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Skin Cancer

If an adult in your life has skin cancer, you may want to learn more about it. This page has information about skin cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease caused by abnormal cells that grow too rapidly. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer that can grow anywhere in the body.1 Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: Incidence. J Am Academy of Dermatology. 1994;30:774.

There are several types of skin cancers, but basically, skin cancers can be classified as either malignant melanoma or non-melanoma skin cancers (NMSC).

  • Non-melanoma skin cancers (NMSC): This group of skin cancers includes mainly basal cell carcinoma, which is the most common, and squamous cell carcinoma.Together, these two types of cancer account for about 95 percent of NMSC.2 American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012. Not all squamous cell cancers and basal cell cancers of the skin are reported to national cancer registries, so it can be difficult to know the exact number of new cases every year. However, according to the American Cancer Society, NMSC were diagnosed in 3.5 million people in the U.S., and 2.2 million people were treated for the disease in 2006, with some patients having multiple diagnoses.2 American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012. Most, but not all, of these forms of skin cancer have a high cure rate because they are often very small when found. Actually, despite millions of new cases of NMSC diagnoses each year, there are fewer than 1,000 deaths related to NMSC.3 Albores-Saavedra J, Batich K, Chable-Montero F, Sagy N, Schwartz AM, Henson DE. Merkel cell carcinoma demographics, morphology, and survival based on 3870 cases: a population based study. J Cutan Pathol. 2010:37:20-27.
  • Malignant melanoma of the skin: This is becoming more common in the U.S. Interestingly, about 25 percent of all melanomas are found on the head and neck. Usually, melanoma is much more serious than NMSC because there is a higher risk of spread to other parts of the body. According to the American Cancer Society, melanoma cases have been increasing for at least 30 years. In fact, since 2004, melanoma has been increasing by almost 3 percent a year in both men and women.2 American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.

Your loved one may have noticed an oddly shaped mole, lump or swelling on his or her skin and brought it to the attention of a doctor. Not every mole, lump or bump is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier the cancer is found, the better the outcome.

Understanding the anatomy

To understand skin cancer, you need a basic understanding of the anatomy (parts) of your head and neck.

The skin is the largest organ in the body. There are three main layers of the skin: the epidermis, dermis and subcutaneous tissue (also called the hypodermis or subcutis).

60_skin

Within the different layers of the skin are different cell types. Any of these cells can, in theory, turn into cancer. For example, lymphocytes are immune cells found all over the body, including in the skin. Lymphocytes can turn cancerous, and this would be called lymphoma of the skin (or cutaneous lymphoma).

61_epidermis CROP

  • Epidermis: This is the outermost layer of the skin. The epidermis has a number of layers, which can be different from one another, depending on the location in the body.

    61_1dermis

  • Dermis: This is generally the thickest of the three layers of the skin, which is still just a few millimeters thick. This layer contains blood vessels, lymphatic vessels, hair follicles, sweat glands, oil glands, nerve endings and fibrous tissue. The dermis is made up of two layers—the papillary dermis and reticular dermis.

60_skin

  • Subcutaneous layer (aka hypodermis or subcutis): This is the innermost layer of the skin. This layer contains fat cells and collagen cells as well as bigger blood and lymphatic vessels.

You might have heard of something called the “Clark Level of Thickness” when talking about the type of skin cancer, so it is worth knowing a little about. This is a way the pathologist reports which layer of the dermis the skin cancer has grown into, no matter how thick the tumor actually is. The greater the Clark Level, the deeper the tumor has grown into the skin. The Clark Levels are as follows:

Clark Levels of Invasion of Skin Cancer

  • Level I: The cancer is limited to the epidermis.
  • Level II: The cancer invades partly into the papillary dermis.
  • Level III: The cancer completely fills the papillary dermis but does not extend into the reticular dermis.
  • Level IV: The cancer extends into the reticular dermis.
  • Level V: The cancer extends into the subcutaneous tissue.
    62_Clarklevels NEW

Causes of skin cancer

You may want to know what caused the skin cancer. The short answer is that most skin cancers are associated with sun exposure. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

We know people with certain genetic disorders are more likely to get skin cancers. A few of these disorders include:

  • Xeroderma pigmentosa
  • Nevoid basal cell syndrome (Gorlin Syndrome)
  • Cowden Syndrome
  • Familial melanoma/dysplastic nevus syndrome
  • Peutz-Jeghers Syndrome
  • Werner Syndrome
  • Muir-Torre Syndrome
  • Gardner Syndrome

Also, some acquired disorders or diseases that lower the body’s defenses can also increase the risk of getting skin cancers, including:

  • Organ transplant patients on immune-suppressing medications
  • HIV-positive patients
  • Lymphoproliferative disorders

Still, it seems that ultraviolet radiation (such as from the sun) is the most important cause of skin cancer.

  • Ultraviolet radiation: At this time, researchers believe that when UV waves (mainly in the UVB spectrum) hit the cells of the skin, they cause mutations in the genes of the cells. Mutated skin cells can then grow uncontrollably; this is cancer. UV radiation may also make natural cancer-fighting cells in the skin less effective. Lighter-skinned people more often get NMSC than darker-skinned people. This may be related to how melanin (dark pigment) protects skin cells from UV damage. The Fitzpatrick classification system is used to classify patients into different groups. Patients who have a lower Fitzpatrick classification are more likely to get NMSC caused by UV radiation than those in a higher Fitzpatrick classification.

Fitzpatrick Classification of Skin Type

Type I White, pale Always burns, never tans
Type II White, fair Usually burns, tans with difficulty
Type III White to light brown (common in U.S.) Sometimes burns, sometimes tans
Type IV White to moderate brown, olive Rarely burns, tans easily
Type V Brown to dark brown Very rarely burns, tans very easily
Type VI Very dark brown to black Never burns, always tans

63_fitzpatrick_classesNEW

Exposure to other risk factors (not just the sun) has also been linked to causing non-melanoma skin cancer:

  • Ionizing radiation
  • Coal tar
  • Asphalt
  • Arsenic ingestion

Finally, there are some skin lesions that doctors think are pre-cancerous lesions. These are growths that are not cancer but, if not removed, might turn into cancer. Examples of pre-cancerous lesions that can lead to NMSC include:

  • Actinic keratoses
  • Keratoacanthoma
  • Bowen’s Disease

For melanoma, many cancers come from dark lesions that have been there for a while. When these suddenly change, there is concern the lesion is melanoma. Examples of lesions that are at increased risk of developing into melanoma include:

  • Congential nevi (especially if large)
  • Dysplastic nevi
  • Lentigo maligna

 

Signs and symptoms of skin cancer

Skin cancer can show up in a few different ways:

  • A lesion on the skin of the face, neck or scalp: Some cancers are very slow to grow and change; others change quickly. Any new lesion on the body should be checked by a dermatologist (skin doctor). Most lesions are not cancer, and most skin cancers are slow growing and easily treated. But if something is growing quickly, don’t wait to have it evaluated.

Keep in mind “ABCDE” for any type of skin lesion. These are signs that can be concerning for melanoma.

  • An itchy and bleeding area: Sometimes you might not be able to see a lesion on the scalp. But if you notice something constantly bleeding or really itchy or painful, it’s worth having it checked out by a doctor.
    64_ABCDE NEW
  • Nothing at all: Some people at an increased risk of getting skin cancer might not notice anything. These patients may visit a dermatologist regularly for a skin evaluation; this is called screening. Patients who have problems with their immune systems should have routine skin screenings due to increased risk of skin cancers in general and specifically more aggressive skin cancers.
  • A lump or bump in the neck or face: In some cases, the first sign of a skin cancer might actually be a bump or lump in the neck or the face; this could be a lymph node. Lymph nodes are located throughout the body, including the neck. Lymph nodes filter fluid accumulated from a nearby part of the body and help the body fight infections and cancers. Cancers from one site in the head and neck can drain into lymph nodes and lead to growth of cancer within the lymph node. These are called metastatic lymph nodes. Lymph nodes behind the big muscle in the neck, called the sternocleidomastoid muscle, and lymph nodes in the salivary gland over the jawbone onto the cheek, called the parotid gland, that turn out to be cancerous could mean skin cancer has spread there.

These symptoms sound scary, but don’t jump to conclusions. A person could have one or more of these symptoms but NOT have skin cancer. There are several non-cancerous causes of the same symptoms. That’s why it is necessary to consult a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s skin. Most of the time, a patient with a skin issue will go to see a doctor who specializes in skin disease, called a dermatologist. In general, the specialist might do some of the following:

  • Look over the entire body for any unusual lesions such as moles or skin spots
  • Look and feel around the neck and face for any lumps or bumps that might be lymph nodes
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing skin cancer

Getting to a diagnosis begins with a history and physical examination. For skin cancer, if there is a suspicious lesion, most doctors will choose to do a biopsy first, because it can be done in the office with very little risk.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit.

Fortunately, biopsies of the skin are more straightforward than for other sites, mainly because they are easier perform. Typically, skin cancers can be biopsied in the office with a little numbing medicine. It usually takes only a few seconds to do a biopsy. The tissue is then sent to a pathology doctor to see if it is cancer and, if so, what type and how far it has spread.

A biopsy can help the doctor plan the surgery if he or she decides it is needed. A biopsy can also prevent unnecessary surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false-positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Sometimes doctors can’t be completely sure a tumor is cancerous from a biopsy.4 LeBoit PE, Burg G, Weedon D, Sarasain A. (Eds.): World Health Organization. Classification of Tumours. Pathology and Genetics of Skin Tumours. IARC Press: Lyon 2006.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting some imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan  MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous .The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Determining the type of skin cancer

After the tumor has been closely looked at, the doctor will need to figure out what type of cancer it is. He or she may be able to tell from biopsy results. The doctor may also want a second opinion from a specialist to be sure.

First, remember that most moles, lumps and bumps found on the skin are not cancer. Most growths are benign (non-cancerous), and some tumors are on the border between benign and malignant (cancerous). Next, some lesions are abnormal and should be removed because they may develop into cancer in the future. Examples of pre-cancerous lesions include:

  • Actinic keratoses
  • Keratoacanthoma
  • Bowen’s Disease

If it is skin cancer, there are two main types:

  • Melanoma (cutaneous malignant melanoma)
  • Non-melanoma skin cancer (NMSC)

Cutaneous Malignant Melanoma (CMM)

Malignant melanoma is a type of cancer that comes from melanocytes. When melanoma is on the skin, it is called cutaneous malignant melanoma. When it is on inner body surfaces (such as inside the nose or mouth), it is called mucosal malignant melanoma. Mucosal melanoma is staged and treated differently than other types of cancers.

There are a number of subtypes of cutaneous malignant melanoma; diagnosing these are based on their appearance and special features seen only under the microscope.

The World Health Organization has identified the following types of malignant melanoma of the skin4 LeBoit PE, Burg G, Weedon D, Sarasain A. (Eds.): World Health Organization. Classification of Tumours. Pathology and Genetics of Skin Tumours. IARC Press: Lyon 2006.:

  • Superficial spreading melanoma
  • Nodular melanoma
  • Lentigo maligna melanoma
  • Acral lentiginous melanoma
  • Desmoplastic melanoma
  • Melanoma arising from a blue nevus
  • Melanomal arising in a giant congenital nevus
  • Melanoma of childhood
  • Nevoid melanoma

Non-Melanoma Skin Cancer (NMSC)

In this group, skin cancers start from cells called keratinocytes in the outer layer of the skin. These include:

  • Basal cell carcinoma: These are cancers from the epidermis cells in the deepest layer of the epidermis. These are the most common type of NMSC, making up about 70 to 75 percent of skin cancers. These are probably also the most common cancer in the U.S. Some people can have many basal cell carcinomas. They are generally very slow growing, slow to invade deeply and rarely spread to lymph nodes. However, some types can be more aggressive than others.
  • Squamous cell carcinoma: This second most common type of NMSC is from cells in the epidermis as well. These can be more aggressive than basal cell carcinomas. About 5 percent of non-melanoma skin cancers come from cells in the skin that are not part of the outer lining or epithelial part of the skin; these are called adnexal (next to an organ) cancers, neural cancers, soft tissue cancers and hematolymphoid cancers.
  • Merkel cell carcinoma: This is a type of cancer from Merkel cells in the epidermis. These are very rare skin cancers, but they can be quite aggressive. They can also recur or spread to lymph nodes as well as spread throughout the body.
  • Sebaceous carcinoma: This is cancer from cells that make up the oil glands in the skin. Most of these cancers are found in the skin around the eye. These are usually slow growing but should be treated by a doctor who specializes in cancer.

Other types of NMSC include: atypical fibroxanthoma, carcionma of the sweat glands, pilomatrical carcinoma, proliferating trichilemmal tumor, microcytic adnexal carcinoma, porocarcinoma, spiradenocarcinoma, malignant mixed tumor, hidradenocarcinoma, mucinous carcinoma, apocrine carcinoma, Ewing sarcoma, primitive neuroectodermal tumor (PNET), granular cell tumor, dermatofibrosarcoma protuberans, and cutaneous angiosarcoma.

Also, because there are lymphatic tissues in the skin, lymphomas can also be found in the skin; those should be evaluated and treated by a medical oncologist.

Finally, even more rarely, cancer from other sites, such as the lung, breast, or ovaries, may spread to the skin.

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is a pathologist’s interpretation of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by the physical exam, imaging studies, laboratory work and biopsies.

Like with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

The staging of skin cancers does vary a little based on the type of skin cancer. According to the AJCC 7 edition staging manual, skin cancer staging is broken down into the following categories:

  • Staging of cutaneous squamous cell carcinoma and other cutaneous carcinomas
  • Staging of Merkel cell carcinoma
  • Staging of malignant melanoma of the skin
  • Staging of cutaneous lymphoma

Staging of Skin Squamous Cell Carcinoma, Basal Cell Carcinoma and Other Skin Carcinomas

This is the staging criteria used for squamous cell cancers of the skin and basal cell cancers of the skin. It can also be used for other skin cancer types that do not have their own staging system. This staging system does not apply to melanoma skin cancers, cancers on the eyelid or lymphomes of the skin.

T stage: The main tumor mass

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

Tx The primary tumor cannot be evaluated.
T0 There is no evidence of a primary tumor.
Tis The cancer is in situ, meaning it has not invaded into deeper layers.
T1 The tumor is 2 centimeters or less at its largest point. Also, it must have fewer than two high-risk features.
T2 The tumor is more than 2 centimeters at its largest point, OR the tumor can be of any size with two or more high-risk features.
T3 The tumor invades the cheekbone (maxilla), jawbone (mandible), eye socket (orbit) or the bone of the ear (temporal bone).
T4 The tumor invades nerves at the base of the skull.

High-risk features are:

  • The cancer is more than 2 millimeters thick.
  • The cancer extends down to Clark level IV or more.
  • There is invasion into/around nerves.
  • The main tumor is located at the ear.
  • The main tumor is on the part of the lip that has hair.
  • The tumor is either poorly differentiated or undifferentiated.

N stage: Spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 It looks like there is a single node, on the same side of the main tumor, that is 3 centimeters or less in greatest size.
N2a The cancer has spread to a single node on the same side as the main tumor, and it is more than 3 centimeters but less than or equal to 6 centimeters in greatest dimension.
N2b More than one lymph node has cancer, on the same side as the main tumor, but none are more than 6 centimeters.
N2c There are lymph nodes in the neck on either the opposite side as the main cancer or on both sides of the neck, but none are more than 6 centimeters.
N3 There is spread to one or more neck lymph nodes, and the size is more than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant spread.
M1 Spread to areas of the head and neck (e.g. in the lungs, bone, brain, etc.)

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Stage 0 Tis N0 M0
Stage 1 T1 N0 M0
Stage 2 T2 N0 M0
Stage 3 T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage 4 T1 N2 M0
T2 N2 M0
T3 N2 M0
Any T N3 M0
T4 Any N M0
Any T Any N M1

Staging of Malignant Melanoma of the Skin

For melanoma, the T stage is all about the tumor thickness.

T stage for malignant melanoma of the skin

Tx The primary tumor cannot be evaluated (it was curetted out or has severely regressed).
T0 There is no evidence of a primary tumor.
Tis The cancer is in situ, meaning it has not invaded into deeper layers.
T1a The tumor thickness is 1 millimeter or less (without ulceration and mitosis <1/mm2).
T1b The tumor thickness is 1 millimeter or less (with ulceration or mitosis >1/mm2).
T2a The tumor thickness is 1.01 mm to 2 mm (without ulceration).
T2b The tumor thickness is 1.01 mm to 2 mm (with ulceration).
T3a The tumor thickness is 2.01 mm to 4.0 mm (without ulceration).
T3b The tumor thickness is 2.01 mm to 4.0 mm (with ulceration).
T4a The tumor thickness is more than 4.0 mm (without ulceration).
T4b The tumor thickness is more than 4.0 mm (with ulceration).

Ulceration means there is a wound caused by a break in the surface of the tumor where dead cells are present. This is seen under the microscope by a pathologist.

N stage for malignant melanoma of the skin

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past).
N0 There is no evidence of any spread to the lymph nodes.
N1 1 node N1a if micrometastasis N1b if macrometastasis
N2 2-3 nodesN2a if micrometasasisN2b if macrometasasisN2c if in-transit metastasis or satellite metastasis without any positive nodes
N3 4 or more nodes with cancer, or nodes that are stuck together, or in transit or satellite metastases with positive nodes
  • Micrometastasis: This is used when there appear to be no large cancerous lymph nodes, but after lymph nodes were removed, it turns out there was microscopic involvement.
  • Macrometastasis: This is used when there are detectable lymph nodes before being removed that are then confirmed to be positive when examined under a microscope.
  • In transit metastasis: These are tumor deposits in the skin or just under the skin more than two centimeters away from the primary lesion. The tumor cells travel within lymphatic channels.
  • Satellite metastasis: These are tumor deposits in the skin or just under the skin that are within two centimeters of the primary lesion. The tumor cells travel within lymphatic channels.

M stage for malignant melanoma of the skin

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body. Notice that the M stage for melanoma takes into account a special blood test for lactate dehydrogenase (LDH). If the level of this protein in the blood is high, the M stage is automatically M1c.

M0 No evidence of distant spread
M1a Spread to the skin, subcutaneous tissue, or lymph nodes distant from the primary tumor and the regional basin of lymph nodes
M1b Spread to the lung
M1c Spread to any other body site

Cancer Stage for Malignant Melanoma of the Skin

After TNM staging, your doctor can assign a cancer stage based on the following chart.

Stage 0 Tis N0 M0
Stage 1A T1a N0 M0
Stage 1B T1b N0 M0
T2a N0 M0
Stage 2a T2b N0 M0
T3a N0 M0
Stage 2b T3b N0 M0
T4a N0 M0
Stage 2c T4b N0 M0
Stage 3 Any T N1-3 M0
Stage 4 Any T Any N M1

Staging of Merkel Cell Carcinoma

T stage for Merkel cell carcinoma

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

Tx The primary tumor cannot be evaluated.
T0 There is no evidence of a primary tumor.
Tis The cancer is in situ, meaning it has not invaded into deeper layers.
T1 The tumor is 2 centimeters or less at its largest point.
T2 The tumor is more than 2 centimeters but not more than 5 centimeters at its largest point.
T3 The tumor is more than 5 centimeters at its largest point.
T4 The tumor invades bones, muscles, fascia or cartilage.

N stage for Merkel cell carcinoma

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the lymph nodes.
cN0 Based on your doctor’s examination and review of the imaging, there do not seem to be any lymph nodes.
pN0 After looking at lymph nodes under a microscope following removal, there is no evidence of spread to neck lymph nodes.
N1a Micrometasasis: This is used when one or more lymph nodes are removed “electively,” and it turns out there is cancer within the lymph nodes.
N1b Macrometastasis: This is used when there are enlarged lymph nodes identified before removing them that are then confirmed to be positive under a microscopic test after removal.
N2 In transit spread: This is used when there is a tumor separate from the main lesion and located either between the main lesion and the draining lymph nodes or anywhere further away (distal) to the primary tumor.

M stage for merkel cell carcinoma

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No distant spread
M1a Spread to the skin, subcutaneous tissue or lymph nodes separate from those related to the main tumor
M1b Spread to the lung
M1c Spread to any other body site orspread to any distant site with an elevated LDH level in the blood

Cancer stage for Merkel Cell Carcinoma

After TNM staging, your doctor can assign a cancer stage based on the following chart.

Stage 0 Tis N0 M0
Stage 1A T1 pN0 M0
Stage 1B T1 cN0 M0
Stage 2A T2-3 pN0 M0
Stage 2B T2-3 cN0 M0
Stage 2C T4 N0 M0
Stage 3A Any T N1a M0
Stage 3B Any T cN1/N1b/N2 M0
Stage 4 Any T Any N M1

The clinical stage

Once the tests are completed, and before deciding on a treatment plan, the patient should be given a clinical stagethat looks like this:

CLINICAL STAGE
Example
Site Skin
Location Left Cheek
Type Basal Cell Carcinoma
cT cT3
cN cN0
cM cM0
cStage cIII

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options:

The latest National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Melanoma, Non-Melanoma Skin Cancers, and Merkel Cell Carcinoma will help the doctor suggest the best treatment.5, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb. 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.6, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc7Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc Let’s look at the types of treatments available.

Surgery

The main treatment for almost all skin cancers is removal of the cancer. This can be done in a number of different ways, including freezing it off, scraping or burning it off, and the complete surgical removal of the tumor. If the last option is used, the surgeon will cut out the lesion or tumor plus a little bit of normal tissue around it to be sure to get all the cancer. Then, another doctor, called a pathologist, will look at the entire tumor under a microscope to identify a more exact stage for the tumor. This report, called the pathologic stage, can help the doctor decide if radiation or systemic therapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays.5, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb. 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc Radiation may be used as a main treatment for tumors that cannot be easily removed. Radiation can be used in combination or alone iwth the other treatment methods.

Chemotherapy

The decision to use chemotherapy, or “chemo,” biologics, and other medicines for skin cancer is more complicated. These drugs might be considered for advanced skin cancers or skin cancers that have spread to other parts of the body.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will life change? These are the big questions on most people’s minds when they find out someone they love has skin cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of a tumor show how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of a cure.
The Tumor Margins (edges) Some say the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone has been shown to indicate a worse prognosis.6Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc

In general, it is very difficult to discuss prognosis (outcomes) without understanding all the details of the cancer; to give a percentage chance of a cure is difficult because cancer research looks at all types of cancers and may include patients from long ago.

What to expect after treatment is completed

When the person in your life who has cancer has completed treatment, he or she will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. A person should have regularly scheduled doctor’s visits for the rest of their life. In addition, the doctor will order scans to help in the monitoring process. You should also make sure you use good sun protection and examine your own skin.5, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb. 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.6, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc7Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc


References

1 Miller DL, Weinstock MA. Nonmelanoma skin cancer in the United States: Incidence. J Am Academy of Dermatology. 1994;30:774.

2 American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012.

3 Albores-Saavedra J, Batich K, Chable-Montero F, Sagy N, Schwartz AM, Henson DE. Merkel cell carcinoma demographics, morphology, and survival based on 3870 cases: a population based study. J Cutan Pathol. 2010:37:20-27.

4 LeBoit PE, Burg G, Weedon D, Sarasain A. (Eds.): World Health Organization. Classification of Tumours. Pathology and Genetics of Skin Tumours. IARC Press: Lyon 2006.

5 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Melanoma V.3.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Feb. 12, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Basal Cell and Squamous Cell Skin Cancers V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc

7 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Merkel Cell Carcinoma V.1.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed Jan. 22, 2014. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc

8 Walling HW, Fosko SW, Geraminejad PA, Whitaker DC, Arpey CJ. Aggressive basal cell carcinoma: Presentation, pathogenesis, and management. Cancer and Metastasis Reviews. 2004;23(3-4):389-402.

9 Cockburn M, Peng D, Key C. Chapter 12: Melanoma. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.