Skin cancer (melanoma)


Melanoma affects more than just the surface layers of the skin. It can easily penetrate the underlying tissues and pass into other organs and systems.

Malignant melanoma

Each year in Europe, more than 100 000 melanoma patients, and deaths from this disease exceed 20 000 per year. These data determine the social significance of the disease, illustrate the need for early diagnosis of the disease and the drive to introduce new drugs into oncology practice. Melanoma malignant cells originate from cells, called melanocytes, which are normally present in the skin (also in eye structures, the meninges, etc.) to all people. Melanocytes produce and are filled with pigment, which gives the color to the skin. The transformation of these normal skin cells into tumor cells is a genetic process, which is started and maintained by the body's exposure to ultraviolet light. The main ways of prevention and early diagnosis of the disease are self-monitoring and regular preventive examinations by a dermatologist. The moles (the nevi) are benign skin growths, composed primarily of melanocytes. Malignant melanoma can occur both on an underlying nevus, underwent a transformation, as well as on a section of skin, where there was no mole. Dynamic monitoring of nevi is the basis of early diagnosis of melanoma.

Risk factors

As you age, the risk of melanoma increases. Most cases of melanoma affect people over the age of 30. Studies show, that in women under 40 years has a higher risk of developing skin cancer, while in men the risk rate increases after this age.

Risk groups include:

  • Smokers
  • HPV carriers (human papillomavirus)
  • People, have undergone radiotherapy with a history of melanoma or non-melanoma skin cancer
  • People with weakened immune systems or people, who have had contact with harmful chemical substances
  • In humans, who suffered sunburn in childhood, there is an increased risk of skin cancer later in life
  • Light skinned people (and/or flammable), in the presence of freckles and more moles.
  • A family history of melanoma – people with a genetic burden. 1 to everybody 10 Melanoma patients have a family history of skin cancer. Some people have a genetic predisposition to the disease, that's why it's important, if the family has been diagnosed with this disease, to carry out active prevention
  • People, whose skin is damaged by trauma or long-term inflammation. Any wounds, appeared on the skin for no apparent reason, may turn out to be cancerous. Wounds, which do not heal, subside and reappear, blistered or reddened areas, should be consulted with a specialist

Risk factors include:

  • Prolonged exposure to ultraviolet light (constant exposure to the sun), living in a climate zone with more sunshine or higher altitude, outdoor work environment with direct sun exposure.
  • Solarium use – studies show, that tanning bed use increases the risk of melanoma. Just one exposure to a tanning bed can significantly increase the risk of squamous cell carcinoma Ultraviolet light, taken directly from the sun or from a solarium, is a strong risk factor, which multiplies the risk of malignancy of the skin. It leads to changes in the DNA of the cells, which can even cause cancer in other organs and systems.

Melanoma has the ability to spread to all organs of the body and be life-threatening.

Some melanomas grow radially on the surface of the skin (horizontally on the skin), without going significantly in depth. Others grow vertically, deep into the layers of the skin. Early detection is especially important, as the success of treatment is directly related to the depth of invasion (penetration) in the skin. Melanomas can appear on any part of the body.

Diagnostics and screening

  1. Using a mirror in a well-lit room, check your face, the neck, shoulders, hands, chest, abdomen, thighs and lower legs.
  2. Turn sideways, raise your hands and carefully examine the right and left sides of your body, including the armpit area.
  3. With a small mirror, check your upper back, neck and scalp. Next, examine the lower back, the buttocks, the back of the thighs and calves.
  4. Examine your forearms, palms, the back of the hands and nails, the skin between the fingers.
  5. Finally, check your steps - the upper parts, the fifth, toenails, the fingers and the skin between them. When examining your skin, don't forget to examine your mouth, scalp, the feet, the nails, the genitals. Melanoma can form on any part of the body, that people forget to check. Such as melanoma, which start in the nail bed, most often appear as a persistent black or brown vein in the nail plate. Most melanomas are black or brown in color, but they can also be the color of the skin, as well as pink, red or purple color. External signs of malignancy of a benign nevus are the change in shape, its size and color, the presence of inflammation (redness, swelling, warming up) around him, the appearance of itching, peeling and bleeding. The reasons for the transformation of nevi into melanoma are various. Most often, a mole on exposed parts of the body is activated under the influence of the sun's ultraviolet rays. Moles are also dangerous, located in places, where the hard edges of clothing constantly irritate them – for example, the rough collar of a shirt, trouser belt, the edge of the shoes. Melanoma can be suspected if even one of the criteria below is met, and according to its appearance it may correspond to 2-3 or even all of them 5 the criterion (from A to E).

Clinical diagnosis

The clinical diagnosis is based on several signs, identified in a diagnostic algorithm – the ABCDE system.

  • (BUT) (Аsymmetry) Asymmetry in the shape of the lesion. The shape of one half does not match the shape of the other half.
  • (AT) (Border) The borders of the nevus are irregular, unclear.
  • (WITH) (Color ) Color In case of malignant transformation of a mole, different intensity of color is observed in its individual parts, as well as different shades of color - from flesh, brown or black, to sometimes white, red or blue in the different zones of the entity. Achromatic ones are also found (colorless) melanomas, which are difficult to diagnose and treat.
  • (D) (Diameter) Diameter greater than 6 mm (the size of a pencil eraser).
  • (E) (Evolving) Elevation – the lesion is raised relative to the surrounding skin and there has been a change in the condition of the mole in the last few weeks.

What to do, if you notice a change in an existing mole, appearance of a new mole or other change on the skin?

The recovery rate for melanoma is high, as long as it is treated before metastases occur. Frequent checkups are the best method for early diagnosis. Patients should notify their physician, if they notice a new or change in an existing mole. The general practitioner may refer the patient to an oncologist in the presence of unusual moles or other changes, related to the skin. Do not burn or remove moles without medical intervention. See a specialist dermatologist, who will recommend the most appropriate treatment and examine the removed entity, to know for sure whether it is benign or malignant.

For the diagnosis of pigmented skin formations, a dermatoscopic examination by a specialist in dermatology is recommended.

How to reduce my risk of melanoma?

Avoid sun exposure, when it is strongest and never use solar lamps or tanning beds. Always use a sunscreen and lip balm with UVB and UVA protection and a sun protection factor 30 or more even on cloudy days. If you are exposed to the sun, follow these precautions:

  • Wear clothes, covering the skin, and a hat to protect the face, ears and neck. You may consider wearing sun protective clothing.
  • Wear sunglasses, which filter 100% from UV light, to protect your eyes and the skin around them.
  • Apply sunscreen at least 20 minutes before going outside, as well as everyone 2 hours after that.
    Stay in the shade, when you can. A tan is not a sign of good health, a risk factor for skin damage.
  • Be aware of additional factors, which may increase the risk of sun exposure. Taking medications such as antibiotics, diuretics and retinoids increase sensitivity to the sun.
  • Consult your doctor about all medications, that you take.
  • Check your skin yourself regularly, to detect any changes as early as possible, if any, tell your doctor.
  • Keep children out of the sun. Childhood sunburns may increase the risk of skin cancer later in life. Set a good example for your children and teach them safe sun exposure habits.
  • Plan every examination with a specialist every year.

Choosing a sunscreen product

Choosing the best sunscreen isn't all about finding the product with the highest SPF (SPF). Because and UVA, and UVB rays cause skin damage, choose broadband or multispectrum protection, which protects against both types of UV rays. The ingredients, which it is advisable to look for, include oxybenzone, titanium dioxide, zinc oxide, avobenzone, sulisobenzone and ecamsul. For UVB protection, use a sunscreen with SPF 15 (and taller, if you fall into a risk group for skin cancer or have increased sensitivity to the sun). The SPF factor shows how much the product protects against sunburn due to UVB rays. For example, if you normally burn at the 10th minute, product with SPF 15 multiplies this time by 15. This means, that you can be in the sun for 150 minutes before you burn out. SPF 30 multiplies time by 30 and so called. Do not forget, that SPF 30 not twice as strong as SPF 15, when it comes to filtering the rays. SPF 15 filters 93% from UVB rays, and SPF 30 – 97%. Select a product, which is sweat and water resistant, if you will be active or in water. If the products are not waterproof, should be applied regularly. For children over 6 months of age, choose a children's sunscreen. These products are chemical free, which would irritate sensitive children's skin. Children under 6 months of age should generally not be exposed to the sun.


Dermatoscopic examination

Not all moles are the same. To assess the potential of moles for malignant transformation, examination with a dermatoscope is necessary. Dermatoscopy is a non-invasive medical procedure, through which with a magnifying glass (magnifying glass) the surface of the skin is examined and morphological changes are looked for, invisible to the naked eye. Videodermatoscopy is a modern variant of dermatoscopy, in which the examination is conducted using a video camera, by which the data is projected onto a video screen, where they are better analyzed. The increase is up to 1000 times. This is a rapid indicative method for evaluating skin neoplasms - melanoma, basal, squamous cell carcinoma, parasitic infections, psoriasis, nail diseases, the hair follicle, scalp and others. If your dermatologist finds an area suspicious for skin cancer, he will cut out the lesion for microscopic histopathological examination - a biopsy. A dermatologist can easily perform this procedure in an outpatient setting.

t for subsequent treatment of the disease, as well as for the resolution of more complex oncological cases.


Nevus biopsy (a mole) is taken by most often cutting out the entire mole wide and deep, to prevent cancer cells from spreading into the cut blood vessels and causing early spread throughout the body.

If the biopsy reveals the presence of cancer, additional treatment is necessary. In cases of early detection, surgical treatment may be sufficient. In more advanced cases (especially when spreading to other organs) treatment protocol may vary. Treatment depends on the type of cancer, its prevalence and its location, as well as the individual characteristics of the patient.

Whatever the external or dermatoscopic appearance of a lesion, definitive diagnosis is made by histopathological examination. If melanoma is suspected, the entire lesion must be excised for histopathological examination. Extremely rarely, it may be necessary to compromise and remove only part of the lesion for histological examination.

If the biopsy shows melanoma

Carrying out imaging studies is suitable for already histologically proven melanoma to clarify the spread of the disease. In the course of the diagnostic search, computed tomography is used to prove distant metastases (CT), Magnetic resonance tomography (MRT) and positron emission tomography (FRI/CT).


The American Academy of Dermatology - the largest professional community of dermatologists, classified 5 stage of melanoma:

Stadium 0 Melanoma is confined to the epidermis (the top layer of the skin).

Stage I: Melanoma has become more- dense. It can have a thickness of up to 1,0 mm.

Stage II: Melanoma has increased density. The thickness varies from 1,01 mm up over 4,0 mm. Stage III: Melanoma has involved one or more regional (close ones) lymph nodes or surrounding skin.

Stage IV: Melanoma has spread to an internal organ or lymph nodes, distant from the primary tumor or established on the skin in situ, distant from the primary focus.



Melanoma can be removed surgically, by removing the tumor along with some of the healthy skin around it. In certain cases (when the disease is in an early stage) this may be the only treatment needed. When the melanoma has spread beyond the skin to nearby or distant lymph nodes and/or other organs, additional surgery and/or drug treatment is required. Radiation therapy has a limited role in the initial therapeutic plan and is discussed as a method of palliative treatment of symptomatic metastatic foci.. Except as a palliative treatment, radiotherapy can be used for multiple affected lymph nodes as adjuvant treatment after surgery or for a small number of metastases as stereotactic radiosurgery. There are three main branches in the systemic drug treatment of melanoma - interferon alpha, targeted and immuno-oncology therapy. How the drugs are combined and in what sequence they are administered depends on the genetic and molecular characteristics of the melanoma, according to the condition and accompanying diseases of the patient.

Steps in Melanoma Treatment

Surgical removal of the suspicious melanoma lesion is the main part of the treatment and should be done as soon as possible after the examination.. Early surgical removal of the mole can be life-saving. If no metastases are found, no further treatment is required, but patients are subject to periodic examinations for possible recurrence. If metastases are found, further behavior includes: chemotherapy, immunotherapy, radiation therapy, surgery and compulsory medical examination.

Immuno-oncology therapies

Data from clinical trials show, that the effects of immuno-oncology therapy on cancer cells can last for a long time, training the immune system to fight cancer cells even after remission. Therefore, different types of immuno-oncology therapy can have an extremely positive impact on patients' ability to return to work and lead a fulfilling life.. Immuno-oncology therapy is currently available for patients with advanced melanoma. In certain cases, a necessary condition for carrying out such therapy is the proof of a specific mutational status, as established in a genetics laboratory.

Sometimes targeted therapy is administered alone, and in other cases together with classical chemotherapy. Modern hormonal treatment is an integral part of medical treatment (endocrine) therapy, which is extremely important in prostate cancer. With them, in certain cases, endocrine therapy can also be preceded by classical chemotherapy.

Source: Bulgarian Oncological Scientific Society (BOND)



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