Posted: January 8th, 2023
Mr. B, a 40-year-old avid long-distance runner previously in good health, presented to his primary provider for a yearly physical examination, during which a suspicious-looking mole was noticed on the back of his left arm, just proximal to the elbow. He reported that he has had that mole for several years, but thinks that it may have gotten larger over the past two years. Mr. B reported that he has noticed itchiness in the area of this mole over the past few weeks. He had multiple other moles on his back, arms, and legs, none of which looked suspicious. Upon further questioning, Mr. B reported that his aunt died in her late forties of skin cancer, but he knew no other details about her illness. The patient is a computer programmer who spends most of the work week indoors. On weekends, however, he typically goes for a 5-mile run and spends much of his afternoons gardening. He has a light complexion, blonde hair, and reports that he sunburns easily but uses protective sunscreen only sporadically.
Physical exam revealed: Head, neck, thorax, and abdominal exams were normal, with the exception of a hard, enlarged, non-tender mass felt in the left axillary region. In addition, a 1.6 x 2.8 cm mole was noted on the dorsal upper left arm. The lesion had an appearance suggestive of a melanoma. It was surgically excised with 3 mm margins using a local anesthetic and sent to the pathology laboratory for histologic analysis. The biopsy came back Stage II melanoma.
- How is Stage II melanoma treated and according to the research how effective is this treatment?
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- According to Melanoma Research Alliance (2021), survival rates have improved significantly additional adjunct therapy with Stage II at a 98.4%. This also depends on early detection and treatment.
- When it comes to treatment for Stage II melanoma, the standard treatment is a wide excision, which is a surgery to remove the melanoma and a margin of normal skin around it) is the standard treatment for stage II melanoma. The width of the margin depends on the thickness and location of the melanoma. Sentinel lymph node biopsy (SLNB) is usually recommended when the doctors think the melanoma has spread to nearby lymph nodes. No further treatment is needed if no cancer cells are found in lymph nodes after an SLNB is done, although close follow-up is still essential. On the other hand, if cancer cells are found after SLNB, then a lymph node dissection a procedure where all the lymph nodes in that area are surgically removed. One other option apart from lymph node dissection is to closely watch the lymph node by doing a regular ultrasound.
- Skin cancer can be divided into three main types; melanoma, cancer that forms in melanocytes, basal cell carcinomas (BCC); these cancers are found in the lower part of the epidermis, and squamous cell carcinomas (SCC), which is located in the flat cells form on the surface of the skin (Huether et al., 2020). Out of these three, melanoma is the most lethal form of skin cancer. (Huether et al., 2020). It does occur at most sites, but some places are more common than others (Ward et al., 2017). Cutaneous melanoma is known to be responsible for the majority of skin cancer-related deaths in the United States. Exposure to ultraviolet rays is the most important modifiable risk factor among environmental exposures (Ward et al., 2017).
- Amandeep KaurSubscribe
- Amandeep Kaur posted Feb 3, 2021 6:05 PM
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- Melanoma is a form of skin cancer that develops in melanocytes. Melanocytes are basilar cells of the skin responsible for skin tone (Davis, Shalin, & Tackett, 2019). Individuals who have light skin that does not tan, blond or red hair and light eyes have a high risk of developing melanoma. This is due to the low amount of eumelanin compared to pheomelanin (pigment produced by melanocytes) which protects the skin from the ultraviolet rays of the sun. Pheomelanin can produce more ultraviolet-A-induced reactive oxidative species (ROS), this damages DNA. Stage II melanoma is when the invasion of the skin extends 0.76 – 1.5 mm, and it has spread to lymph nodes. This is indicated by Mr. B’s physical exam. Treatment of melanomas includes surgical resection, chemotherapy, targeted therapies, and immunotherapies. Since this is a stage II tumor oncologists are most likely to initially suggest an excision of the mole with wide margins. Margins should be 2-3 cm whenever it is anatomically possible (PDQ Adult Treatment Editorial Board, 2021). The wide margins are to ensure there are no cancerous cells left on the skin. This was not adequate with Mr. B as there were 3mm margins indicated. A study was conducted to assess the effectiveness of 1 cm and 3 cm margins and it showed that 1 cm margins had a higher rate of local recurrence. Following the excision, a sentinel lymph node biopsy can be completed of Mr. B’s left axillary region lymph node. This region has a hard, enlarged, non-tender mass. If the lymph node had cancerous cells, the remaining lymph nodes in the region are removed. Studies indicate that these biopsies have a false negative rate of 0%-2%. Targeted therapy can also be used if there is a BRAF mutation; BRAF inhibitors, vemurafenib, dabrafenib (Davis, Shalin, & Tackett, 2019). These drugs are very effective in 50% of individuals with BRAF mutation. However, many individuals do develop resistance to these drugs. Stage II has a higher rate of survival than if the cancer were to metastasize and progress to Stage III or IV.Davis, L. E., Shalin, S. C., & Tackett, A. J. (2019). Current state of melanoma diagnosis and treatment. Cancer biology & therapy, 20(11), 1366–1379.