About skin cancer

The number of skin cancer patients who treated in Kumamoto City Hospital dermatology department in 2014 was 106 cases (Table 1). The most common were 45 cases of basal cell carcinoma, and 21 cases of squamous cell carcinoma were second.
Table 1 Skin cancer treatment record at Kumamoto citizen's hospital (2014)

Figure 1: Structure of human skin
(2) Most of the cells making the outermost epidermis are keratinocytes (keratinocytes). This keratinocyte will change from basal cell to spinocyte to granule cell to keratin, from birth to death. The part where each cell exists is called basal layer, spinous layer, granular layer, horny layer.
Figure 2: Structure of epidermis
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(3) This keratinocyte became cancer, basal cell carcinoma and spinocellular carcinoma.
(4) Also, since keratinocytes contain a pigment called melanin, there are colors in humans. Melanocytes supply melanin to keratinocytes, and melanoma is the melanocyte that is cancerous.

Epidemiology of skin cancer
In recent years, the number of skin cancer patients has increased rapidly. Details are unknown because the nationwide patient registration system is not maintained, but there are reports that the incidence doubled in the 10 years from 1998 to 2007 (Okayama Prefecture Medical Association Report No. 1312, 2011 Issued on June 25th). The cause is considered to be aging and environmental changes such as ultraviolet rays amount. Because young people 's skin cancer is not increasing, aging is expected to be the most important factor. Therefore, in Japan where the aging of the population is progressing further, the number of skin cancer patients is expected to increase in the future.

Classification of skin cancer
Skin cancer is divided into epithelial (epidermal) system and nonepithelial system that originate from the surface of the skin, but most (90% or more) is epithelial (epidermis) type cancer.
1 from occurring skin cancer skin portion
　(1) basal cell carcinoma, squamous cell carcinoma, melanoma
　(2) actinic keratosis, Bowen's disease, extramammary par jet disease
skin cancer occurring than 2 non-skin portion
　(1 ) Sarcoma
　　　A. Raised Skin Fibrosarcomae A Leiomyosarcoma
　　　Tumor
　　　Sarcoma
　(2) Malignant Lymphoma
　　　A Adult T Cell Leukemia / Lymphoma
　　　I Mycosis fungoerosis

Skin cancer is the order of basal cell carcinoma> spinal cell carcinoma> melanoma from the larger number of patients. However, the degree of malignancy is opposite, it is the order of melanoma> squamous cell carcinoma> basal cell carcinoma.

Basal cell carcinoma (BCC)
Basal cell carcinoma is the most common cancer in the skin cancer, but it is
1. Do not cause metastasis
2. Therefore, basically not related to life
3. However, it
is characterized by recurrence without sufficient surgery .

Classification of basal cell carcinoma
Basal cell carcinoma is classified into the following 6 types depending on its shape and personality.
(1) Nodular ulcer type: Most frequent type, often with ulcers on the surface
(2) Scarring flat type: scar like in the center, embankment rising around the periphery
(3) Type: flat, large in trunk
(4) spotted scleroderma type: it looks as if the center is depressed and the skin becomes hard
(5) destruction type: mold with
developed nodular ulcer type (6) Pinkus tumor:
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Treatment of basal cell carcinoma
① Test
basal cell carcinoma does not basically transfer, so it is not necessary to examine metastasis by CT or MRI.
However, surgery (local anesthesia or general anesthesia) is required for surgery if surgery is necessary.

② Surgical
recommendation sentence: Most of the clinically well-established basal cell carcinomas are resected 3 to 10 mm apart, resulting in high complete resection rate and long term remission. (From Guidelines for Skin Malignancy Clinical Practice)
　1. For types other than the plaque scleroderma type, remove it 3 to 5 mm apart from the tumor
　2. In the case of the plaque scleroderma type, resection is performed 7 to 10 mm away from the tumor

③ For anticancer drugs, immunotherapy etc. Basal cell carcinoma is basically unnecessary because it does not cause metastasis.

④ Radiation therapy is effective for treatment of basal cell carcinoma, but it is inferior in terms of outcome when compared with surgery. If surgery is not possible, it is worth considering radiation therapy.

⑤ follow-up
Basal cell carcinoma does not cause metastasis but it is highly likely that it will recur (20% to 40% is said to recur), so if after scrub, the scratches calm down, regularly on your own Please check whether there is a recurrence (black spots are not formed, ulcer is not formed etc) (self check). If you think it is doubtful, please do it again at an early stage.

Squamoid cell carcinoma (SCC)
Skin cancer derived from cutaneous epidermal cells, other than basal cell carcinoma is called squamous cell carcinoma. Its characteristic is to recognize many preceding lesions (skin diseases that cause cancer). For example, injuries and burns, sunlight, arsenic (hidden) exposure, radiation, viral infections, sometimes congenital nevus (cutaneous malformations) and the like can lead to lesions of spinous cell cancer.

Squamous cell carcinoma is the second most common cancer in skin cancer after basal cell carcinoma, but
1. Transit when left untreated
2. Therefore, it concerns life
3. Clinically make nodules and ulcers, and when it grows there is a characteristic malodor
. It is the most common skin cancer including prodromal lesions and
features early (precursor lesion) surgery is recommended .

Precursor lesion

Solar keratosis
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It is skin aging (carcinogenesis) caused by long-term exposure to sunlight, and it is said that 20 to 40% will become spinous cell carcinoma within 5 years. Most occur on the face and hand back.
The most serious problem of the recent increase in skin cancer is this increase in sunscreen keratosis.

Bowen's disease
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In the past, relationships with arsenic (hiss) ingestion were said, but recently it has been pointed out that it is involved with virus infection. It is characterized by rustling and reddish surface. It will be transferred to spinous cell carcinoma (Bowen cancer) from several years to over ten years.

(Burn) scar
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Spinal cell carcinoma that occurred on a burn scar. If you leave burns due to burns, you may develop cancer several years to decades later.

Sebaceous nevus
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Congenital skin malformation that occurs mostly in the head. In many cases it is noticed as born hair loss (baldness). When left untreated, most of it will become cancerous by the middle age.

Treatment of squamous cell carcinoma
① When
premature lesion is examined , basically it will not spread, so there is no need to check metastasis by CT or MRI. However, in a state where the surface grows large and forms ulcers, CT, MRI, echocardiography etc. are used to examine the presence or absence of metastasis of the whole body.

② Surgical
Recommendation Text: Remove the primary tumor at least 4 mm apart. For high-risk lesions (see commentary and appendix), remove them 6 to 10 mm apart. (From Guidelines for Dermatologic Malignancy Clinical Practice)
If a lymph node metastasis is suspected by whole body examination, it will be applied for sentinel lymph node biopsy (described later) or lymph node dissection.

③ For anticancer drugs, postoperative anticancer drugs are not recommended. There are several kinds of regimens for anticancer drug treatment against spinous cell carcinoma that caused metastasis.

④ Radiation therapy is effective as a treatment for spinal cell cancer. However, if the patient is older or the tumor is huge and surgery is not possible, we will consider radiotherapy.

⑤ Progress Observation Since
spinal cancers can cause metastasis, if scratches calm down, check yourself regularly for recurrence (self-check). If you think it is doubtful, please do it again at an early stage.

Melanoma (malignant melanoma, MM, malignant melanoma)
Melanoma is one of the most unfavorable cancers among skin cancer. Melanoma patients are only about 5% of all skin cancers, but over 80% of those who die of skin cancer are melanoma patients.
This is
1. Metastasize to lymph nodes and lungs at an early stage
2. There are few effective anticancer drugs (anti-cancer drugs are less effective)
3. It depends on radiation sensitivity being low (radiotherapy is not effective)
. However, immunotherapy (monoclonal antibody, T cell recognition tumor regression antigen, gene therapy) for so-called cancer is expected to be an immunologic tumor.

Classification of melanoma
Melanoma is classified into the following four types of clinical disease depending on its shape and personality.
(1) Malignant lentiginous melanoma (LMM) : Many occur in the face (frequent in Westerners)
(2) Expanded melanoma (SSM) : Many occur in the back and arms (many in Europeans and Americans)
(3) Nodular melanoma (NM) : Many occurs in extremities and bodies
(4) Terminal melanogaster type melanoma (ALM) : Many occurs in the soles of the feet and the palm of the hand (many in yellow race)

(1) Malignant lentiginous melanoma (LMM) : LMM developed on the left cheek. The center of pigment spots is invasive carcinoma.
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(2) Superficial expanded melanoma (SSM) : A mass with reticular pigment spots is characteristic.
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(3) Nodular melanoma (NM) : a tumor without pigment spots.
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(4) end Kuroko melanoma (ALM) : and easy to be in the sole of the foot type, about half of the Japanese of melanoma is ALM.
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Progress of melanoma (progress of stage)
Stage classification of melanoma
→ Stage 0 to IV.
→ It becomes difficult to recover as the stage progresses.
→ Determine the stage:
· Depth of tumor cellsh
- the presence or absence of ulceration of the tumor surface
(from the tumor or not and out of the blood)
of lymph node metastasis whether
the presence or absence of metastases to the-other

pT N M classification
For example, if the depth is 1 mm (pT1), there is no ulcer (a), lymph node metastasis, no transition to the other, pT1aN0M0 will be in the state of stage IA.
Stage of skin malignant melanoma (UICC, 2010 revision)


Treatment of melanoma
1) Tests
The main treatment for melanoma is surgery, anticancer drug treatment and examination for the presence or absence of metastasis. Before surgery, we will check whether there is metastasis other than skin.
Examination of the presence or absence of metastasis
1. Echocardiography: Inspect for lymph node metastasis, etc.
2. CT examination: The lungs are examined for metastasis to internal organs such as the liver (sometimes omitted in early melanoma)
3. MRI examination: Examine presence / absence of metastasis to the brain (sometimes omitted in early melanoma)
4. PET-CT examination: examination of whole body metastasis (sometimes omitted in early melanoma)
5. Inspection for surgery (local anesthesia or general anesthesia)

② Surgery
1. Depending on the degree of progress (size and depth of the tumor), presence or absence of metastasis to the regional lymph node
is judged by sentinel lymph node biopsy (see Appendix) 2. The tumor is 0.5 cm (In the case of Stage 0), 1.0 cm (in the case of Stage 1 or 2), 2.0 cm (in the case of Stage 2 to 3) separated and excised
3. In cases where a clear transition to the lymph node is suspected in the preoperative examination Do not conduct sentinel lymph node biopsy, do lymph node dissection

③
Depending on the degree of progression of anticancer drugs , treatment other than Stage 1 A basically requires immunotherapy with interferon.

④ follow-up observation
After leaving hospital, we will visit the outpatient at regular intervals (initially in about 1 to 2 weeks, after that, depending on the degree of progress, every 3 months, every 6 months, after 12 months) I will check for melanoma recurrence / metastasis.
Specifically, we do image examination such as consultation, echo, CT and blood sampling test.
About sentinel lymph nodes
Melanoma in most cases causes lymphatic metastasis. In other words, cancer cells do not jump suddenly around the body, but
1. Cancer cells enter the lymph duct of the skin
2. It flows to the belonging lymph node, and it grows there
3. Then it transfers to the surrounding lymph nodes and
so on.
In other words, in the early days, the lymph nodes that migrate are considered to be limited to 1 or 2 lymph nodes.
This lymph node that initially transfers is called sentinel lymph node. A sentinel is a sentry (guard).
In other words, if the sentinel lymph node is excised and there is no cancer cell metastasis there, it is considered to be an early melanoma that has not yet metastasized.
This procedure to acquire the sentinel lymph node and to confirm that there are no cancer cells is called sentinel lymph node biopsy.
In recent years, the usefulness of sentinel lymph node biopsy has been confirmed with melanoma and breast cancer, and it is applied for insurance.

Extramammary Paget's disease
Out-of-breast Paget's disease was previously rare skin cancer, but it is one of skin cancers that has increased markedly with the aging of the population in recent years. It is said that there are many racial differences, and it is said to be more in oriental series such as Japanese as compared with Westerners. Extra-breast Paget's disease is classified as in situ (cancer in the epidermis) as skin cancer, but when it progresses it becomes extra-breast Paget Cancer (adenocarcinoma), death by lymph node metastasis or distant metastasis Sometimes.
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1. Most occur in the genital region, rarely also in the axilla and the navel umbilical cord
2. Because of erythema occurring in the vulva, many cases are misunderstood as ringworm (indigestion, tamugi) and diaper rash
3. Apocrine sweat gland-derived adenocarcinoma is thought to be
4. Although it is cancer in the epidermis, cancer cells also exist in the epidermis of the hair follicle (pore) part, so if the hair follicle part is not completely resected, recurrence · Metastasis
5. The boundary of cancer is often unclear
6. Since cancer cells have various hormone receptors, hormonal therapy and molecular targeted drugs are effective
7. Although radiation sensitivity is good , It
is characterized by not being able to hope for complete cure by radiation therapy .

Treatment of extramammary paget
(1) Examination
of the presence or absence of examination transfer
1. Echo examination: examination of lymph node metastasis etc.
2. CT examination: examination of the presence of metastasis to the internal organs such as lung and liver (done with advanced breast Pudget cancer)
3. PET-CT examination: examination of whole body metastasis (advanced breast-spread breast cancer is prone to bone metastasis)
4. examination for surgery (local anesthesia or general anesthesia)
5. mapping biopsy: breast In outside Paget 's disease, the boundary of the tumor is often unclear, and it is difficult to judge the range of cancer only with macroscopic findings. In that case, pathological examination of 6 to 12 places of skin 1 cm away from the range of cancer clearly confirms the presence or absence of cancer cells in advance

② Surgical
operation scope: Recommendation sentence (From skin malignancy clinical practice guidelines)
There is no highly reliable evidence on the cut-out area (resection margin) on the skin side necessary to completely excise the primary lesion of extravascular Paget's disease, For a part where the macroscopic boundary of the lesion is clear or a part determined to be negative by mapping biopsy, an ablation margin of about 1 cm is considered good. For other unclear border areas, a margin of about 3 cm is recommended.
Sentinel lymph node biopsy: If you have been diagnosed as extramammary Pudget cancer by preoperative examination, sentinel lymph node biopsy (described above) will be performed.
Lymph node dissection: If clear lymph node metastasis is observed in preoperative examination, lymph node dissection is performed.

③ There are several types of anti-cancer drug regimens and molecular targeted drugs in case of anticancer drug transfer.

④ follow-up observation
After discharge, we will visit the outpatient at regular intervals (initially every 3 months, every 6 months, every 12 months) and check for recurrence / metastasis of extramammary Paget's disease.
Specifically, we do image examination such as consultation, echo, CT and blood sampling test.