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Diagnosis skin cancer – what happens next?

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Michael Tripolt_medaia

OA Dr. Michael Tripolt, MPH, Dermatology and Venereology

Studied medicine at the Karl-Franzens-University Graz and Cambridge University (degree in Human Medicine 1999 and Public Health 2005). Residency at the Univ. Clinic Graz (graduated in surgery in 2006, graduated in dermatology in 2012).

The diagnosis skin cancer hits those affected like a bolt from the blue. It is a diagnosis that is frightening and often leaves those affected and their family and friends in a state of helplessness. It is not only the uncertain health future that is frightening, but also the potentially high treatment costs associated with it.

Increase in skin cancer cases

In 2018, 287,723 cases of malignant skin cancer and 1,042,056 cases of non-malignant skin cancer were diagnosed worldwide. The numbers are steadily increasing year after year. For example, between 2008 and 2018, there was a 44% increase in skin cancer cases.

Top 5 countries with the highest incidence rate per capita

2018 per 100,000 inhabitants
1 Australia 57 melanoma diagnoses
2 Norway 50 melanoma diagnoses
3 Denmark 45 melanoma diagnoses
4 Sweden 43 melanoma diagnoses
5 Germany 38 melanoma diagnoses
2018 per 100,000 inhabitants
1 Australia
57 melanoma diagnoses
2 Norway
50 melanoma diagnoses
3 Denmark
45 melanoma diagnoses
4 Sweden
43 melanoma diagnoses
5 Germany
38 melanoma diagnoses

Statistically men are 10% more likely to develop melanoma skin cancer than women.
and also are 4% more likely to die from melanoma than women.

Every year, around 290,600 people in Germany are newly diagnosed with skin cancer. The number of diseases is increasing every year and now every third cancer diagnosis is skin cancer. In the UK, approximately 160,000 people are diagnosed with non-malignant skin cancer and 16,700 with malignant skin cancer each year.

Tissue removal (biopsy)

In order to be able to diagnose skin cancer, the suspicious tissue must be examined under the microscope – regardless of the type of skin tumour.

If the suspicion of melanoma is confirmed, the tumor is then removed completely with a safety margin, depending on the thickness of the tumor (excision). From a tumour thickness of 1 mm, the so-called sentinel lymph node is also removed.

Tumor thickness - Breslow's depth

The thickness of skin cancer is differentiated between different T-classifications. The tumor thickness of the primary tumor in malignant melanoma is classified according to Breslow after surgical removal. This classification is the most important prognostic factor of malignant melanoma.

The larger the tumor thickness, the worse is the probable course of the disease and the chance of cure.

T-Classification Tumor thickness Other prognostic parameters
Tis Melanoma In-situ, no tumor invasion
Tx Not specified Stage not determinable
T1 ≤ 1.0 mm a: without ulceration, mitoses <1/mm²
b: with ulceration or mitosis rate/mm² ≥ 1
T2 1.01 - 2.0 mm a: without ulceration
b: with ulceration
T3 2.01 - 4.0 mm a: without ulceration
b: with ulceration
T4 > 4.0 mm a: without ulceration
b: with ulceration
T-Classification Tumor thickness
Other prognostic parameters
Tis -
Melanoma In-situ, no tumor invasion
Tx Not specified
Stage not determinable
T1 ≤ 1.0 mm
a: without ulceration, mitoses <1/mm²
b: with ulceration or mitosis rate/mm² ≥ 1
T2 1.01 - 2.0 mm
a: without ulceration
b: with ulceration
T3 2.01 - 4.0 mm
a: without ulceration
b: with ulceration
T4 > 4.0 mm
a: without ulceration
b: with ulceration

Safety distance for primary excision

After the malignant melanoma has been classified according to the tumor thickness, an excision is performed with a specific safety distance to the tumor margin, depending on the tumor thickness. This is extremely important to prevent the tumor from coming back.

Studies recommend a safety distance of 1 cm for a tumor thickness of 1-2 mm. For melanomas with a tumor thickness of 2 mm or more, a 2 cm safety distance should be made.

Stage Tumor thickness - Beslow's depth Safety distance
pT1, pT2 ≤ 1.00 - 2.00 mm 1 cm
pT3, pT4 2.01 - 4.00 mm 2 cm
Stage Tumor thickness - Beslow' depth
Safety distance
pT1, pT2 ≤ 1.00 - 2.00 mm
1 cm
pT3, pT4 2.01 - 4.00 mm
2 cm

Before the surgical procedure, the surgeon should make the final decision for deviating
safety distances together with the patient. 
The localization of the tumor and the results of
the spread diagnostics should be taken into account.

Follow-up care

A standardized follow-up care over a 10-year period is an important component in the care of melanoma patients. The aim is to detect returning and secondary melanomas at an early stage.

Especially in the first 3 years after the primary diagnosis an intensive follow-up care should occur, since in this period 80% of returning malignant melanomas develop.

In addition, skin cancer patients should regularly and lifelong perform a self-examination of their skin for changes.

Follow-up care scheme
Year 1 - 3 Year 4 - 5 Year 6 - 10
IA 6-monthly annual annual
IB-IIB 3-monthly 6-monthly 6- to 12-months
IIC-IV* 3-monthly 3-monthly 6-monthly
Follow-up care schema
Year 1 - 3 Year 4 - 5 Year 6 - 10
IA 6-monthly annual annual
IB-IIB 3 - monthly 6 - monthly 6 - 12 monthly
IIC-IV* 3 -months 3 -months 6 -months

The follow-up care of melanoma patients should take place in risk-adapted and regular intervals.

Counselling centres

During this difficult time, affected persons and their relatives should not bear the entire burden of the diagnosis alone. For this reason, there is a nationwide network of cancer counselling centres in Germany.

There are also more than 60 Cancer Aid counselling centres in Austria. In the UK, the Macmillan Cancer Centre provides cancer patients with the support they need.

Summary

In summary, the earlier malignant melanoma is detected, the better the possible course of the disease and the chance of cure.

The correlation between early detection and tumor thickness is verifiable and also determines the safety margin for excision. In the early stages, skin cancer is easily treatable.

Through regular self-examination of the entire body, malignant and non-malignant skin cancer can be detected early. Remember, you are in your skin for life!

Sources:
2020 Melanoma UK Skin Cancer Report
Oncology guideline program (German Cancer Society, German Cancer Aid, AWMF): Diagnostics, therapy and follow-up of melanoma, long version 3.3, 2020, AWMF register number: 032/024OL, http://www.leitlinienprogrammonkologie.de/leitlinien/melanom/ (retrieved on: 10.11.2021).

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