Best Tips on Causes, Symptoms and Treatment of Malignant Melanoma Nursing Care

Malignant Melanoma
Malignant Melanoma

Melanoma refers to a common skin cancer that comes from the melanin cells within the upper layer of the skin also known as the epidermis or from cells that are the same that may mostly be found in moles or the nevi. This type of skin cancer can end up sending down roots into deeper layers of the skin. A number of these tiny roots may spread bringing about a new swelling growth in important organs of the body. 

Types

There are different types and these types are usually treated in the same manner.

Types of Melanoma

Superficial spreading melanoma

The Superficial Melanoma appears to start growing outwards rather than downwards into the skin. This is the most common type of melanoma and 60 to 70 % of people have this type of melanoma. It is mostly diagnosed in people of between the age of 30 and 50 years. Superficial Melanoma can develop anywhere on the body but it is common on the central part of the body in men which is also known as the trunk and in women it is common on the legs.   

Nodular

Nodular Melanoma grows downwards into the deeper layer of the skin. They can develop very fast and there is often a raised area on the skin surface with this type of melanoma. Nodular Melanoma is the second most common type of melanoma and between 15 and 30 out of every 100 melanomas are on this type.It is mostly diagnosed in people in their 50’s. It can develop in any given part of the body.

Lentigo maligna

Lentigo Maligna Melanoma develop just from very slow growing  coloured patches of the skin called Lentigo Maligna  or the Hutchinson’s melanotic freckle. The lentigo maligna type of melanoma is usually flat and grows outwards in the surface layers of the skin. It might end up getting bigger gradually over a given period of years and might even change in shape or colour.  Once it becomes lentigo maligna melanoma, it begins to grow down into the deepest layers of the skin and may form lumps that are also known as the nodules.

Approximately 5 to 15% out of 100 melanomas are this type and it is common in people older than 60 years. They mostly appear in areas of skin that is greatly exposed to the sun and so they are most common on the face. They can also be common in people who have spent a lot of time outdoors. Amelanotic melanoma

Amelanotic simply means without melanin or simply no melanin.Melanin is a dark coloured pigment and so unlike other melanomas, amelanotic melanomas are usually red or skin coloured rather than appearing dark.

Other types of melanoma like the acral lentiginious can be having no colour and are amelanotic melanomas. This type of melanoma is usually not common and approximately 8 out of 100 melanomas are on this type. They are mostly very hard to treat because of their lack of colour and they can be mistaken for their skin condition.

Acral lentiginous melanoma

The acral lentiginous type of melanoma is commonly found on the palms of the hands and under the feet or around the big toe nail. It can also develop under the nails but it is more common on the feet compared to the hands. This type is rare since 5 to 10 out of every 100 people diagnosed with melanoma have this type. The most affected people are the dark skinned. 

Other types of melanoma

Mucosal melanoma

This is the layer of tissue that covers the inner surface of the parts of the body like the mouth or vagina 

Possible area where the mucosal melanoma can start include the:

  • Anus
  • Vagina
  • Penis
  • Vulva
  • Mouth
  • Digestive system

Melanoma of the eye

Rarely melanoma can start in the eye and it is at times called uveal melanoma or choroid melanoma.Uveal melanoma mostly starts in the uvea and uvea is the middle layer of the eye and contains three parts.

Uveal melanoma starts in the uvea. The uvea is the middle layer of the eye and has 3 parts:

  • Iris (the coloured part)
  • ciliary body
  • Choroid

Mostly the uveal melanomas develop in the choroid part of the uvea (choroid melanoma).

Signs

The immediate sign of melanoma is often a new mole of a change in the appearance of a current mole

Normal moles are normally round or oval and have a smooth edge and usually not bigger than 6mm in diameter but the size is not an assurance of melanoma. A healthy mole can be larger than 6mm and a cancerous mole can appear to be smaller than this.

There is another vital sign that appears to be different from all of the other spot on your skin and it is known as the ugly duckling sign.

If you spot any of these warning signs, have a skin checkup from your doctor.

There is also a rule known as the ABCDE that guide to the usual sign of melanoma. Talk to your doctor about spots that have any of the features mentioned below.

    A is for Asymmetry: One half of a mole or birthmark does not match the other.

    B is for Border: The edges are irregular, ragged, notched, or blurred.

    C is for Color: The color is not the same all over and may include different shades of brown or black, or sometimes with patches of pink, red, white, or blue.

    D is for Diameter: The spot is larger than 6 millimeters across (about ¼ inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this.

    E is for Evolving: The mole is changing in size, shape, or color.

There are some melanomas that do not actually fit these rules and it is good to speak to your doctor about any changes or new spots on the skin that appears to be different from the other moles.

There are also other warning signs of melanoma like:

A sore that does not heal

Spread of a pigment from the boarder of a spot into surrounding skin

Swelling beyond the border of the mole or some redness may be spotted

Change in feeling like itchiness, tenderness or pain

Change in the surface of a mole i.e. scaliness, oozing, bleeding or the appearance of a lump or bump  

Do not have fear to show your doctor any of the areas that concern you also ask him or her to look at the areas that may be very hard for you to see. It at times appears to be very difficult to tell the difference between melanoma and an ordinary mole even for doctors and so it is good to show your doctor any mole that you are not certain about.         

Do not also forget that a small part of the melanomas start in places other than the skin like under the fingernails or toenails , in the mouth or even in the coloured part of the eye. So it is advisable for you to show your doctor any new or changing spots in these areas also.

What Causes Melanoma Skin Cancer?

There are a lot of risks for melanoma that have been spotted, but it is not always clear exactly how they might end up causing cancer.

For instance, while most moles never turn out to become melanoma, a few do. According to researchers, there are some gene changes that have been found in the mole cells that may end up causing them to become melanoma cells. It is yet not well known exactly why a number of moles turn out to be cancerous while most don’t.   

DNA is usually the chemical that is found in every cell that composes our genes that usually control how cells do function. We typically resemble our parents because they are the source of our DNA but DNA does affect more than just how we look.

Some genes control when our cells grow, divide into new cells and die.

The genes that usually help the cells to grow, divide and remain alive are known as the oncogenes.

   There are other genes that usually keep the growth of cell in check, also repair mistakes in DNA or cause make cells to die at the intended time are known as the tumor suppressor genes.    

Cancers can typically be caused by DNA mutations or any other types of changes that keep the oncogenes turned on, or that turn off tumor suppressor genes. These types of gene changes can lead to cells growing out of control. Changes in a number of different genes are mostly needed for a cell to become a cancer cell.

Acquired gene mutations

Mostly, gene changes related to melanoma are gained during a person’s lifetime and are not passed on to a person’s children or in short it is not inherited. At times, these acquired mutations tend to take place randomly within a cell with no even clear cause. In other cases, they are likely to happen as a result of exposure to an outside cause. 

For instance, Ultraviolet rays are a major cause of melanoma. These UV rays can damage the DNA in skin cells. There are times that this damage affects certain genes that control how the cells grow and divide. If these genes are found to be no longer working, the affected cells may turn out to be cancer cells

Most UV rays come from sunlight but there are some that can come from man-made sources such as tanning beds. Some DNA damage from exposure of UV might take place in the few years before the cancer shows up, but a lot of it could be from exposures that took place many years ago. Children and young adults mostly get a lot of intense sun exposure that might not lead to cancer until very many years or even decades later. 

The most common change that takes place in the melanoma cells is the mutation in the BRAF oncogene that is found in approximately half of the melanomas. Other genes that can be affected in melanoma include NRAS, CDKN2A and NF1.mostly only one of these genes is affected.

Some melanomas take place in parts of the body that are rarely exposed to sunlight. These melanomas often have different gene changes than those in melanomas that develop in areas that are exposed to sunlight like in the C-KIT or just the (KIT) gene.

Inherited gene mutations

It is on rare cases for people to inherit gene changes from a parent that clearly raise their risk of melanoma.

The familial also known as the inherited melanomas often have changes in tumor suppressor genes like CDKN2A also called the p16 or CDK4 that usually prevent them from performing their normal duties of controlling cell growth. This could finally lead to cancer.

Some people like those with xeroderma pigment sum (XP), do inherit a change in one of the XP (ERCC) genes that usually help in repairing damaged DNA in the cell. Changes in one of these genes can result to skin cells that have trouble in repairing DNA damaged by UV rays and so these people are more likely to be in the danger of developing melanoma more so on the parts of the body that are exposed to the sun.

Gene mutations can sometimes affect treatment

There are some gene changes that are found in the melanoma cells have proven to be good targets for drugs that will help in treating these changes

Treatment

Surgery is the main treatment for melanoma.

Malignant Melanoma
Malignant Melanoma

If in any case you realize you have the melanoma skin cancer, you will be taken good care of by  a team of specialists that should include a specialist in areas of skin or rather the dermatologist if I may simplify it, a plastic surgeon , a specialist in the field of radiotherapy and chemotherapy also known as the oncologist, an expert in tissue diseases or also known as the pathologist and a qualified nurse.

When helping you decide on your treatment, the team will consider:

The type of cancer you have

The stage of the cancer (the stage and how far it has spread)

Your general health   

The team that will be treating you will recommend the best treatment that they believe will work for you but at long last the final decision will be yours.

Before going to the hospital for treatment options, you may find it good to write a list of some questions that you will ask the specialist on arrival.

For instance you may need to find out on the advantages and disadvantages of a given treatment.

Treating stage 1 to 2 melanoma

Treatment of stage 1 melanoma involves surgery to eliminate the melanoma and a small area of skin around it. This process is known as surgical excision.

Surgical excision is on most cases performed using local anaesthetic, which implies that you will have to be awake but the area around the melanoma will be numbed, so you will not feel any pain. In some cases, general anaesthetic is used and this means that you will be unconscious in the whole process.

If a surgical excision is more likely to leave a major scar, it may be done together with a skin graft. Nevertheless, skin flaps are now commonly used because the scars are usually not easy to be noticed compared to those resulting from a skin graft.

Mostly once the melanoma has been removed there’s a little possibility of it returning and no extra treatment should be required. A lot of people at around 80 to 90% are monitored for 1 to 5 years and are then discharged with no further problems.

Sentinel lymph node biopsy

A sentinel node biopsy is a procedure used to test for the spread of cancer. It may be offered to people with stage 1B and 2C melanoma.It is mostly done the same time as surgical excision.

You will have to agree with your specialist whether to have a sentinel lymph node biopsy. If you make up your mind to have the procedures and the results show no spread to nearby lymph nodes, it’s unlikely you will have further problems with this melanoma.

If your results confirm melanoma has spread to nearby nodes, your specialist will have to discuss with you whether further surgery is needed. Extra surgery involves removing the nodes that are remaining which is known as a lymph node dissection or completion lymphadenectomy.

Treating stage 3 melanoma

If the melanoma has spread to nearby lymph nodes (stage 3 melanoma), further surgery may be required to remove them.

Stage 3 melanoma may be diagnosed by a sentinel node biopsy, or you or even a member of your treatment team may have felt a swelling in your lymph nodes.

Diagnosis of melanoma is usually confirmed using a needle biopsy (fine needle aspiration).Removal of lymph nodes that are affected is usually done under general anaesthetic.

The procedure of removal of lymph node commonly known as lymph node dissection can disrupt the lymphatic system leading to a build-up of fluids in your limbs and this is known as lymphedema.   

Treating stage 4 melanoma

If in any case melanoma does not go away and it resumes or spreads to other organs, it is called stage 4 melanoma.

In the past, cure from stage 4 melanoma was very rare but new treatments like the immunotherapy and targeted treatments show encouraging results.

In the past, cure from stage 4 melanoma was very rare but new treatments, such as immunotherapy and targeted treatments, show encouraging results.

Treatment for stage 4 melanoma is given in the hope that it can in any case slow the growth of cancer, reduce symptoms and extend life expectancy. You may be offered a surgery to remove melanomas that have grown away from the original site. You may also be in a position of having other treatments to help with your symptoms like radiotherapy and medicine.

If you have advanced melanoma, you may decide not to undergo treatment if it’s unlikely to significantly extend your life expectancy or if you do not have any of the symptoms that cause pain or discomfort.

It is your final decision and will have to be respected by the treatment team. If you decide not to receive treatment, pain relief and nursing care will be made available when you need it. This is called palliative care.

Immunotherapy

Immunotherapy is used to treat advanced (stage 4) melanoma, and it’s sometimes offered to people who have stage 3 melanoma as part of clinical trial. Immunotherapy usually uses medicine to help the body’s immune system find and kill the melanoma cells. There are several medicines available, some of which can be used on their own (monotherapy)or  together also known as combination therapy.  

Medicines comprise of:

  • Ipilimumab
  • Nivolumab
  • Pembrolizumab
  • Talimogene laherparepvec

These medicines are mostly recommended for people with previously treated or untreated advanced melanoma that’s spread or cannot be removed using surgery. They are mostly given either though a drip or by injection every few weeks. Some medicines are given on a short-term basis over a few weeks. Others are given on a longer-term basis. 

Side effects of immunotherapy medicines include:

  • Diarrhea
  • Rash
  • Itching
  • Fatigue
  • Feeling and being sick
  • Decreased appetite
  • Tummy (abdominal) pain

Targeted treatments

Around 1 in 2 with melanoma has a change (mutation) in a gene called BRAF. This mutation causes cells to grow and divide very fast. Targeted medicine can be used to target this mutation to slow or stop cancer cells from growing. 

Some targeted treatments for melanoma include:

  • Vemurafenib
  • Dabrafenib
  • Trametinib

These medicines may be recommended as a treatment for people who are suffering from gene mutation and have a very aggressive type of melanoma I part of their body or melanoma that’s spread.

The side effects of these medicines can include:

  • Decreased appetite
  • Headache
  • Cough
  • Feeling and being sick
  • Diarrhea
  • Rash
  • Hair loss or thinning

Radiotherapy and chemotherapy

You may have radiotherapy after a surgery to remove your lymph nodes, and it can also be used to help relieve the symptoms of advanced melanoma. Controlled doses of radiation are used to kill the cancerous cells.

If you have advanced melanoma, you may be forced to have a single treatment or a few treatments. Radiotherapy after an operation mostly consists of a course of 5 treatments a week (1 every day from Monday to Friday) for some few weeks. There’s a rest period over the weekend.

Common side effects associated with radiotherapy include:

  • Tiredness
  • Feeling sick
  • Loss of appetite
  • Hair loss
  • Sore skin

Most side effects can be prevented or controlled with prescription medicines, so inform your treatment team if you have experience with any. The radiotherapy side effects should slowly reduce once treatment is over.

Chemotherapy type of treatment is now rarely used in treating melanoma. Targeted treatments and immunotherapy are the preferred treatment options.

Melanoma vaccines

Research is under way to produce vaccines for melanoma, either to treat advanced melanoma or to be used after operation in people with a high risk of the melanoma coming back. They are currently only given as part of a clinical trial.

Follow-up

Immediately after your treatment, you will have regular follow-up appointments with your doctor to check whether:

  • There are any signs of melanoma coming back
  • The melanoma has spread to your lymph nodes or other areas of your body
  • There are signs of any new primary melanomas

 Your specialist will examine you and they will ask about your general health and whether you have any questions or concerns.

You may be given treatments like immunotherapy, to try to prevent the melanoma coming back. This is known as adjuvant treatment.

There is no full evidence that the adjuvant treatment helps in prevention of melanoma coming back, so it is currently only offered as part of clinical trial.

There is a prove that checkpoint therapies, which boost the body’s immune responses to cancer, may be spared for future use if the clinical trials offer evidence that they are effective.

Help and support

Being diagnosed with melanoma can be very tricky to deal with because you may feel shocked, upset, numb, frightened, uncertain and confused. These feelings are natural and you can go ahead and ask your treatment team about anything you have doubt in.

Your relatives and friends can play a very vital role of being a great source of support. Talking about cancer and how you are feeling can help both you and members of your family cope with the situation.