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02.16 Melanoma

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Overview

  1. The skin is made of three layers
    1. Hypodermis
    2. Dermis
    3. Epidermis (most superficial)
  2. The epidermis has 3 cell types
    1. Squamous cells
    2. Basal cells
    3. Melanocytes
      1. Make melanin which pigments the skin
      2. Protects from harmful effects from the sun
  3. Basement membrane
    1. Separates the epidermis from deeper layers of the skin

Nursing Points

General

  1. Classifications of melanoma
    1. In-situ
      1. Has not crossed the basement membrane
      2. Good prognosis
    2. Invasive
      1. Has spread beyond the basement membrane
      2. Poorer prognosis especially with distant spread
  2. Several types of melanomas
    1. Superficial spreading
      1. Most common type
      2. Often arises from long-standing nevi (mole)
    2. Nodular
      1. Dark brown or black- extra melanin
      2. Vertical growth
    3. Lentigo maligna
      1. Appear in sun-exposed areas
      2. Might have hypopigmentation- loss of melanin
    4. Acral lentiginous
      1. Occurs on palms, soles, and nails
    5. Mucosal lentiginous
      1. Occurs on a mucosal surface
        1. Conjunctiva
        2. Respiratory tract
          1. Oral cavity
        3. GI
          1. Esophagus
          2. Anus
        4. GU
          1. Urethra
          2. Vagina
          3. Penis
  3. Risk factors
    1. Fair complexion and light eyes
    2. Multiple nevi (moles)
    3. Unprotected or excessive sun exposure
      1. Teach sun safety
    4. Severe sunburns as a child
    5. Genetic mutation
      1. BRAF
        1. Gene that can cause normal cells to become cancerous

Assessment

  1. Changes to the skin- ANY of these is suspicious in a mole (doesn’t have to have ALL these characteristics) -ABCD-
    1. Asymmetry
      1. One side looks different than the other
    2. Border
      1. Irregular border
    3. Color
      1. Black, blue, variation in color in the same mole
    4. Diameter
      1. >6 mm is concerning
    5. ANY suspicious lesion should be checked by a dermatologist- blistering, draining, etc.
  2. No other symptoms unless it has spread to other sites
    1. With lymph node involvement
      1. Palpable lymph node
    2. Also commonly spreads to the brain, lungs, and liver

Therapeutic Management

  1. Removal of the suspicious lesion (mole/ suspected cancer)
    1. Punch biopsy- an instrument “punched” into the skin to remove the lesion
    2. Shave biopsy- sterile razor used to remove the lesion
    3. Incisional biopsy- scalpel used to cut out part of the lesion
    4. Excisional biopsy- scalpel used to cut out entire lesion
    5. The goal is to have clear margins when removed
      1. 1cm tissue around lesion without cancer
  2.  Diagnostics
    1. Pathology
      1. Biopsy sample sent to review for cancer cells
    2. MRI/ CT/ PET Scan
      1. To assess for metastasis
    3. Lymph node biopsy
      1. To assess for micro-spread
  3. Antineoplastics
    1. Chemotherapy
      1. Side effects
        1. Pancytopenia- ↓WBC, ↓ Plts, ↓ RBC
        2. Fatigue
        3. Nausea and vomiting
    2. Immunotherapy
      1. Enhances immune system response
    3. Targeted therapies
  4. Radiation therapy
    1. Used for brain metastasis

Nursing Concepts

  1. Cellular regulation
    1. Abnormal growth of cells
  2. Patient education
    1. Know A, B, C, D
  3. Skin integrity
    1. Disruption in skin integrity
    2. Skincare after removal

Patient Education

  1. Skin self-assessments
    1. Know your skin and recognize changes
  2. Annual skin checks by a dermatologist for high-risk patients
  3. Treatment specific education
    1. Chemotherapy
    2. Care of excision site
  4. Sun Safety
    1. Slip on a shirt
    2. Slop on sunscreen
    3. Slap on a hat
    4. Wrap on sunglasses

Reference Links

Study Tools

Video Transcript

All right. Hi guys, today, we’re going to be talking about melanoma, which you know, is a type of skin cancer. So both talk about the skin. There’s three layers of the skin, the epidermis, the dermis, and the subcute tests, or I know of the hypodermis the fatty layer, right? And then in this epidermis, there’s three main cell types. We have squamous cell cells, basal cells and Milena sites. They all can form types of skin cancer, right? But we’re talking about melanoma and melanoma is formed from the Melina site, which is that third type of cell Melinda sites make melanin, which causes our skin pigment or the color of our skin. And it also protects us from harmful effects of the sun. And then I want to point out here between the epidermis and the dermis, there is a basement membrane, and that’s important for talking about melanoma because if the melanoma spreads beyond this basement membrane, if it goes past it, then we consider that melanoma to be invasive, which means it’s harder to treat. 

 

Then we’ll talk more about this right here. So in situ or noninvasive, just exactly means that it does not cross that basement membrane that we just talk about. And then invasive, we talked about it has crossed it and metastatic means it has spread to different sites, and it is a much poor prognosis with metastatic melanoma. So we always want everything to be diagnosed early, and then we have good outcomes. There’s different types of melanoma. We’ll talk these pictures point out. Most of them here. So superficial spreading this picture is of superficial spreading. And this is the most common type of melanoma. 70% of melanomas are superficial spreading, and it typically occurs from a mole or nearby that changes. So it could have just been a mole you had for years and years. And then all of a sudden it starts spreading out nodular melanoma. 

This is this picture down here, and this is a really dark color, dark Brown or black. So that tells us that the melanocytes are hyperactive, right? They’re making extra picnic growing this cancer. And this one actually grows vertically. So meaning up this nodular melanoma, lentigo, maligna. This one grows on sun. This is an example of it. It grows on sun exposed skins and it actually might have hypo pigmentation. So that would mean that,it has a loss of color, those melanocytes they’re not functioning anymore. Acral antagonists. I do not know if I’m saying that one. Exactly. Right. So sorry guys. And that one occurs. This is a picture of it on the palms of the hands, the soles of the feet and the nail beds. And then you coastal antagonist. I do not have a picture of this one, but the name pointed out, right. 

It is occurs in the mucus membranes. So we don’t really think of that with melanoma typically, but melanoma also can occur in the eyes, the respiratory track, in the oral cavity, the esophagus,  in the anus, or can also Kern the vagina or the penis anywhere where there’s mucosal surface at all. Okay. And risk factors. We probably know this right. A fair complexion. So we’re talking about light eyes, fair skin, light hair, multiple Nevi, our moles. So if you have a lot of them, you have some hyperactive Milena sites, right? Excessive sun exposure. And we know this, right. We need to teach our patients about not having excessive sun exposure. And also if they had severe sunburns as a child, they’re more likely to get melanoma. So that’s important to teach our parents right. 

Prevent sunburns in your children. Cause they could be, get melanoma later in life as if there’s not enough to worry about it as parents. Right. Okay. And then genetic mutations, melanoma has been linked to a specific gene mutation called B R a F or breath. And that’s a gene that can cause normal cells to become cancerous. I’m talking about education for our patients and for us to identify skin cancer. These is any skin cancer.  We want to teach our patients a, B, C, D. So a symmetry. That would mean if we cut it in half, one side does not look like the other right. A border if it has an ear, regular border. So this is like all crazy, right? We’re concerned about this color. This is showing us the color. In this case it looks, uh, black, right? But it can even have a bluish variation and then diameter. 

So this one doesn’t have a ruler on it, but it must be very large if it’s greater than six millimeters, then we’re concerned. Also if it’s draining at all, I’m going to add D diameter and draining. That’s not typically talked about, but if it has a blister, if it’s bleeding or producing anything at all, then that’s concerning. Okay. The goal would be to remove the melanoma. And hopefully that’s the only treatment we have to do. It can be removed in a few different ways, a punch biopsy. That’s what this picture is of. So there’s a tool that they punch into the skin and that removes the site that they want to take out. A shave biopsy is removing the lesion. The lesion is the cancer with a sterile razor and then incisional and exegetical biopsies use a scalpel to cut out the lesion. Incisional takes out part of it, excisional. It takes out the whole thing. And when we take out the whole thing,  if we pretend like the melanoma is right here, like it’s kind of an ugly thing, irregular borders, we would want to cut out an area around it to have clear margins. And that would mean that there’s no cancer in this skin around it, that we took out at least one millimeter around. It needs to be clear to consider that we’ve removed the whole thing. 

Okay. 

And then I’ll just mention those lesions can be really large that they removed to get those clear margins. Okay. Diagnostics, obviously we’re going to send anything to pass all the G right. To test it in the lab to review for cancer cells and MRI, CT and pet scan are done to look for metastasis. And then a lymph node biopsy is done to assess if we have spread to the lymph system. So if this is where the melanoma is, they can inject something. And that can spread to the most to the closest lymph node where the lymph drains to. And they’ll cut this one out to see if there’s any micro metastasis there that we can’t necessarily see an imaging other treatment for melanoma. Like most cancers, we have options for chemotherapy that is going to come with systemic side effects. So it’s going to the whole body, right? 

And you can review the chemotherapy lecture for side effects. We’re talking about nausea, vomiting, fatigue, and decrease in all these cell counts, right? Targeted therapy is going to that gene. We talked about that mutation. If they have this mutation, we can treat it with this targeted therapy. I mean, you know, therapy is enhancing our own immune system and then radiation, this is often used for brain metastasis and you can review the lecture about brain tumors to see how we treat those okay. Patient education. We definitely want to educate our patients about skin checks, right? Definitely, definitely that a, B, C, D making sure they’re aware of changes to their skin. And they get them checked out by a provider, if something is abnormal and then sun safety, this is kind of funny, but they put this out and they educate patients on this. So I’ll just write it on here. 

Slip slop, slap and rap. So this is, we want to slip on a shirt, slop on sunscreen, slap on a hat and wrap on sunglasses, educate our patients about sun safety with those tips. And then treatment specific skin care is huge. Like I said, sometimes those biopsy sites are massive. Even they sometimes need skin grafts. So educating them about care of the skin. And then if they’re going through chemo or radiation, depending on their treatment, they’ll have specific education needs. So some concepts we reviewed here, cellular regulation went out of whack, right? That’s how the cancer formed in those melanocytes is patient education, huge, huge, and then skin integrity, whether it’s just because they, you know, they have cancer in their skin or sometimes even more important is if they have that biopsy site remove to care for. Okay. So some key points here early diagnosis is key. And in order to get that, we need our patients to know, to check their skin for ABCD, asymmetry, border color, and diameter changes to the skin, right? Send safety, slip, slop, slap, rap, teach, and model this, right. And then there are multiple types of melanomas. There’s different distinguishing features. Right? All right, guys, we learned a lot today. We love you guys go out and be your best self and as always happy nursing.

 

 

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