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& Health Medical M C For many people, the desire to be outdoors and in the warm summer sun is hard to resist. The warmer months are filled with people cycling, walking and jogging, gardening or just relaxing in the outdoors. While this is enjoyable, what is often overlooked is that unprotected skin is susceptible to damage, especially from the potentially harmful rays of the sun. Although many of us may be in the routine of packing sunscreen for the beach, everyday sun exposure can be damaging as well; thus, it is important to protect the skin dayto-day. Various skin cancers may occur that can be directly attributed to the amount of sun (ultraviolet radiation) that we are exposed to. A common misconception is that skin cancer only occurs in the elderly. This is far from the truth as skin cancer can occur in the young as well. The three most common skin cancers that everyone should be aware of include basal cell carcinoma, squamous cell carcinoma, and melanoma. Although squamous cell and basal cell carcinomas are the most common, melanoma is the most dangerous. While it is hard to predict exactly who will get skin cancer, there are factors that play a role such as skin type, hair and eye color as well as history of indoor tanning use, sun exposure and burning. Fortunately, there are many sources of information that can be accessed to better understand ones risk of developing skin cancer and how to take the appropriate steps to minimize that risk (American Cancer Society). This article will focus on melanoma and review relevant epidemiologic data as well as anatomy, prevention, identification, and treatment. Current statistics from the By Maurice Nahabedian, MD, FACS Professor of Plastic Surgery Georgetown University Hospital Maurice Nahabedian, MD, FACS is currently a Professor of Plastic Surgery, Vice Chairman for Clinical Affairs, and Chief of the Division of Microvascular Reconstruction in the Department of Plastic Surgery at Georgetown University Hospital. His primary clinical and research interests are focused on breast as well as abdominal wall reconstruction. He has published over 130 manuscripts, editorials, and discussions as well as 42 book chapters on a variety of topics that include breast reconstruction and abdominal wall reconstruction. Dr. Nahabedian Melanoma Update: 2013 American Cancer Society are that invasive melanoma ranks fifth in men and seventh in women as the most common cancers. Its incidence has increased every year for the past 30 years. It is estimated that 76,690 people will be diagnosed with invasive melanoma in 2013 of which 45,060 will be in men and 31,630 will be in women. It is also estimated that about 9,480 people will die of melanoma this year. This represents about 80% of all deaths due to skin cancer. Survival is directly related to the stage of the melanoma with 5-year survival rates that range from 95% for stage I melanoma all the way down to 2% for stage IV melanoma. As the incidence of melanoma continues to increase worldwide, many epidemiologists and physicians are promoting awareness campaigns to slow down and reverse this trend. It is important to remember that prevention is the number one strategy in avoiding skin cancers. . There is a direct link between ultraviolet (UV) radiation and the incidence of melanoma. For that reason, it is important for people to limit their sun exposure, especially in those with fair skin who may be at higher risk for Friday, July 12, 13 10 & developing skin cancer. The use of sunscreens is recommended by dermatologists and the American Cancer Society to reduce the skin damage that is caused by ultraviolet radiation. Sunscreens come in various degrees of sun protection factor (SPF) that should be selected based on one’s skin type. The use of a broad-spectrum water resistant sunscreen of at least 30 or higher, avoiding sun exposure during the peak hours between 10 AM and 4 PM, as well as wearing protective hats and clothing is recommended. Sunscreen should be applied liberally and reapplied every 80-90 minutes or after Anissa G. Nahabedian, R.N., B.S.N Baltimore, Maryland swimming. Recent studies have also found that UV-A radiation found in artificial tanning units is 15-20 times stronger than midday natural sun. (Autier, 2010) It is recommended that people check with their primary care provider or dermatologist to determine what is best for them. It is a well known fact that melanoma is the most dangerous and deadliest of the three skin cancers for several reasons. The first is because it can mimic a benign pigmented lesion that may be mistaken as a freckle or a mole. If left untreated, it can spread beyond Melanoma
& Health Medical M C has been the principal editor of 3 textbooks and co-edited 2 textbooks focused on reconstructive and aesthetic breast surgery and is in the process of completing a 6th textbook on abdominal wall reconstruction. He is the Section Editor for Breast Surgery with the Journal of Plastic and Reconstructive Surgery (PRS), serves on the editorial board for 3 other journals, and has reviewed manuscripts for 23 different journals. Dr. Nahabedian currently serves on the clinical symposia committee and the instructional course committee for the American Society of Plastic Surgery, is the PRS representative to the Joint Business Operations Committee, and is a frequent oral board examiner for the American Board of Plastic Surgery. In 2012, Dr Nahabedian chaired three national symposia that included the 4th Annual Abdominal Wall Reconstruction Conference, the Santa Fe Breast and Body Contouring Symposia, and the Challenging Complications in Plastic Surgery Conference. Dr. Nahabedian has also been a visiting professor 55 times over the past 8 years at various universities and hospitals around the country. its borders and metastasize to vital organs such as the lungs or brain. The second is based on its origin. The skin is composed of two layers, the epidermis (superficial layer) and the dermis (deeper layer). The dermis contains lymphatic channels that are linked to the lymph nodes that are scattered throughout the body. Basal and squamous cell cancers originate in the superficial layers of the skin and rarely spread to other areas of the body. These tumors are locally aggressive if left untreated but rarely result in loss of life. Melanomas on the other hand originate in the deeper layers of the skin where the melanocytes and lymphatics are located. Melanocytes are responsible for skin pigment and melanoma is a malignant tumor or these cells. Ultraviolet radiation can cause DNA changes in these cells promoting malignant cell growth. These tumors frequently will spread via the lymphatics to other areas of the body. The unrecognized melanoma can spread rapidly and can be lethal if left untreated. Evaluation of the Suspected Melanoma In light of the increasing incidence of melanoma, public awareness has improved. There has been extensive media coverage on this topic and plastic surgeons, dermatologists, and oncologists have been educating patients on prevention and management. As a result, patients with pigmented skin lesions are seeking attention with increased frequency. Fortunately, the vast majority of pigmented skin lesions are benign and normally do not require treatment. The decision as to which skin lesions require biopsy can be clinically challenging and sometimes difficult because of the diversity in the appearance. The clinical criterion that is currently used to evaluate a suspected melanoma is the “ABCDE” acronym. Pigmented lesions are commonly evaluated based on Asymmetry, Border, Color, Diameter, and Evolution. Many melanomas will be asymmetric and appear irregular with some parts of the lesion having a different appearance. The borders can also be irregular and can be ragged, notched, or blurred. The color of a melanoma is often dark but may contain different colors such as brown, black, blue, pink or white. The diameter of a melanoma is often greater than 6 mm but can sometimes be less. Finally, these lesions are evolving or continually changing over time. It is a good rule of thumb to biopsy any pigmented lesion that stands out on your body, is new, or has changed in behavior or appearance. Changes in appearance may include border irregularity, tone, color, and size. Changes in behavior may include bleeding, itching, and texture. Biopsy of the Suspected Melanoma There are a variety of biopsy techniques that include incisional, punch, excisional, and shave. The indications for each are varied and based on the clinical characteristics and location of the lesion. For pigmented lesions in which there is a low suspicion for malignancy, a shave biopsy is often performed that often does not include the full thickness of the lesion. This is a quick and simple office based procedure that usually heals nicely. For suspicious lesions measuring less than 1 cm in diameter, an excisional biopsy is usually recommended and should include the full thickness of the lesion and a 1 – 2 mm margin of normal skin. For suspicious lesions measuring greater than 1 cm in diameter, an incisional or punch biopsy is 11 usually recommended and should also include the full thickness of the lesion. These specimens are than sent to the pathologist who will evaluate the tissues for melanoma and provide a formal report usually within 1 week. In the event that the biopsy is benign, no further treatment is required. In the event that the biopsy is melanoma, additional surgery will usually be necessary and usually includes reexcision and a sentinel lymph node biopsy. Management of the Confirmed Melanoma In the event that the final pathology confirms the presence of a melanoma, further management is usually necessary. The melanoma will need to be re-excised with a wider margin of normal skin because these melanomas tend to spread through the lymphatic channels. These lymphatic channels lead to the lymph nodes that are concentrated in the armpit, groin, and neck areas. The appropriate margin of excision for a confirmed melanoma is based on the thickness of the melanoma. For melanomas that are less than 1 mm in thickness, a 1 cm margin of normal skin is excised. For melanomas that range from 1 to 2 mm in thickness, a 1 - 2 cm margin is recommended. For melanomas that are greater Maurice Nahabedian, MD, FACS Professor: Plastic and Reconstructive Surgery Georgetown University Washington DC than 2 mm in thickness, at least a 2 cm margin is recommended. Because these melanomas have a tendency to spread to the lymph nodes, a sentinel lymph node biopsy is usually performed. With this procedure either a blue dye or a radioactive tracer is injected into the dermis of the skin adjacent to the melanoma. These compounds enter the lymphatic channels and go to the regional lymph nodes. The first lymph node that acquires the compound is detected using specialized instruments and biopsied. If that lymph node has melanoma, then additional lymph nodes may be randomly removed and more advanced treatments may be required. A thorough description of the advanced treatment options for melanoma may be found by visiting the American Cancer Society website. In summary, as the incidence of melanoma continues to increase, public awareness and proper education is mandatory. People should be aware of the preventative maneuvers to reduce the incidence. Sunscreen and skin precautions should be utilized and careful skin examinations should be routinely performed looking for the ABCDE’s of melanoma. Early identification and treatment can result in longterm cure. 202-444-2000 DrNahabedian@aol.com www.MauriceNahabedian.com 3800 Reservoir Road, NW Washington, DC 20007
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