Skin Cancer and MELANOMA Treatment in Gurgaon India
Skin cancer is the most common cancer type observed in the United States (US). Skin cancer is mainly divided into 2 types, melanoma and non-melanoma skin cancers. The incidence rate of non-melanoma skin cancers is highest among all cancer types; however, due to the good prognosis, it accounts for less than 0.1% of all cancer-related deaths. On the other hand, melanoma accounts for about 1% of all skin cancers but causes most cancer-related deaths. Skin cancers are more common among older age individuals with most cases reported at an age between 55 and 74 years. In the US, the overall incidence and mortality of skin cancer have been increasing significantly during the last three decades.
Skin is the largest organ of our body that protects the internal structures from the harsh external environment. In an average adult, the skin weighs about 4.5 to 5 kg and covers an area of about 2 to 2.2 meter-square. The skin is made up of the epidermis (superficial non-vascular epithelial layer) and the dermis (deeper vascular connective-tissue layer). The epidermis can be divided into five layers: Stratum Basale, Stratum Spinosum, Stratum Granulosum, Stratum Lucidum, and Stratum Corneum. The epidermis is composed of mainly three types of cells: Squamous cells, Basal cells, and Melanocytes. The squamous cells are flat, keratinized cells located in the superficial epidermal layers that keep shedding due to constant wear and tear. The basal cells are cuboidal or columnar keratinized cells located in the deepest epidermal layer that constantly divide and give rise to the new cells. The new cells are pushed towards the surface and eventually become squamous cells. Melanocytes are specialized cells that produce melanin, a yellow-red to brown-black pigment that absorb harmful ultra-violet (UV) rays and protect the skin from harmful effects of UV light. Melanocytes are interspersed between other epidermal cells located in the deepest layer. The melanin produced by the melanocytes is taken-up by nearby cells, which impart a characteristic colour to the skin. These three types of cells give rise to the following three major types of skin cancers.
What are the Types of Skin Cancer?
There are more than 50 types of non-melanoma skin cancers with different behavior and characteristics. These are not discussed here.
Basal cell carcinoma (BCC)
BCC is the most common type of skin cancer and accounts for about 80% of all new skin cancers. It mostly develops due to high cumulative exposure to sunlight (mainly UV light) mainly in the Head and Neck region (e.g., periorbital region, eyelids, nasolabial fold, nose-cheek angle, postauricular region, pinna, ear canal, forehead, and scalp). It usually grows and spreads very slowly and has the least tendency to invade and spread to distant body parts. However, if not treated, BCC can invade nearby tissues, such as adipose tissue, cartilages, and bones. It possesses a high tendency for recurrence and increases the risk of developing secondary cancer at any other location later in life. It contains non-keratinized cells derived from the Stratum Basale. It may have a wide range of appearance, such as pale-yellow flat patches; pink/red/translucent, shiny/pearly bumps with blue/brown areas; raised reddish, itchy patches; or open sores. Many of these cancers are found to be associated with a characteristic mutation in the patched 1 tumor suppressor gene (PTCH1) that codes for the sonic hedgehog receptor.
Squamous cell carcinoma (SCC)
Skin cancer doctor in Gurgaon: SCC is the second most common type of skin cancer accounting for about 20% of all new skin cancers. Like other skin cancers, SCC mostly develops in the area of high cumulative sunlight exposure. It mostly affects the skin of the face, lips, ears, neck, and dorsal surface (back side) of hands. It shows moderate aggressiveness with a comparatively higher tendency (than BCC) to invade nearby tissues or to spread to distant body parts. It is composed of keratinized cells. SCC may have a wide range of appearances, such as rough scaly patches; round pink/red protuberance with a depressed central area, open sores, wart-like growths, and differently-colored patches on the skin. It may develop from pre-cancerous lesions called actinic keratoses (AK) that generally develop due to high exposure to sunlight in the affected area. Some AK may slowly develop into SCC, but this is not true for most AK cases. SCC in situ or Bowen disease is a non-invasive, superficial pre-cancerous condition thought to be an early form of SCC. SCC in situ is sometimes related to sexually-transmitted HPV infection and may lead to the development of invasive SCC over time. Both AK and SCC in situ are treated right away to avoid development of SCC later in life.
What is Malignant Melanoma?
Melanoma accounts for about 1% of all new skin cancers. It is the most aggressive type of skin cancer and generally requires intensive treatment. It grows rapidly and can invade nearby tissue or spread to distant body parts. Melanoma may develop at any location but the skin of the trunk in men and lower limbs in women are the most common locations. Most melanomas produce melanin and are presented as brown-black masses, but some may be devoid of melanin and are presented as pink to tan colored masses. A few melanocytes are present at non-cutaneous sites, which can give rise to melanomas outside of the skin, such as those on mucosal membranes (e.g. mucosal membrane of sinuses, oral cavity, anorectal region, vulva, and vagina), in the uveal tract of the eye, and in leptomeninges. These non-cutaneous melanomas behave differently than the cutaneous melanomas and are considered a different entity from the prognosis and treatment perspective.
What are the Risk Factors for Skin Cancer and Melanoma?
Different epidemiological studies have revealed various risk factors that can predispose skin cancer. Different skin cancers may have different risk factors along with some common factors that can predispose to their development. Following is the list of such risk factors:
Exposure to Ultraviolet (UV) radiation
Exposure to UV radiation has been considered as the major risk factor for the development of most skin cancers. The UV exposure is mostly acquired from the sunlight or UV beds usually employed for the treatment of hypopigmented skin. The UV rays can damage the DNA of skin cells and thereby trigger the development of skin cancer. A high cumulative exposure to UV light has been indicated as the most important factor in the development of skin cancers, especially melanoma, basal cell cancer, and squamous cell cancer. Individuals with a history of sunburns are also more susceptible to develop skin cancer.
Fair skin, red or blond hair, and light eye color
Individuals with skin, hair, and eye color towards the lighter side (that is, those who have less melanin in their skin, hair, and eye) and had substantial exposure to sunlight are considered at increased risk of developing skin cancer. Most cases of skin cancer are reported in Caucasians (Whites) while very few cases are observed in African Americans or Hispanics. Also, the individuals with albinism, a disorder in which people lack melanin in their skin, are at higher risk of developing skin cancer.
Moles
Individuals with atypical moles (larger, irregular, abnormal colored mole) or congenital melanocytic nevi (especially large-size moles) are at increased risk of developing melanoma. Thus, these moles should be checked regularly along with complete skin checkup and removed surgically right away if they start growing or changing appearance.
Genetic cancer predisposition syndromes
Some inherited cancer predisposition syndromes (caused by a mutation in certain genes which are generally transferred from one generation to other) have been reported to be associated with the increased incidence risk of skin cancer. Following are certain examples of such genetic disorders:
- Xeroderma pigmentosum (XP) (caused by a mutation in the genes that encodes proteins involved in DNA repair process) may elevate the risk of developing skin cancers in childhood
- Basal cell nevus syndrome or Gorlin’s syndrome usually leads to the increased incidence of the basal cell carcinoma
- Familial atypical multiple mole melanoma syndrome (FAMMM) or Dysplastic nevus syndrome (caused by a mutation in the CDKN2A or CDK4 gene) may increase the chances of developing melanoma
- Rothmund-Thomson syndrome and Bloom syndrome (caused by a mutation in the helicase gene) may lead to early development of squamous cell carcinoma. Werner syndrome (caused by a mutation in the helicase gene) may increase the risk of developing melanoma.
Other syndromes, such as Muir-Torre syndrome, Ferguson-Smith syndrome, and Fanconi anemia have also been implicated in enhancing the risk of developing skin cancer.
Occupational exposure
Higher risk of developing skin cancer has been linked to chronic exposure to certain chemicals like arsenic, coal tar, paraffin, and petroleum products, generally experienced by the workers of plastic, road-construction, petroleum, dyestuffs, paint, and dry-cleaning industries.
History of radiation treatment
Individuals who had received radiation treatment in past for the treatment of any other cancer are at higher risk of developing skin cancer in the area previously exposed to therapeutic radiation dose. The development of skin cancer may take up to 15 years, and thus, this factor is of potential concern in the case of children.
Personal history
Individuals with a personal history of skin cancer (melanoma, basal cell carcinoma, or squamous cell carcinoma) are at higher risk of developing secondary skin cancer.
Family history of melanoma
Individuals with a history of melanoma in close relatives are at increased risk of melanoma. About 10% of all melanoma cases are reported in such individuals.
Weakened immune system
Individuals with a weak immune system that may be due to HIV infection, auto-immune disease, chronic use of corticosteroids, or immunosuppresants in patients who have undergone an organ/hematopoietic stem cell transplant are considered at higher risk of developing certain types of skin cancers, for example, melanoma, squamous cell carcinoma, Merkel cell carcinoma, and Kaposi sarcoma (KS).
Human papillomavirus (HPV) or Merkel cell polyomavirus (MCV) infection
HPV is a group of about 150 DNA viruses with high-risk subtypes including HPV-16 and HPV-18 that have been reported in many cases of skin cancer, especially basal cell carcinoma and squamous cell carcinoma. HPV infection is common in some geographical locations, like some areas of Africa. MCV infection has been reported in many cases of Merkel cell carcinoma. However, all individuals with HPV or MCV infection do not develop skin cancer.
Tobacco/Cigarette Smoking
Chronic tobacco chewing or cigarette smoking exposes the body to various carcinogens that suppress the immune system to fight against HPV infection and increase the risk of squamous cell carcinoma of the lips.
Age and Gender
Older age individuals especially males are generally at increased risk of developing skin cancer. Older age has been linked to the build-up of UV exposure over time which may cause skin cell’s DNA to degrade. However, skin cancer is now being observed in children probably due to more time spent under sun.
Pre-existing skin conditions
Risk of developing certain skin cancer increases in an individual with a history of psoriasis and who had received treatment with psoralens and ultraviolet light (PUVA). Also, certain chronic skin inflammatory conditions, scars, burns, or chronic skin/bone infections may lead to the development of skin cancer in the affected area, although the risk is relatively less.
What are the Signs and Symptoms of Skin Cancer and Melanoma?
Due to some easily visible early symptoms, most skin cancers are found at an early stage. Following are some common signs and symptoms of skin cancers, which may help in early diagnosis of the disease:
Basal Cell Carcinoma
The BCC usually presents as a superficial manifestation in the head and neck region, especially the area with exposure to the sun. The BCC may present as a wide range of skin lesions that may appear as:
- Flat, firm, pale or yellow irregularly-shaped patches on the skin
- Pink/red/translucent, shiny/pearly bumps with blue/brown areas
- Raised reddish, itchy projections on the skin
- Open sores that may ooze or crust
- Round, pink protuberance with depressed central area
Squamous cell carcinoma
The SCC usually presents as a superficial manifestation in the area with elevated exposure to the sun, especially on the face, lips, ears, neck, and dorsal surface of hands. The SCC may sometimes affect the genitalia or anorectal region. Most of these cancers appear as:
- Rough or scaly red patches
- Round, pink protuberance with depressed central area
- Open sores that may ooze or crust
- \Wart-like growths in genitalia or anorectal region
- Flat, firm, pale-yellow or different colored patches on the skin
Melanoma
Melanoma may present as a new spot on the skin, with an abnormal size, shape, or color. Melanoma may also develop from an existing mole that starts behaving differently when such a conversion from a benign mole to melanoma takes place. Thus, it is important to identify such changes for early diagnosis, and thus, better treatment of the disease. The ABCDE rule is generally adopted for identification of spots that are most likely to be melanoma, where A = asymmetry, B = border, C = color, D = diameter/size, and E = evolving. According to this rule, the spots that are asymmetrical compared to other normal spots, have irregular border, have different color, are >/=6 mm in size, and have evolving characteristics (i.e., changing color, size, or shape with time) are most likely to be melanoma and should be checked right-away by an oncologist.
Other signs and symptoms of melanoma may include:
- Development of itchiness, tenderness, or pain
- A change in the mole behavior, such as scaliness, oozing or bleeding
- Redness or swelling in the nearby area of an existing mole
- Appearance of a pigmented mass near the min spot of concern
- Development of sore that doesn’t heal
What are the Tests or Investigations to be done to confirm the diagnosis of Skin Cancer and Melanoma?
If a person is suspected to have skin cancer due to the presence of signs and symptoms or based on the physical examination, some investigations are required to confirm the diagnosis of the disease. Further, these investigations can help in determining the extent of invasion and spread of disease to other body parts, which in turn help in selecting an appropriate treatment option.
Following are some commonly used diagnostic tools for different types of skin cancers:
Skin Biopsy
Skin cancer surgeon in Gurugram: Biopsy samples contain a small number of cells or a tiny piece of tissue collected from the affected area with the help of a special biopsy instrument. Biopsy sample(s) are generally collected when an abnormal area(s) is observed during the physical examination indicating skin cancer. It is very important to obtain a biopsy sample because it can establish the diagnosis of skin cancer. It can also provide other useful information about the cancerous cells, such as the type of skin cancer, the severity of cancerous changes involved (grade of cancer), and the presence of specific defective genes. Following are common techniques used for collecting the biopsy samples from the affected area/lymph nodes:
Shave Biopsy
In shave biopsy, a biopsy sample is obtained by shaving the upper layer of the skin using a surgical blade. This technique is generally employed for early-stage disease confined to the superficial skin layer.
Punch Biopsy
In this technique, a biopsy sample containing deeper skin tissues is obtained using a tool with a round blade that cuts through all the skin layers. This technique enables biopsy of skin cancers that have invaded into nearby tissues.
Surgical biopsy
In this technique, a tissue sample from the affected site is removed via a surgical procedure. When only a part of the tumor is removed, the procedure is known as the incisional biopsy. While in the case of excisional biopsy, the whole tumor is removed surgically. The magnitude of the procedure depends upon the location and the size of the tumor. Excisional biopsy is usually performed when the tumor is located at an accessible site and do not involve any critical structure. It usually combines both diagnosis and treatment for the skin cancer. The surgical biopsy technique may also be used to obtain a biopsy sample from an affected lymph node.
Sentinel Lymph Node Biopsy (SLNB)
In this surgical biopsy procedure, the sentinal lymph node (the first lymph node affected by cancer) along with some nearby lymph nodes are removed and checked for the presence of cancer cells. An absence of cancer is the sentinel lymph node indicates cancer has not spread to other lymph nodes. To find a sentinel lymph node, a surgeon first injects a radioactive substance and/or a dye into the cancer tissue. The sentinel lymph node is then determined as the first node detected to have radioactivity and/or the first lymph node that take-up the dye color. Detected sentinel lymph node is then removed and tested in a laboratory for the presence of cancer cells.
Fine Needle Aspiration (FNA) Biopsy
This technique is generally used to collect a biopsy sample from an enlarged lymph node near the skin via a fine hollow needle attached to a syringe. A very small sample is usually obtained with this technique that can be tested to establish the diagnosis of the skin cancer in the suspected lymph node(s). This technique is most commonly used and very easy to perform with minimum side effects. It can also be utilized to diagnose disease progression or recurrence in patients who have received treatment.
Imaging Tests
These tests help in scanning a larger body area to assess the exact size and location of the disease and the spread of disease to distant body parts. The extent of invasion within the primary tissue affected and in the nearby tissue can also be assessed with the help of these techniques. These are primarily employed after the establishment of the pathological diagnosis to estimate the extent of disease. Also, they can be employed after treatment to evaluate the treatment efficacy and to detect any signs of disease progression/recurrence.
Computed tomography (CT) scan
In this technique, detailed cross-sectional images of internal structures are generated using x-rays with or without intravenous/oral contrast (like barium). This technique can accurately detect the tumor’s size, location, invasion to nearby structures (for example, the bones), and spread of disease to nearby lymph nodes or to distant body parts (for example, the lungs and the liver). This is very helpful for planning the treatment in case radiation therapy is indicated for the treatment. It can sometimes be used to guide a biopsy needle to collect biopsy samples from the affected area/lymph node.
Magnetic resonance imaging (MRI) scan
This technique provides detailed images of soft tissues in the body using radio waves, strong magnetic field, and gadolinium – the contrast material, which is used via intravenous injection to improve the clarity of the MRI images. Similar to CT, it can accurately diagnose the size, location, extent of invasion, and spread of disease to distant body parts, especially soft tissues like the muscles, eyeballs, blood vessels, brain, spinal cord, etc. This technique is better than CT for the examination of soft tissues in the limbs, but inferior to CT for examining the bones. Additionally, it can be used for planning radiation treatment.
Positron emission tomography (PET) scan
Skin Cancer treatment in gurgaon: This technique uses a radioactive substance (known as fluorodeoxyglucose or FDG) that is given via intravenous injection prior to the procedure. Cancer cells absorb larger amounts of the radioactive substance than normal cells. The areas of higher radioactivity indicate cancerous tissue on the PET scan. It is usually combined with CT scan (PET/CT) to accurately diagnose the spread of disease in distant body parts.
Bone Scan
In this test, a radioactive material is injected into the vein of the patient, which gets accumulated in the areas of bones affected by the disease, which are then detected with the help of radioactivity detectors. In this way, it may help to detect the spread of cancer to bones.
Certain blood tests may also be employed in the patients with skin cancer for the estimation of overall health, nutritional status, liver and kidney functions, and blood cells counts. These tests help in assessing whether the standard treatment like surgery, chemotherapy, or radiotherapy can be safely employed for the patient.
What is the Staging and Risk Stratification of Skin Cancer and Melanoma?
Staging systems are used to describe the severity of cancer, based on the size, extent of invasion, and the spread of disease to different body parts. Staging helps to determine disease prognosis and treatment strategy.
Since different skin cancers behave differently and have variable tendency to invade nearby tissue or to spread to distant body parts, they are staged differently.
Basal Cell Carcinoma (BCC)
BCC rarely spreads to distant body parts. Fortunately, most of the cases of BCC are cured before they can spread to distant body parts. Thus, assessment of tumor spread and staging of BCC is not required. However, several prognostic factors have been described for BCC that can predict poor prognosis of the disease. Following is the list of such high-risk factors: Anatomic site and tumor size (mask area of face, genitalia, hands, and feet with any tumor size; cheeks, forehead, scalp, neck, and pretibial region with tumor size >/=1 cm; and Trunk/remaining extremities areas with tumor size >/=2 cm), tumor invading deeper skin layers, poorly defined borders, perineural invasion, extranodal extension, extension to bony structures, nodal disease, site of prior radiotherapy, immunosuppression, advanced disease/aggressive growth pattern, recurrent disease, poor overall health, comorbidity, and tobacco use.
Squamous Cell Carcinoma (SCC)
TNM is the most commonly used system for staging squamous cell carcinoma. “T” stands for “Tumor Size”, “N” for “Lymph Nodes”, and “M” for “Metastasis”. Numbers and/or letters after T (is, 1, 2, 3, 4, 4a, and 4b), N (0, 1, 2, 2a, 2b, 2c, 3, 3a, and 3b), and M (0 and 1) provide more details about each of these factors. Once T, N, and M categories of a skin cancer are determined through different diagnostic techniques, this information is combined to assign an overall stage (from 0 to IV) to the disease. Following table describe the characteristics of different pathological stages assigned to the SCC of the Head and Neck region:
|
Pathological Stage
|
TNM Score
|
Description
|
|
0
|
Tis N0 M0
|
Carcinoma in situ or non-invasive pre-cancerous
lesion confined to the superficial skin layer.
|
|
I
|
T1 N0 M0
|
A primary tumor is <2 cm
in size. No spread to nearby lymph nodes or distant body parts.
|
|
II
|
T2 N0 M0
|
A primary tumor size may
range from >/=2 cm to <4 cm. No spread to nearby lymph nodes or distant
body parts.
|
|
III
|
T3 N0 M0
|
A primary tumor is >/=4 cm
in size with minor bone, perineural, or deeper skin layer involvement. No
spread to nearby lymph nodes or distant body parts.
|
|
T1-3 N1 M0
|
A primary tumor size may
range from <2 cm to >/=4 cm with minor bone, perineural, or deeper skin
layer involvement. The disease has spread to a single ipsilateral lymph node
measuring </=3 cm without any sign of extranodal extension. No spread to
distant body parts.
|
|
IV
|
T1-3 N2 M0
|
A primary tumor size may
range from <2 cm to >/=4 cm with minor bone, perineural, or deeper skin
layer involvement. The disease has spread to a single ipsilateral lymph node
measuring </=3 cm with extranodal involvement; or measuring >3 cm but
<6 cm without extranodal involvement; or involvement of multiple
ipsilateral/ bilateral/ contralateral lymph nodes, all measuring <6 cm
without extranodal involvement. No spread to distant body parts.
|
|
Any T N3 M0
|
A primary tumor of any size with
or without invasion to nearby tissues/structures. The disease has spread to a
single lymph node measuring >6 cm without extranodal involvement or involvement
of single/multiple lymph nodes with extranodal involvement. No spread to
distant body parts.
|
|
T4 Any N M0
|
A primary tumor of any size
with gross cortical bone/marrow, skull base invasion and/or skull base
foramen invasion. The disease might or might not have spread to nearby lymph
nodes. No spread to distant body parts.
|
|
Any T Any N M1
|
A primary tumor of any size
with or without invasion to nearby tissues/structures. The disease might or
might not have spread to nearby lymph nodes. The disease has spread to
distant body parts, such as the lungs, liver, etc.
|
Similar to BCC, several prognostic factors have been described for SCC that can predict poor prognosis of the disease. Following is the list of such high-risk prognostic factors: Anatomic site and tumor size combinations (mask area of face, genitalia, hands, and feet with any tumor size; cheeks, forehead, scalp, neck, and pretibial region with tumor size >/=1 cm; and Trunk/remaining extremities areas with tumor size >/=2 cm), tumor invading deeper skin layers or tumors with greater thickness, poorly defined borders, perineural invasion, extranodal extension, extension to bony structures, vascular involvement, lymphatic involvement, site of prior radiotherapy, immunosuppression, advanced disease/aggressive subtype/poorly differentiated cells, recurrent disease, poor overall health, comorbidities, and patients with certain genetic disorders such as albinism or xeroderma pigmentosum.
Melanoma
TNM is the most commonly used system for staging melanoma. “T” stands for “Tumor Thickness”, “N” for “Lymph Nodes”, and “M” for “Metastasis”. Instead of tumor size, tumor thickness or Breslow measurement is used for assessing melanoma stage, because vertical tumor thickness is considered a better indicator of the disease prognosis and the tendency of disease spread to distant body parts. Also, ulceration status of the melanoma lesion is important and can affect disease prognosis. Numbers and/or letters after T (is, 1, 1a, 1b, 2, 2a, 2b, 3, 3a, 3b, 4a, and 4b), N (0, 1, 1a, 1b, 1c, 2a, 2b, 2c, 3, 3a, 3b, and 3c), and M (0 and 1) provide more details about each of these factors. Once T, N, and M categories of melanoma are determined through different diagnostic techniques, this information is combined to assign an overall stage (from 0 to IV) to the disease. Following table describe the characteristics of different pathological stages assigned to melanoma:
|
Pathological Stage
|
TNM Score
|
Stage Description
|
|
0
|
Tis N0 M0
|
Carcinoma/Melanoma in situ or non-invasive pre-cancerous
lesion confined to the superficial skin layer.
|
|
IA
|
T1 N0 M0
|
A primary tumor </=1 mm in
thickness without ulceration. No spread to nearby lymph nodes or distant body
parts.
|
|
IB
|
T2a N0 M0
|
A primary tumor >1 mm but
</=2 mm in thickness without ulceration. No spread to nearby lymph nodes
or distant body parts.
|
|
IIA
|
T2b/3a N0 M0
|
A primary tumor >1 mm but
</=2 mm in thickness with ulceration or >2 mm but </=4 mm in
thickness without ulceration. No spread to nearby lymph nodes or distant body
parts.
|
|
IIB
|
T3b/4a N0 M0
|
A primary tumor >2 mm but
</=4 mm in thickness with ulceration or >4 mm in thickness without
ulceration. No spread to nearby lymph nodes or distant body parts.
|
|
IIC
|
T4b N0 M0
|
A primary tumor >4 mm in
thickness with ulceration. No spread to nearby lymph nodes or distant body
parts.
|
|
IIIA
|
T1/2a N1a/2a M0
|
A primary tumor </=1 mm in
thickness without ulceration or >1 mm but </=2 mm in thickness without
ulceration. A microscopic disease spread to 1–3 nearby lymph nodes. No spread
to distant body parts.
|
|
IIIB
|
T0 N1b/1c M0
|
A primary tumor is not
present, but the microscopic disease has been detected in a nearby lymph node
or in lymphatic channels around the tumor or presence of satellite tumors (nearby
microscopic skin involvement). No spread to distant body parts.
|
|
|
T1/2a N1b/1c/2b M0
|
A primary tumor </=1 mm in
thickness without ulceration or >1 mm but </=2 mm in thickness without
ulceration. A microscopic disease has been detected in a nearby lymph node or
in lymphatic channels around the tumor or the presence of satellite tumors or
a spread of disease to 1–3 nearby lymph nodes. No spread to distant body
parts.
|
|
|
T2b/3a N1a-2b M0
|
A primary tumor >1 mm but
</=2 mm in thickness with ulceration or >2 mm but </=4 mm in
thickness without ulceration. A microscopic disease has been detected in a
nearby lymph node or in lymphatic channels around the tumor or the presence
of satellite tumors or a spread of disease to 1–3 nearby lymph nodes. No spread
to distant body parts.
|
|
IIIC
|
T0 N2b/2c/3b/3c M0
|
A primary tumor is not
present, but the disease has detected in 1 or more nearby lymph nodes with or
without the presence of satellite tumors. No spread to distant body parts.
|
|
T1/2/3a N2c/3 M0
|
A primary tumor >1 mm to
</=4 mm in thickness with or without ulceration. The disease has spread to
1 or more nearby lymph nodes with or without the presence of satellite tumors.
No spread to distant body parts.
|
|
T3b/4a N>1 M0
|
A primary tumor >2 mm but
</=4 mm in thickness with ulceration or >4 mm in thickness without
ulceration. The disease has spread to 1 or more nearby lymph nodes with or
without the presence of satellite tumors. No spread to distant body parts.
|
|
T4b N1-2 M0
|
A primary tumor >4 mm in
thickness with ulceration. A microscopic disease has been detected in a
nearby lymph node or in lymphatic channels around the tumor or the presence
of satellite tumors or a spread of disease to 1–3 nearby lymph nodes. No
spread to distant body parts.
|
|
IIID
|
T4b N3 M0
|
A primary tumor >4 mm in
thickness with ulceration. The disease has spread to 4 or more nearby lymph
nodes with or without the presence of satellite tumors. No spread to distant
body parts.
|
|
IV
|
Any T Any N M1
|
A primary tumor of any
thickness with or without ulceration. The disease might or might not have spread
to nearby lymph nodes with or without the presence of satellite tumors. The
disease has spread to distant body parts, for example, the skin, soft tissue
including muscles, distant lymph nodes, or visceral organs, such as the
lungs, liver, or brain.
|
What is the best Treatment of Skin Cancer and Melanoma in Gurgaon?
The treatment for skin cancer usually depends on many factors, including but not limited to the type of skin cancer, stage of disease, location of the disease, patient’s age & overall health, patient’s preference along with other factors. Following are the preferred treatment approaches for different stages of NSCLC, but the final decision is taken after clinical assessment of the patient by an oncologist.
Oncoexperts is a cancer clinic in Gurgaon for treatment for melanoma from our team of cancer experts that include surgical oncologists, medical oncologists, and radiation oncologists who are experts in treating all types of melanoma.
Treatment of Basal Cell Carcinoma
Low Risk
For low-risk BCCs, the following options are generally employed as the first-line treatment:
Curettage and Electrodesiccation (C&E) is employed for most low-risk BCCs except when the affected area contains hairs, that is, C&E should not be employed for terminal hair-bearing regions, such as the scalp, pubic and axillary regions, and beard area in men.
Standard surgical excision may be employed when a standard 4-mm clinical margin can be obtained after surgery and surgical cut can be closed using any of the following techniques: linear closure, second intention healing, or skin graft.
For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.
For patients who do not prefer to undergo surgery and radiotherapy, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.
High Risk
For high-risk BCCs, the following options are generally employed as the first-line treatment:
Standard surgical excision may be employed when wider margins can be obtained after surgery and surgical cut can be closed using a linear closure or by delayed repair. Alternatively, Mohs Micrographic Surgery (MMS or Excision with Intraoperative Frozen Section Assessment) or Excision with complete circumferential peripheral and deep margin assessment (CCPDMA) techniques can be utilized for removing BCC.
For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.
For patients who do not prefer to undergo surgery and radiotherapy, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.
Treatment of Squamous Cell Carcinoma
Low Risk
For low-risk SCCs, the following options are generally employed as the first-line treatment:
C&E is employed for most low-risk SCCs except when the affected area contains hairs, that is, C&E should not be employed for terminal hair-bearing regions, such as the scalp, pubic and axillary regions, and beard area in men.
Standard surgical excision may be employed when standard 4- to 6-mm clinical margins can be obtained after surgery and surgical cut can be closed using any of the following techniques: linear closure, second intention healing, or skin graft. In the case of positive (non-clear) margin after surgical resection, radiotherapy and/or chemotherapy with a hedgehog pathway inhibitor can be employed.
For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.
For patients with SCC in situ (Bowen’s disease) and when the disease is present at an anatomically challenging location, topical treatment with 5-Fluorouracil, imiquimod, Photodynamic therapy (PDT), or cryotherapy may be employed as the first-line treatment.
High Risk
For high-risk SCCs, the following options are generally employed as the first-line treatment:
Standard surgical excision may be employed when wider margins can be obtained after surgery and surgical cut can be closed using a linear closure or by delayed repair. Alternatively, MMS or CCPDMA techniques can be utilized for SCC resection. In the case of positive (non-clear) margin after surgical resection, radiotherapy should be employed.
For individuals who cannot undergo surgery, radiotherapy is usually employed as the first-line treatment.
Node-positive SCC
For node-positive SCC, the preferred treatment is surgical excision of the primary tumor along with the lymph node dissection for the affected lymph nodes. The extent of surgical procedure generally depends upon the location, number, and size of the affected lymph nodes. Radiotherapy after surgery is generally recommended in the case of multiple lymph node involvement or extranodal involvement. Patients with incomplete lymph node excision should also receive systemic therapy along with the post-surgery radiotherapy.
For patients with node-positive SCC and who cannot undergo surgery, radiotherapy with or without a systemic therapy is usually employed as the first-line treatment. If tumor shrinks sufficiently, surgery may be employed later.
Metastatic SCC
For patients with metastatic (widely spread) SCC, the preferred treatment is a systemic therapy that may include chemotherapy, targeted therapy, or immunotherapy.
Surgery or radiotherapy may be employed as the palliative treatment for symptomatic disease control.
Treatment of Melanoma
Stage 0
For Stage 0 melanoma, wide surgical resection with 1 cm margin to remove all cancerous tissue is the preferred treatment approach. For some patients with positive margins, topical imiquimod or radiotherapy may be employed.
For patients with melanoma in a challenging location, MMS or topical imiquimod can be employed as the first-line treatment as per physician discretion and patient preference.
Stage I
For Stage I melanoma, wide surgical resection with 1 cm to 2 cm margin is considered the preferred treatment approach. The margin of normal skin tissue removed should be based on the location and thickness of the primary tumor.
It is generally recommended to perform a sentinel lymph node biopsy for melanoma. If cancer is detected in the sentinel lymph node, complete lymph node dissection of the involved node is recommended.
Stage II
For Stage II melanoma, wide surgical resection with 1 cm to 2 cm margin is considered the preferred treatment approach. The margin of normal skin tissue removed should be based on the location and thickness of the primary tumor.
It is generally recommended to perform a sentinel lymph node biopsy for melanoma. If cancer is detected in the sentinel lymph node, complete lymph node dissection of the involved node is recommended.
Biochemotherapy or immunotherapy may be employed after surgical resection of node-negative disease or after lymph node dissection.
Stage III
For Stage III melanoma, wide surgical resection with 1 cm to 2 cm margin for the primary tumor and complete lymph node dissection for the affected lymph node is considered the preferred treatment approach.
Immunotherapy, biochemotherapy, or targeted therapy may be employed after surgical resection. Radiotherapy may sometimes be employed, especially in case of multiple node involvement or aggressive/poorly differentiated subtype.
Stage IV
For Stage IV melanoma with a limited number of resectable primary and secondary tumors, wide surgical resection with 1 cm to 2 cm margin for the primary tumor and secondary tumors is considered the preferred treatment approach. Sentinel lymph node biopsy is usually performed, and complete lymph node dissection is employed in the case of a node-positive disease. The remaining disease may be treated with radiotherapy.
For multiple regional secondary tumors that cannot be managed by complete surgical resection, intralesional chemotherapy, laser ablation, topical imiquimod, or radiotherapy may be employed.
For widespread disease, Immunotherapy or targeted therapy is considered as the preferred treatment approach. Patients who progress on the first-line therapy may receive second-line therapy with agents not used in the first-line treatment.
Surgery for Skin Cancer
Surgery is the treatment of choice for most early-stage and some higher stage Skin cancers that have not spread to distant body parts and can be completely removed. The goal of surgery is to remove entire cancerous tissue along with some healthy tissue to ensure no cancer cell is left behind. This is possible for some early-stage disease at a favorable location where the tumor is confined to a specific area, and complete resection can be performed with ease.
However, a complete resection is not always possible, such as in the case of advanced-stage disease, the disease involving a vital organ/structure, or when a surgical resection will lead to a significant cosmetic disfigurement. In such cases, surgery may still be employed with an objective to remove maximum possible cancerous tissue along with the administration of other treatment (e.g. topical treatment, systemic treatment, or radiotherapy) to kill the remaining cancer cells in the body. Surgery may also be performed to collect biopsy sample in some cases. In case of node-positive disease, surgery is required to remove the affected lymph node (the procedure is called lymph node dissection). Sometimes, a reconstructive surgery is required to improve/restore appearance.
Relative to the site of disease, surgery is generally associated with the risk of change in cosmetic appearance or disfigurement and other common surgery-associated complications, such as pain, chances of infection, bleeding, damage to nearby structures like arteries or nerves etc. Thus, surgery may not be employed in old-aged or otherwise frail individuals. Also, some individuals may not prefer surgery due to cosmetic reasons.
Curettage and Electrodesiccation (C&E)
In this technique, superficial skin layer containing cancerous cells is first removed via a curette (a long, thin instrument with a sharp looped edge on one end) and the area is then denatured using an electrode to destroy any remnant cancer cells. This process is repeated once or twice after the first procedure to achieve complete cancer cells removal. This technique is generally employed for early-stage skin cancers that can be managed by removing superficial skin layers. This is a fast and cost-effective technique. This technique is not generally utilized for areas with hair growth, such as the scalp, pubic, axillary regions, and beard area in males due to a risk of tumor extension to the hair follicles that cannot be adequately removed. The procedure does not cause many side-effects but pain and a scar at the procedure site are common.
Mohs Micrographic Surgery
This surgical technique is generally utilized when a high-risk skin cancer is involved, when the exact depth of tumor is not assessable, or when treating skin cancer in anatomically challenging location where preservation of healthy skin tissue is crucial, for example, skin cancer near eyes, eyelids, central face, ears, and fingers. In this technique, successive thin layers of skin tissue containing cancer are removed and checked under a microscope for the presence of cancer cells until the cancer-free margins are obtained. This technique helps in reducing the chances of cancer coming back, but this is a complex procedure and requires much more time than standard surgical resection.
Excision with Complete Circumferential Peripheral and Deep Margin Assessment (CCPDMA)
Like MMS technique, this technique enables intraoperative assessment of tumor margin. The added advantage is that both peripheral and deep margins are assessed simultaneously using frozen dissected sections. Thus, this procedure is faster than MMS and has all the advantages of MMS.
Topical treatment
Skin cancer treatment in gurgaon: These treatments provide local control and are generally employed for carcinoma in situ or some early-stage skin cancers confined to the superficial skin layers. These treatments may also be employed for some advanced-stage disease to treat secondary cancers limited to superficial skin layers. Alternatively, these treatments can be employed in combination with other treatments like surgery to kill remaining cancer cells. Imiquimod and 5-Fluorouracil are the two most commonly used topical agents for treating skin cancers. These may be associated with minor side-effects such as skin reactions and flu-like symptoms.
Cryotherapy/Cryosurgery
In this technique, some early-stage skin cancers are treated using a supercooled agent, for example, liquid nitrogen. One to three freeze-thaw cycles is utilized to kill the cancerous cells present in superficial skin layers. The treatment may result in a wound that takes time to heal completely or may lead to the development of a scar tissue. The overall cosmetic outcome is poorer compared to other topical treatments, but the procedure is fast and cost-effective.
Photodynamic Therapy (PDT)
In this technique, a liquid is injected into the area near the skin cancer. The liquid contains a drug, for example, methyl amino levulinate (MAL) or 5-amino levulinic acid (ALA). These drugs have a high affinity for cancerous cells and get accumulated in the cancerous cells over several hours or days. Inside the cancerous cells, the drugs get converted into a different chemical and render the cancerous cells sensitive to light. The cancer is then exposed to a light source to kill cancer cells. This technique cannot be utilized for deep-sited cancer cells. However, this technique provides better cosmetic output and thus generally utilized for treating superficial cancerous lesions on the face or scalp.
Radiation Therapy
Radiation therapy uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill cancerous cells. For the treatment of skin cancer, radiotherapy is generally employed using an external radiation source, for example, external beam radiation therapy (EBRT). Radiotherapy can be employed alone as the first-line treatment for certain early-stage skin cancers when the patient does not prefer surgery for cosmetic reasons, in the case of skin cancers that cannot be completely removed by surgery, or in some patients who cannot tolerate surgery. Radiotherapy can also be combined with other treatment options such as surgery to kill remaining cancer cells when complete removal is not achieved with surgery. It is sometimes used for palliation of symptoms of the widespread disease, such as pain, bleeding, and obstructive problems. It is generally associated with several side effects like skin reactions, sores/ulcers, nausea, vomiting, dry mouth/eyes, loss of hairs in the irradiated area, chances of secondary cancer development, and accidental damage to nearby organs.
Chemotherapy for Skin Cancer
Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. Chemotherapy is generally employed for the treatment of advanced-stage skin cancers that have spread to distant body parts and cannot be removed completely with surgical resection. Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options, like radiotherapy, to accelerate the benefit achievement. Chemotherapy may be associated with side effects due to its effect on normal body cells apart from cancerous cells. Common side effects of chemotherapy include nausea, vomiting, hair-loss, diarrhea, mouth ulcers, increased chances of infection, fatigue, decrease in the number of blood cells, etc.
Targeted Therapy for Skin Cancer
Targeted drugs work differently than chemotherapy drugs that they target a specific gene or protein characteristic of the cancer cells that help them to divide and grow indefinitely. They are generally used alone or in combination with chemotherapy for the treatment of advanced-stage skin cancers or skin cancers that possess specific protein/gene change. The side effects of targeted therapy are generally mild, but these can be severe in some cases, for example, autoimmune reactions. These therapies require an appropriate immunohistochemical/genetic evaluation of biopsy sample to ensure the efficacy of treatment.
Example of targeted drugs include vismodegib and sonidegib that target proteins involved in this hedgehog pathway (commonly found in BCC); vemurafenib and dabrafenib that target BRAF protein, a characteristic protein found in more than 50% of melanoma; trametinib and cobimetinib that target MEK protein, a protein generally found in melanoma with BRAF mutation; and imatinib that targets C-KIT gene/protein commonly found in melanoma affecting non-cutaneous locations, hands, soles of the feet, under the nails, and areas with maximum sun exposure.
Immunotherapy for Skin Cancer
Immunotherapy involves treatment with drugs that stimulate a person’s own immune system to identify and kill cancer cells. These agents are generally employed for the treatment of advanced-stage/widespread melanoma that cannot be managed with surgery or local treatment. These agents have transformed the way advanced-stage disease is managed and have improved overall treatment outcome. Many different classes of agents have been designed to target different protein or cell-component to produce their effects. Examples of such agents include the immune checkpoint inhibitors, nivolumab and pembrolizumab, that target PD-1 protein on T-cells and activate them to kill melanoma cells; CTLA-4 inhibitor, Ipilimumab, that blocks CTLA-4 protein on T-cells and activate them to kill melanoma cells; and cytokines, interferon-alfa and interleukin-2, that are man-made version of natural proteins and help in boosting the immune system to kill cancer cells.
Where can I find the best specialists for Skin Cancer and Melanoma treatment in Gurgaon?
Dr Sunny Garg is a renowned Medical Oncologist in Gurgaon with an experience of more than 10 years of treating skin cancer patients. He has treated skin cancer patients with Chemotherapy, Targeted Therapy and Personalized Cancer Treatment. He is currently practicing at Sanar International Hospital, Golf Course Road, Gurgaon.
Call or whatsapp +91 9686813020 for appointment