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Melanoma: The Cancer Saga!

malignant melanoma treatment

What Is Melanoma?

Melanoma is the name given to the cancer of the cells containing the melanin pigment in the skin. These cells are known as melanocytes. Many a times melanoma may spring up in an already existing wart or mole and proceed towards abnormal multiplication. Melanomas are usually found on the skin; however they may also involve mucus membranes of the oral cavity, intestines and the eye. It most commonly affects the thighs and legs in women and the upper back in men, considering these areas are prone to intermittent sun exposure. It can rarely be found in the nape of neck, stomach, arms and genital areas. It has an equal predilection of occurrence in both men and women; attributes its cause to the ultraviolet light and radiation. Off late, it has been considered as the most dangerous forms of skin cancer, leading to life threatening conditions.

Causes of Melanoma:

  • Ultraviolet Radiation: A majority of melanomas occur due to exposure to ultraviolet UV light. The UV light has a tendency to get absorbed by the DNA present in the nucleus of the skin cells. The radiation brings about an abnormal mitosis of the nucleus and brings about an increase in the number of cells eventually. The newly formed nucleus is weak in structure and organization and in turn undergoes rapid multiplication along with excessive production of melanin pigment which imparts blackish brown hue to the cancer areas.
  • Decreased Immune system: A reduced immune system does not make the leucocytes and macrophages available to fight the cancer cells and thus the invasion of cancer in the body becomes very easy.
  • Existing wart/mole: A wart or mole can always serve as an ideal site for the multiplication of the melanocytes. The trigger again will be UV radiation, exposure to sun, smoke. Sunburns also have a tendency to transform into melanomas.
  • Genetics: There are a few classes of genes which have a tendency to undergo mutations owing to the exposure of UV light. Once mutated, the genes also have a tendency to pass on the defect to the next generations.
  • Climatic conditions: People residing closer to the equator are more prone to melanomas considering the intensity of sunlight will obviously be very high.

Signs and Symptoms of Melanoma:

  • Appearance of a mole/wart at an unobvious place on the skin
  • Change in the size and shape of an already existing mole
  • Bleeding, itchiness, ulceration, pain in and around the mole/wart
  • Sudden increase in the number of warts/moles in the body
  • Asymmetrical lesions, more than 6 mm in diameter
  • Lymph nodes adjacent to the lesion are palpable, tender

Classification of Melanoma:

There are two methods of classifying melanoma. First is based on the histopathology of the tumor, second on the survival rate depending on the stage of the cancer.

Based on the histopathology:

  • Lentigo maligna: It is a malignant and non invasive form of melanoma
  • Lentigo maligna melanoma: It is a precursor to melanoma, again  on invasive in nature
  • Superficial spreading melanoma: It is the most common form of cutaneous melanoma, occurring in the elderly people in the sun exposed skin surfaces.
  • Acral lentiginous melanoma: It is found at the nape of neck, shoulders and thigh regions in darker individuals.
  • Mucosal melanoma: This is a rare type of melanoma involving the mucus membranes of the intestines, mouth and eyes.
  • Nodular melanoma: Most aggressive form of melanoma, arises on a normal skin texture, increases rapidly in size and thickness
  • Polypoid melanoma: It is a variant of nodular melanoma, occurs due to an added viral infection
  • Desmoplastic melanoma: A rare form of melanoma, occurs when the lesion crosses the epidermis and the dermis and invades the fibrous matrix.
  • Vaginal melanoma: an aggressive and incurable form of melanoma, occurs in the vaginal epithelium in the elderly women
  • Uveal melanoma: Tumor arising in the choroid plexus and iris of the eye, has a genetic heretibility
  • Melanoma with small nevus like cells: These are nests of melanocytes that grow abnormally and show variable colors. Histologically, the nucleus is also variable in size and shape.
  • Melanoma with features of a split nevus: This is similar to melanoma with small nevus like cells except that it has a well defined nodule amongst the lesions of the tumor.

Based on the stage of cancer and survival rate:

1. Stage 0: Melanoma in situ (99 percent survival rate)

2. Stage I: Invasive melanoma (85 to 95 percent survival rate)

    • T1a: Less than 1.0 mm primary tumor thickness, without ulceration, and mitosis < 1/mm2
    • T1b: Less than 1.0 mm primary tumor thickness, with ulceration or mitoses ≥ 1/mm2
    • T2a: 1.01–2.0 mm primary tumor thickness, without ulceration

3. Stage II: High risk melanoma (45 to 75 percent survival rate)

    • T2b: 1.01–2.0 mm primary tumor thickness, with ulceration
    • T3a: 2.01–4.0 mm primary tumor thickness, without ulceration
    • T3b: 2.01–4.0 mm primary tumor thickness, with ulceration
    • T4a: Greater than 4.0 mm primary tumor thickness, without ulceration
    • T4b: Greater than 4.0 mm primary tumor thickness, with ulceration

4. Stage III: Regional melanoma (25 to 70 percent survival rate)

    • N1: Single positive lymph node
    • N2: Two to three positive lymph nodes or regional skin/in-transit metastasis
    • N3: Four positive lymph nodes or one lymph node and regional skin/in-transit metastases

5. Stage IV: Distant metastasis (7 to 20 percent survival rate)

    • M1a: Distant skin metastasis, normal LDH
    • M1b: Lung metastasis, normal LDH
    • M1c: Other distant metastasis or any distant metastasis with elevated LDH

Diagnosis of Melanoma:

  • Visual inspection by the dermatologist: This is the most common and the first line of diagnostic tool. The number of moles is counted, observed for any changes in size, colour, rugged borders and edges. The moles are checked for any signs of bleeding. 
  • Physical examination: This involves palpation of the lesion to check for any signs of pain or tenderness. The surrounding lymph nodes are palpated for their increase in size and number, also tenderness.
  • Dermatoscopy/Confocal microscopic examination: This is a diagnostic tool that the dermatologist uses in order to view the lesion. This method is used when the daylight or the clinical light is inadequate to view the lesions. It focuses light on the lesions and enlarges the area in particular so as to check for the color changes and the edges and borders of the lesion.
  • Biopsy: This involves excising a part of the lesion and sending it to the labs for histological examination in order to study the type, nature and degree of the cancer. Also to confirm whether it is a cancer or not. Various kinds of biopsies can be indicated and contraindicated for all types of melanomas. Biopsies are always done under local anesthesia. The elliptical type of excision biopsy removes the tumor totally and is sent to the pathology labs for histological examination. A punch biopsy is seldom done in melanoma since there will be a possibility of spreading the lesion to blood or the lymph vessels and promote metastasis. Biopsy is also advised for the lymph nodes where a small node is excised and studied in histo pathological slides to determine the metastatic nature of the cancer.
  • Lactate dehydrogenase test LDH: The LDH levels in blood are raised when the melanoma has initiated metastatic nature via the blood and/or lymph vessels. Thus the raised levels of LDH in blood can give an estimation of malignant melanoma.
  • Total body photography: This is the photographic examination of the maximum surface area of the skin of the body to rule out the possibility of melanomas. It can be done at any stage in life to rule out the pathology, done as screening method or done when a single melanotic lesion is detected so as to know the other parts affected with it.

Treatment Procedures of Melanoma:

  • Surgery: The standard method is to excise the lesion completely along with a small surrounding border of healthy tissues so as to prevent recurrence. This however is always followed by a timely check up for recurrence and if needed, an additional surgical excision is performed. The sentinel lymph node biopsy is the surgical procedure done to remove the lymph nodes when the lesion becomes metastatic and involves the adjacent lymph nodes. Nevertheless, frequent checking is always needed to keep a track of the lesion if in case it recurs.
  • Radiation therapy: This is the method used for stage II and III melanomas where a beam of photons is directed towards the lesion. Photons have a tendency to cause degradation of the nucleus of the cells and thus kill the cancer cells. The dose, frequency and radiation exposure is decided by the dermatologist and the onco surgeon and conveyed to the radiotherapist. Radiation therapy is can be the sole treatment or can be done as an adjunct to surgical procedure. Many a times it is done prior to the surgery so that the lesion shrinks in size and the removal becomes easier.
  • Chemotherapy: Another line of treatment of skin cancers and melanoma, is the technique of using a combination of lethal drugs to bring about disintegration of the cancer cells. Again here, the dose, type of drug or combination of drugs used along with the frequency and mode of drug administration is decided by the dermatologist and the oncologist. Most commonly method used for administration of drug is the intravenous injection method.
  • Targetted therapy: These are medications given to the patient with melanomas where they target the metabolic functions of the cancer cells. These functions are the proliferative abilities of the cells to multiply rapidly, the function where they rapidly utilize the nutrients from the surrounding tissues. These include BRAF inhibitors, C kit and NRAS inhibitors. 
  • Immunotherapy: This is the line of treatment opted to enhance the decreased immunity of the patient suffering from melanoma, considering a boosted immune system will help the individual to fight the cancer cells quite efficiently. This involves administration of artificial immune cells into the body, such as cytokines, adoptive cell transfer and immune check point inhibitors.
  • Oncolytic virotherapy: This method is under trial and studies and is practiced in quite many countries. It is used to kill the cancer cells and increase the life span of the individual. Oncolytic viruses are used to increase the metabolism of the body, reduce the anti tumor immunity and disorganize the vasculature.

Prevention:

Avoiding ultraviolet radiation: The best preventive way is to keep out of reach of UV rays, wear full body covered clothes if you happen to reside near the equator and also avoid sunburns and sun beds.

Use of sunscreen: This is an additional preventive way where use of sunscreens will form a layer over the epidermal layer and avoid the initiation of melanoma.

Complications and Risk Factors Associated With Melanoma:

  • Scarring and infections at the site of wound after the excision biopsy has been done
  • Nausea, vomiting, general weakness, hair loss which occur as side effects of radiation and chemotherapy sessions
  • Lymphoedema, this occurs when the lymph nodes are removed due to the metastatic nature of the cancer and the removal leads to building up of lymph fluids
  • Depression and anxiety that comes along with the detection of cancer, post surgical removal, at or during the chemo and radiation sessions
  • In almost 20 percent of cases, there are chances of recurrence
  • Wrinkling, dimpling of skin, change in the texture of skin where once the melanoma lesion was present.

Am I Good Candidate For Melanoma Treatment?

If you happen to fall into any of the categories below, you surely are an ideal candidate for melanoma treatment:

  • Stage II and III call for a surgical removal
  • Melanoma has invaded your lymph nodes, calls for an excision for sure
  • Widely spread to major parts of your skin
  • Lesions greater than 4 mm in diameter with or without ulcerations

Recovery Time:

It is common to recover from the lesion within one to two weeks after the surgical removal has been done. However if lymph node removal is also attempted, then the recovery extends by one to two weeks more. the patient is advised to visit the doctor in concern timely for the early detection of recurrence.

Success Rate of Melanoma:

The early the melanoma is detected, the more are the success rates. Chances of success for a period of five years for stage I melanoma are 98 percent. The same for stage II and III lies in the range of 57 to 68 percent. The least chances of success are for the stage IV where only intermittent radiation therapy and chemotherapy sessions are used to prolong the life and reduce the cancer symptoms.

Benefits of Melanoma:

Treatment of melanoma at the correct time will help you in the following ways:

  • Primarily it will avoid the complication of metastasis and the invasion of lymph nodes
  • Prevent ulcerations, bleeding and itching from the moles/warts/lesions
  • Save you from the unnecessary pain and discomfort
  • Avoid radiation  and chemotherapy sessions, save your time and energy

Cost Comparisons:

Surgical removal, a single session of radiation/chemotherapy or immunotherapy will cost you around 3000 INR as opposed to 10,000 USD which you will be required to pay in the United States

Why choose India?

Considering the versatility of medical treatments available in our country on such a wide scale, it gives our team an immense pleasure in providing assistance and guidance for all types of medical ailments, inclusive of melanomas. From the charges to the treatment outcome, we make sure our medical tourists are given the best of treatments without any hassle and totally cost effective.

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