and coming back over month, growing in size very slowly. 
The general growth is in size, but not in depth, only when left unattended over years it can grow deep and after 10 years or more reach bones and can invade vital structures. 
Most BCCs are pink or scaly, but some are pigmented or some are even black. BCCs are sometimes not easy to distinguish from seborrhoic keratoses (age warts). 
There are always some exceptions to this and also some BCCs directly grow deeper down.

Click on images for magnification



case 1

case 2

case 3




case 4

case 5

case 6


There are different types of BCCs described:
There is a solid type, a nodular or cystic type. With these types we can see the actual size, but there is s scleroderma type of BCCs that grows underground, where it is quite difficult to find where it ends when trying to remove it.

Very rarely there are borderline BCC types named metaplastic BCCs that mix with squamous cell carcinoma and have a small risk of metastazation.

How to diagnose a BCC
Beside the more or less typical look and the slow developement again it needs the expert´s examination, supported with a magnfying glass or better with a dermatoscope. There one can see the typical structures of pigmentation and typical blood vessels, if present.

There are a variety of treatment modalities possible, but treatment of first choice is surgical excision. 
If an operation is not possible or being refused there is radiation therapy, photodynamic therapy, Imiquimod cream for superficial cases, or 5-Fluor Uracil cream, cryotherapy with liquid Nitrogen or curettage. 
Decision is made by the physician on individual factors and available means.
The recurrence rate that a BCC can grow back is still around 5% with best treatment applied.

Follow up
There are no fixed rules. We recommend the first follow up after treatment after 3 month, than about twice a year and according to the type of BCC, type of treatment and the needs of the patient. There are no blood tests or x-rays useful.

More details can be found in the national guidelines .


Squamous cell carcinoma (SCC)

squamous cell carcinoma

SCC on the back of a hand.

It is less common than BCC, but similar in growth habits. In rare cases a metastazation may occur. Mainly found is SCC on sun exposed skin areas of elderly people. On the lower lip it is found in smokers growing with a more agressive behaviour.
Surgical removal is treatment of first choice. In some cases radiation therapy can substitute excision, if surgical thearpy is unwanted or not possible. Ultrasound of regional lymphnodes may be useful, no bloodtests are indicative.