Melanoma

Melanoma is the 7th most common cancer in Canada. It is a skin cancer that has the potential to spread to lymph nodes and other organs in the body. 50% of melanomas are thin (less than 1mm) and when treated with wide local excision alone, have a survival of over 95-98%.

The other 50% are high risk thin melanomas (any melanoma ≥ 0.8mm or thinner if has ulceration, mitoses or microsatellites), intermediate thick melanomas (1-4mm) or thick (more than 4mm) melanomas need further investigation with a staging procedure known as a sentinel node biopsy to evaluate if melanoma has spread to the lymph nodes.

Not all melanomas are the same and therefore a detailed consultation with your physician/surgeon is very important once the diagnosis has been made.

Merkel Cell Carcinoma

Merkel Cell Carcinoma is very rare type of skin cancer that can spread to lymph nodes and other organs. It often looks like a rapidly growing pinkish/purple nodule. It is important that this rare cancer be treated in a specialized tertiary care cancer center as The Ottawa Hospital.

Squamous Cell Carcinoma

Squamous Cell Carcinoma is often very localized and local surgical excision is often the only treatment required. In rare cases, however, these skin cancers can be more locally advanced and spread to lymph nodes requiring more extensive surgeries.

 

Dr. Carolyn Nessim actively treats melanoma and other skin cancer patients through the Ottawa Hospital Regional Cancer Center.

She is currently the regional lead of the Melanoma Communities of Practice for the Ottawa Regional Cancer Program.  She sits on the Cancer Care Ontario Melanoma Advisory Board and guidelines working group. She also sits on the American Society of Clinical Oncology (ASCO) – Melanoma Measures Panel – Technical Expert Group and is an active member of the Global Melanoma Research Network and she is the Co-Chair of the Regional Cancer Program’s Melanoma and skin cancer Communities of Practice who’s goal is to ensure quality care for skin cancer in Eastern Ontario. Melanoma is cared for by a multidisciplinary team including a Dermatologist, Surgical Oncologist, Plastic Surgeon, Medical Oncologist, Radiation Oncologist, Pathologist and Nuclear Medicine Physician.  The Ottawa Hospital has a dedicated melanoma team to care for melanoma and other skin cancer patients.

 

Dr. Nessim has been on CTV discussing the typical features of melanoma and what to look out for:

Mole or Melanoma?

Dr. Nessim was recently involved in an educational Webinar about adjuvant treatment (treatment after surgery) for melanoma patients. 

Check out the webinar here

Frequently asked questions: Melanoma

 

Why do I need a wider excision if my melanoma was already removed at the time of the biopsy?

Depending on the thickness of your melanoma, you will require an additional 1-2cm wider excision around the original site of your melanoma and this skin must be removed all the way down to your underlying muscle.  You may require a skin graft or flap to fill in the gap that was created by the excision.  This may require the expertise of a plastic surgeon.  This wider excision is to prevent the melanoma from coming back in this location.

 

What is a skin graft or a skin flap? 

A skin graft or a skin flap may be required to replace the skin that was removed around the melanoma. For a skin graft, we remove skin from a different area of your body, often the thigh, and lay it over the gap left from the melanoma excision. A skin flap is very similar to a skin graft except it is the rotation of a layer of skin and its associated blood supply from beside the gap created by the excision. The need for a skin graft or a skin flap depends on the size and location of the melanoma

 

What is the likelihood of getting another melanoma?

Your risk of getting another melanoma ranges between 5-7% in your lifetime.  This is why you will require regular skin checks by a dermatologist after your surgery.

 

What are the different stages of melanoma?

All cancers are classified from stage 1 to stage 4. In the setting of melanoma, stage 1 and stage 2 disease are based on the depth of invasion of the melanoma. Stage 3 disease means that the melanoma has spread to your surrounding lymph nodes. Lastly, stage 4 disease indicates spreading of the melanoma to other organs in the body. The most common areas for melanoma to spread to are lymph nodes, other areas of skin, lungs, liver, and brain.

 

What are lymph nodes?

Lymph nodes form a network throughout our body. They act as a filter for our body’s immune system. They are connected to one another by very small vein-like structures called lymphatic vessels. In general, if the melanoma is above the belly button, its cells will drain to the lymph nodes under the armpit (axilla) first and if the melanoma is below the belly button, its cells will drain to the lymph nodes in the groin first. Lastly, if the melanoma is on the head or neck, the lymph nodes on the neck will be the first to become enlarged.

 

What is a sentinel node? 

The sentinel nodes are the first few nodes that drain a specific area of skin.  The Nuclear medicine physician injects a special dye around your melanoma.  This dye will travel through your lymphatics and stop in the first few nodes that drain that specific area of skin.  These are the sentinel nodes. If cancer will spread, it will go to these nodes first. Most people have 1-4 sentinel nodes, it all depends on your personal anatomy.  The entire node is removed and then analyzed by a Pathologist under a microscope to see if the melanoma has spread.

 

What if my sentinel node is positive?

If your node is positive, you may require more surgery or other medical treatments by a medical oncologist such as BRAF + MEK inhibitors or Immunotherapy. You need to have a BRAF mutation in your melanoma to be eligible for BRAF + MEK inhibitors, you also still have the option of immunotherapy. If you are BRAF negative then you may be offered immunotherapy. This will be discussed in detail with you by the medical oncologist . You will require continued surveillance with physical examination and imaging tests as well as skin checks from your dermatologist and surgeon/medical oncologist at a minimum of 5 years after your surgery.

 

What if my sentinel node is negative?

This is a good prognostic sign and puts your melanoma at a lower risk.  You will require continued surveillance with physical examination and skin checks from your dermatologist and surgeon at a minimum of 5 years after your surgery.

 

What if I already have large nodes that I can feel in my neck, armpit or groin?

These nodes will require a biopsy to confirm if this is melanoma.  If it is melanoma, then you will require removal of all of the nodes in this area.  The main risk of nodal removal is lymphedema, or swelling of the neck, arm or leg respectively.  This may be permanent but can be actively treated and can significantly improve or even resolve with appropriate physiotherapy and lymphatic drainage massage.  If you have lymphedema, request a Physiotherapist who specializes in lymphedema.

 

What tests do I need if I have melanoma in my lymph nodes?

If a biopsy confirms melanoma in the lymph nodes, tests are required to confirm that the disease has not spread to other parts of the body. An MRI (magnetic resonance imaging) of the brain is required to make sure the cancer cells have not spread to the brain. A PET (positron emission tomography) scan is a special full-body imaging test that measures the spread of an injected sugar throughout your body. The injected sugar is not toxic and you urinate it out. If there is melanoma that has spread the PET Scan will “light” up in that area. It is a full body scan. Lastly, you would be asked to get blood work.

 

What does it mean to have metastatic disease?

Metastasis means the spread of disease. Regional metastasis refers to spread of the cancer to the surrounding lymph nodes. In melanoma, the lymph nodes are the first area where the cancer cells spread to. Distant metastasis refers to the spread of cancer to different organs throughout the body. In melanoma, these organs are most commonly other areas of skin, the lungs, the liver, and the brain. If you have distant metastasis limited to one or a limited number of sites, it is possible to have the areas of spread surgically removed. However, more widespread metastases may mean that surgery is not a possibility and instead you may need immunotherapy or targeted therapy.

 

What is targeted therapy?

We have discovered 4 genetic mutations that you may have acquired in your lifetime (not born with) that cause melanoma.

They are:

BRAF (50% patients)

NRAS (20% patients)

CKIT (1-2% of patients)

GNAQ (rare)

We currently have targeted therapy, that specifically inhibit both BRAF and CKIT positive melanoma.  We have not currently identified appropriate targets for NRAS and GNAQ but these are being actively studied.

You must have the mutation in order to benefit from this treatment.  We can do an analysis on your tumour tissue to find out if you have one of these mutations. If you are BRAF positive the recommendation may be treatment with a BRAF inhibitor or Immunotherapy. If you are CKIT positive you may benefit from a CKIT inhibitor but responses are variable. This is something you would discuss further with your medical oncologist.

 

What is Immunotherapy?

Immunotherapy is a new innovative way of fighting off cancer cells.  It works very differently than chemotherapy.  It is a drug that is however also given IV every few weeks.  The drug boosts your own immune system to fight off the cancer. In melanoma, this treatment has shown to be quite effective with a response rate of about 50%. The side effects of immunotherapy are very different than those of chemotherapy.  This is something you would discuss further with your medical oncologist.

 

What is adjuvant treatment? 

Adjuvant therapy is a term that describes therapy that is used after the surgical management of cancer. In the setting of melanoma, it can be thought of as treatment with immunotherapy or targeted therapy that is given systemically to treat your whole body and prevent future spread of disease or radiation after surgery to prevent the melanoma from coming back in the same location. At the current time, only patients that have melanoma that has spread to the lymph nodes (Stage 3) will be offered adjuvant therapy.  This would be further discussed with your surgical and medical oncologist.

 

What is neoadjuvant treatment?

Neoadjuvant therapy is a term that describes therapy that is used before the surgical management of cancer. In the setting of melanoma, it can be thought of as treatment with immunotherapy or targeted therapy before surgery to shrink very large disease to allow for surgery. This is evaluated on a case-by-case basis. This would be further discussed with your surgical and medical oncologist.

 

Will I need Chemotherapy?

You will not need chemotherapy.  Chemotherapy is mostly ineffective in melanoma. It is only used in very rare occasions.

 

Will I need Radiation Therapy?

Only patients with large nodal disease or multiple positive nodes may require additional radiation therapy after surgery. This will be discussed with your radiation oncologist.

Lymphedema

Lymphedema is a potential consequence of nodal surgery. This may require some physiotherapy. For more information you can go to the following website:  https://bethhoagphysio.ca

Frequently asked questions: Merkel Cell Carcinoma

 

Why do I need a wider excision if my merkel cell carcinoma was already removed at the time of the biopsy?

Depending on the size of your merkel cell carcinoma, you will require an additional 1-2cm wider excision around the original site of your merkel cell and this skin must be removed all the way down to your underlying muscle and we may have to remove the muscular fascia in some cases. You may require a skin graft or flap to fill in the gap that was created by the excision. This may require the expertise of a plastic surgeon. This wider excision is to prevent the merkel cell from coming back in this location.

 

What is a skin graft or a skin flap?

A skin graft or a skin flap may be required to replace the skin that was removed around the merkel cell carcinoma. For a skin graft, we remove skin from a different area of your body, often the thigh, and lay it over the gap left from the merkel cell excision. A skin flap is very similar to a skin graft except it is the rotation of a layer of skin and its associated blood supply from beside the gap created by the excision. The need for a skin graft or a skin flap depends on the size and location of the merkel cell carcinoma.

 

What is the likelihood of getting another merkel cell carcinoma?

Your risk of getting another merkel cell ranges between 5-7% in your lifetime. This is why you will require regular skin checks by a dermatologist after your surgery. Being immunosuppressed by certain medications increases the risk of getting a merkel cell carcinoma. Examples of immunosuppression include medications for transplant patients and biologic therapies.

 

What are the different stages of merkel cell carcinoma?

All cancers are classified from stage 1 to stage 4. In the setting of merkel cell carcinoma, stage 1 and stage 2 disease are based on the size and depth of invasion of the merkel cell carcinoma. Stage 3 disease means that the merkel cell carcinoma has spread to your surrounding lymph nodes. Lastly, stage 4 disease indicates spreading of the merkel cell carcinoma to other organs in the body. The most common areas for merkel cell to spread to are lymph nodes, other areas of skin, lungs, liver, and brain.

 

What are lymph nodes?

Lymph nodes form a network throughout our body. They act as a filter for our body’s immune system. They are connected to one another by very small vein-like structures called lymphatic vessels. In general, if the merkel cell is above the belly button, its cells will drain to the lymph nodes under the armpit (axilla) first and if the merkel cell is below the belly button, its cells will drain to the lymph nodes in the groin first. Lastly, if the merkel cell is on the head or neck, the lymph nodes on the neck will be the first draining lymph nodes.

 

What is a sentinel node?

The sentinel nodes are the first few nodes that drain a specific area of skin. The Nuclear medicine physician injects a special dye around your merkel cell carcinoma. This dye will travel through your lymphatics and stop in the first few nodes that drain that specific area of skin. These are the sentinel nodes. If cancer will spread, it will go to these nodes first. Most people have 1-4 sentinel nodes, it all depends on your personal anatomy. The entire node is removed and then analyzed by a Pathologist under a microscope to see if the merkel cell has spread.

 

What if my sentinel node is positive?

If your node is positive, you may require more surgery or radiation or both. This is discussed on a case-by-case basis based on risk. We do not currently have a specific approved adjuvant therapy (medical treatment after surgery) for merkel cell carcinoma that has shown definite clinical benefit. This is currently under clinical study in clinical trials. You will require continued surveillance with physical examination and imaging tests as well as skin checks from your dermatologist and surgeon/medical oncologist at a minimum of 5 years after your surgery.

 

What if my sentinel node is negative?

This is a good prognostic sign and puts your merkel cell carcinoma at a lower risk. You will require continued surveillance with physical examination and skin checks from your dermatologist and surgeon at a minimum of 5 years after your surgery.

 

What if I already have large nodes that I can feel in my neck, armpit or groin?

These nodes will require a biopsy to confirm if this is merkel cell carcinoma. If it is merkel cell carcinoma, then you will require removal of all of the nodes in this area potentially followed by radiation therapy to the area. The main risk of nodal removal and radiation is lymphedema, or swelling of the neck, arm or leg respectively. This may be permanent but can be actively treated and can significantly improve or even resolve with appropriate physiotherapy and lymphatic drainage massage. If you have lymphedema, request a Physiotherapist who specializes in lymphedema.

 

What tests do I need if I have merkel cell carcinoma in my lymph nodes?

If a biopsy confirms merkel cell carcinoma in the lymph nodes, tests are required to confirm that the disease has not spread to other parts of the body. An MRI (magnetic resonance imaging) of the brain is required to make sure the cancer cells have not spread to the brain. A CT Scan of the Chest/Abdomen/Pelvis will also be performed to rule out spread of disease to other organs. Lastly, you would be asked to get blood work.

 

What does it mean to have metastatic disease?

Metastasis means the spread of disease. Regional metastasis refers to spread of the cancer to the surrounding lymph nodes. In merkel cell carcinoma, the lymph nodes are the first area where the cancer cells spread to. Distant metastasis refers to the spread of cancer to different organs throughout the body. In merkel cell carcinoma, these organs are most commonly other areas of skin, the lungs, the liver, and the brain. If you have distant metastasis limited to one or a limited number of sites, it is possible to have the areas of spread surgically removed. However, more widespread metastases may mean that surgery is not a possibility and instead you may need immunotherapy or chemotherapy.

 

What is Immunotherapy?

Immunotherapy is a new innovative way of fighting off cancer cells. It works very differently than chemotherapy. It is a drug that is however also given IV every few weeks. The drug boosts your own immune system to fight off the cancer. In merkel cell carcinoma, this treatment has shown to be quite effective with a response rate of about 50% in patients with metastatic disease. The side effects of immunotherapy are very different than those of chemotherapy. This is something you would discuss further with your medical oncologist.

 

What is Chemotherapy?

Chemotherapy is a medication that acts upon rapidly dividing cells to kill them. Since cancer cells rapidly divide, most cancers will respond to varying degrees to chemotherapy. This is given as an IV injection every 2-3 weeks depending on the type of chemotherapy. Side effects often include, nausea, fatigue and more specific side effects occur depending on the type of chemotherapy. Merkel Cell carcinoma does respond to chemotherapy about 50-60% of the time. This is something you would discuss further with your medical oncologist.

 

What is adjuvant treatment? 

Adjuvant therapy is a term that describes therapy that is used after the surgical management of cancer. In the setting of merkel cell carcinoma unfortunately there is no adjuvant therapy that has proven beneficial to improve survival in merkel cell carcinoma. In very high- risk patients however this may be considered on a case-by-case basis. This is something you would discuss further with your medical oncologist.

 

What is neoadjuvant treatment?

Neoadjuvant therapy is a term that describes therapy that is used before the surgical management of cancer. In the setting of merkel cell carcinoma, it can be thought of as treatment with immunotherapy or chemotherapy before surgery to shrink very large disease to allow for surgery. Radiation is another option that may help shrink disease to allow for surgery. This is evaluated on a case-by-case basis. This would be further discussed with your surgical, medical and radiation oncologist.

 

Will I need Chemotherapy?

If the merkel cell carcinoma has spread to other organs, chemotherapy will be recommended. This is something you would discuss further with your medical oncologist.

 

Will I need Immunotherapy?

This is a new and very effective treatment for merkel cell carcinoma for patients where the disease has spread to other organs or if the nodal disease is too large for surgery and it needs to shrink to allow for surgery. This type of therapy boosts your own immune cells to fight off the cancer. This will be discussed with your medical oncologist.

 

Will I need Radiation Therapy?

Only patients with large nodal disease or multiple positive nodes may require additional radiation therapy after surgery. This will be discussed with your radiation oncologist. If the disease cannot be removed by surgery, radiation is also very effective in treating merkel cell carcinoma to shrink the disease.

Frequently asked questions: Squamous Cell Carcinoma

 

Do Squamous Cell Carcinomas (SCC) spread?

90-95% of SCCs do not spread. They are a local disease and surgical removal is often curative. In a very small number of patients 2-10%, SCC will spread to lymph nodes or to other organs in the body

 

Why do I need a wider excision if my squamous cell carcinoma was already removed at the time of the biopsy?

If the margins were positive on the biopsy, there is a 50% chance that there remains some tumour in the skin and so we need to fully excise this to ensure the entire tumour was removed. Depending on the size of the Squamous cell Carcinoma (SCC), you may require a skin graft or flap to fill in the gap that was created by the excision. This may require the expertise of a plastic surgeon. This wider excision is to prevent the SCC from coming back in this location.

 

What is a skin graft or a skin flap?

A skin graft or a skin flap may be required to replace the skin that was removed around the SCC. For a skin graft, we remove skin from a different area of your body, often the thigh, and lay it over the gap left from the SCC. A skin flap is very similar to a skin graft except it is the rotation of a layer of skin and its associated blood supply from beside the gap created by the excision. The need for a skin graft or a skin flap depends on the size and location of the SCC.

 

What is the likelihood of getting another SCC?

The risk is quite high if you have chronically sun-damaged skin. This is why you will require regular skin checks by a dermatologist after your surgery. Being immunosuppressed by certain medications increases the risk of getting an SCC. Examples of immunosuppression include medications for transplant patients.

 

What are the different stages of SCC?

All cancers are classified from stage 1 to stage 4. In the setting of SCC, stage 1 and stage 2 disease are based on the size of the SCC. Stage 3 disease means that the SCC has spread to your surrounding lymph nodes (This only occurs in about 2-10% of patients). Lastly, stage 4 disease indicates spreading of the SCC to other organs in the body. The most common areas for SCC to spread to are lymph nodes, other areas of skin and lungs. This is extremely rare. The mortality from SCC is very low at 2%.

 

What are lymph nodes?

Lymph nodes form a network throughout our body. They act as a filter for our body’s immune system. They are connected to one another by very small vein-like structures called lymphatic vessels. In general, if the SCC is above the belly button, its cells will drain to the lymph nodes under the armpit (axilla) first and if the SCC is below the belly button, its cells will drain to the lymph nodes in the groin first. Lastly, if the SCC is on the head or neck, the lymph nodes on the neck will be the first draining lymph nodes.

 

What if I already have large nodes that I can feel in my neck, armpit or groin?

These nodes will require a biopsy to confirm if this is SCC. If it is SCC, then you will require removal of all of the nodes in this area potentially followed by radiation therapy to the area. The main risk of nodal removal and radiation is lymphedema, or swelling of the neck, arm or leg respectively. This may be permanent but can be actively treated and can significantly improve or even resolve with appropriate physiotherapy and lymphatic drainage massage. If you have lymphedema, request a Physiotherapist who specializes in lymphedema.

 

What tests do I need if I have SCC in my lymph nodes?

If a biopsy confirms SCC in the lymph nodes, tests are required to confirm that the disease has not spread to other parts of the body. A CT Scan of the Chest/Abdomen/Pelvis will also be performed to rule out spread of disease to other organs. Lastly, you would be asked to get blood work.

 

What does it mean to have metastatic disease?

Metastasis means the spread of disease. Regional metastasis refers to spread of the cancer to the surrounding lymph nodes. In SCC, the lymph nodes are the first area where the cancer cells spread to. Distant metastasis refers to the spread of cancer to different organs throughout the body. In SCC, these organs are most commonly other areas of skin and the lungs. If you have distant metastasis limited to one or a limited number of sites, it is possible to have the areas of spread surgically removed. However, more widespread metastases may mean that surgery is not a possibility and instead you may need immunotherapy or chemotherapy.

 

What is Immunotherapy?

Immunotherapy is a new innovative way of fighting off cancer cells. It works very differently than chemotherapy. It is a drug that is however also given IV every few weeks. The drug boosts your own immune system to fight off the cancer. This is currently being studied in clinical trials for SCC and has shown promising results. This is something you would discuss further with your medical oncologist.

 

What is Chemotherapy?

Chemotherapy is a medication that acts upon rapidly dividing cells to kill them. Since cancer cells rapidly divide, most cancers will respond to varying degrees to chemotherapy. This is given as an IV injection every 2-3 weeks depending on the type of chemotherapy. Side effects often include, nausea, fatigue and more specific side effects occur depending on the type of chemotherapy. SCC can potentially respond to chemotherapy but response rates are low. This is something you would discuss further with your medical oncologist.

 

What is adjuvant treatment? 

Adjuvant therapy is a term that describes therapy that is used after the surgical management of cancer. In the setting of SCC, unfortunately there is no adjuvant therapy that has proven beneficial to improve survival in SCC. This is currently being studies in clinical trials and there have been some discoveries recently of some effective treatments after surgery. This is something you would discuss further with your medical oncologist.

 

What is neoadjuvant treatment?

Neoadjuvant therapy is a term that describes therapy that is used before the surgical management of cancer. In the setting of SCC, it can be thought of as treatment with immunotherapy or chemotherapy before surgery to shrink very large disease to allow for surgery, this again would be on study. Radiation is another option that may help shrink disease to allow for surgery. This is evaluated on a case-by-case basis. This would be further discussed with your surgical, medical and radiation oncologist.

 

Will I need Chemotherapy?

If the SCC has spread to other organs, chemotherapy will be discussed. This is something you would discuss further with your medical oncologist.

 

Will I need Immunotherapy?

This is a new and promising treatment for SCC for patients where the disease has spread to other organs or if the nodal disease is too large for surgery and it needs to shrink to allow for surgery. This type of therapy boosts your own immune cells to fight off the cancer. This currently only under study, and not standard of care. This will be discussed with your medical oncologist.

 

Will I need Radiation Therapy?

Only patients with large nodal disease or multiple positive nodes may require additional radiation therapy after surgery. This will be discussed with your radiation oncologist. For very large or difficult to resect SCC of the head and neck, radiation can be quite effective to shrink the tumour and offer good treatment.