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Skin Cancer

SKIN CANCER
It is a malignant condition caused by uncontrolled growth and spread of abnormal cells in the specific layer of the skin. Three most common types: basal cell carcinoma, squamous cell carcinoma, malignant melanoma. The first two types are slow growing and more than 90% of skin cancer fall under them.

It is the most common CA in the US The most successfully treated type of CA It is diagnosed by biopsy and histologic examination

Exposure to the sun is the most leading cause (r/t total amount of exposure)

RISK FACTORS
Changes in the ozone layer from the effects of world-wide industrial air pollutants (CFCs) Fair-skinned, fair-haired, blue-eyed people, particularly those of Celtic origin, with insufficient skin pigmentation to protect underlying tissues. People who sustain sunburn and do not tan Chronic sun exposure (certain occupations, farming, construction work)

Exposure to chemical pollutants (industrial workers in arsenic, nitrates, coal, tar and pitch, oils and paraffins) Sun-damaged skin (elderly people) Hx of x-ray therapy for acne/benign lesions Scars from severe burns Chronic skin irritations Immunosuppression Genetic factors

DANGER SIGNS SUGGESTIVE OF MALIGNANT TRANSFORMATION OF MOLES


Change in color Change in diameter Change in outline Change in surface characteristics Change in consistency Change in symptoms Change in shape Change in surrounding skin

Skin Cancer

Basal Cell Carcinoma


Is the most common type of skin cancer It generally appears on sun-exposed areas More prevalent in regions where the population is subjected to intense and extensive exposure to the sun Incidence: average @ age 60; inversely proportional to the amt of melanin in the skin

Basal Cell Carcinoma

Manifestations
Usually begins as small waxy nodule with rolled translucent, pearly borders Telangiactic vessels may be present Undergoes central ulceration/crusting as it grows Appears more frequently at the FACE Rarely metastisezes; recurrence is common Other variants of BCC: shiny, flat, gray or yellowish plaques

Squamous Cell Carcinoma


It is a malignant proliferation arising from the epidermis. Usually appears on sun-damaged skin It may also arise from normal skin/from preexisting skin lesions. Greater concern than BCC because it is truly invasive carcinoma, metastasizing by the blood/lymphatic system.

Squamous Cell Carcinoma

Manifestations
Appears as rough, thickened, scaly tumor that may be asymptomatic/may involve bleeding Border may be wider, more infiltrated, more inflammatory than BCC lesion Face, lower lip, ears, nose, and forehead (common sitesexposed areas)

Incidence/Prognosis
Increased in immunocompromised people (HIV+) BCC is usually good (tumors remain localized) SCC depends on the incidence of metastases -arises from sun-exposed areas prognosis -unknown - prognosis

Medical Management
Goal: Eradicate the tumor Surgical excision Mohs micrographic surgery Electrosurgery Cryosurgery Radiation therapy

Mohs Micrographic Surgery


Most accurate and that best conserves normal tissue Removes tumor layer by layer The specimen is frozen and analyzed by section to determine if all the tumor has been removed Recommended tissue-sparing procedure, with extremely high cure rates for BCC and SCC

TOC and most effective around the eyes, nose, upper lip, auricular and periauricular areas.

Electrosurgery
Destruction or removal of tissue by electrical surgery. Current is converted to heat, which then passes to the tissue from a cold electrode. May be proceeded by a curettage (excision) Electrodessication implemented to achieve hemostasis and to destroy any viable malignant cells at the base of the wound or along its edges; useful if lesions are 1-2 cm

The tumor is removed and the base has been cauterized Process is repeated 2x; healing occurs within a month

Cryosurgery
Destroys the tumor by deep freezing the tissue A thermocouple needle is inserted into the skin and liquid nitrogen is directed to the center of the tumor until the tumor base is -40 to -60 degrees Swelling and edema follows Normal healing occurs w/in 4-6 wks

Radiation Therapy
Frequently performed for CA in the eyelid, tip of the nose, and areas near vital structures (facial nerve) Reserved for older pts Skin may become red and blistered so a bland ointment may be applied to relieve discomfort Avoid sun exposure

Nursing Management
Teach patient about prevention of skin CA Teach patient self-care after treatment

Teaching Patient Self-care


Cover wound with a dressing Dressing changes should be done Hand hygiene should be done prior to changing dressing W/O for excessive bleeding and tight dressing that might compromise circulation Lesions @ periorial area: drink liquids through straw and limit talking and facial movement

Dental work is avoided until area is healed completely Emollient cream may be applied after sutures has been removed to p/v dryness Apply sunscreen over the wounds to p/v post.op hyperpigmentatx (outdoor activities) Ff.up examinations every 3 mos for a yr Life-long ff up evaluotion is emphasized

Teaching About Prevention


Regular use of sunscreens (4 to 50) 10 mins a person can normally stay under the sun Remind pt that 50% of UV rays penetrate on loosely woven clothing UV light penetrate cloud cover Teach children avoid modest sun exposure and regular use of sunscreen Avoid tanning if their skin burns easily, never tan or tans poorly

Avoid unnecessary exposure to the sun (10am-3pm) Use sunscreen with SPF higher than 15 Avoid applying oils before/during sun exposure Use lip balm with SPF higher than 15 Wear protective clothing (hat/long-sleeved) Avoid commercial tanning booths

Malignant Melanoma
It is a cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis (sometimes in sq) More lethal than all skin CA Peak incidence: 20 and 45 yrs

Manifestations
visible mole changes Pruritus Tenderness Pain

Risk Factors
Unknown UV rays People who used tanning bed more than 10x/yr Ethnicity: Caucasians Dysplastic nevus syndrome (abnormal moles) Genetics Hx of giant congenital nevi

Types
Superficial Spreading Melanoma Occurs anywhere; most common form of melanoma Middle-aged; usually @ trunk & lower extremities Circular lesions w/ irregular outer portions Margins of lesions may be flat/elevated Color may vary

Types
Lentigo-Maligna Melanoma Slowly evolving pigmented lesion that occurs on exposed areas (dorsum of the hand, head and neck in elderly) Lesion is present before it is being examined Tan, flat lesion but it changes in size and color in time

Types
Nodular Melanomas Is spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color Dome-shaped with a smooth surface May be red, gray, purple Blood blister that fails to resolve (subjective) Invades directly to adjacent dermis; poorer prognosis

Types
Acral-Lentiginuous Melanoma Occurs @ areas not excessively exposed to sunlight where hair follicles are absent Palm of the hands, soles, nail beds, mucuous membrane in dark-skinned people Irregular, pigmented macules that develop nodules. May become invasive early.

Prognosis
5 yr ( LT survival) is poor if lesion is more than 1.5 mm thick Pt with melanoma on the scalp,hand, foot have better prognosis Those @ torso have increased chance of metastases @bone, liver, spleen, lungs, CNS Men and elderly have poor prognosis

Assessing ABCDs of MOLES


ASYMMETRY IRREGULAR BORDER VARIEGATED COLOR DIAMETER

Asymmetry
Lesion does not appear balanced on both sides Irregular surface with uneven elevations either palpable/visible Change in surface: smooth to scaly Nodular melanoma smooth surface

Irregular Border
Angular indentations/multiple notches appear at the border Border is fuzzy or indistinct

Variegated Color
Normal: light to med brown; Darker coloration indicate melanocytes penetratx Red, white, blue indicates malignancy White areas w/in pigmented lesion suspicious Some are uniformly colored (bluish-black, bluish-gray, bluish-red)

Diameter
Exceeding 6mm more suspicious

Medical Management
Surgical excision TOC for small, superficial lesions Wide local excision with skin grafting deeper lesions Regional lymph node dissection to rule out metastasis; sentinel node biopsy Immunotherapy (vaccines BCG)

Tyrosinase lab assay; enzyme produced only by melanoma Chemotherapy (if metastatis occurs) dacarbazine, nitrosoureas, cisplatin Regional perfusion (melanoma in extremity); chemotherapeutic agent is perfused directly onto the area that contains melanoma; in combinatx of surgical excision & lymph node dissection to p/v metastasis

Nursing Diagnosis
Acute pain r/t surgical excision and grafting Anxiety and depression r/t possible lifethreathening consequences of melanoma and disfigurement Deficient knowledge about early signs of melanoma

Nursing Management
Relieving pain and discomfort Reducing anxiety and depression especially when disfiguring surgery is performed Teaching patient self-care and emphasizing importance of monthly SSE

Metastatic Skin Tumor


Primary caused by breast cancer

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