**9. Patient education**

**•** greater than 4 per square millimeter

110 Highlights in Skin Cancer

a decreasing survival [165, 166].

The higher the mitotic count, the more likely the tumor is to have metastasized. The logic is that the more cells are dividing, the more likely they will invade the blood or lymphatic systems and thus spread around the body. Research has shown that the odds of survival for patients with stage I melanoma and a mitotic rate of 0 per square millimeter is twelve times better than that of patients with a mitotic rate of greater than 6 per square millimeter. Also, only 4% of lesions with low mitotic rate recur compared to 24% of those with a high mitotic rate. Mitotic rate can also help to predict that your sentinel lymph node biopsy will be positive or not. Although mitotic rate has no role in the current staging system for melanoma, research has demonstrated that it is a more important prognostic factor than ulceration, which does have an important role in staging. The American Academy of Dermatology argues that mitotic rate should be optional in biopsy reports or not. On the other hand, the National Comprehensive Cancer Center recommends that mitotic rate should be reported for all lesions in stage I to II patients. Still other experts argue that measuring the mitotic rate should only be done in large academic medical centers for future research purposes. Increasing mitotic rate is related with

Tumor-infiltrating lymphocytes (TILs) describe the patient's immune response to the mela‐ noma. One marker used to determine immune activity in melanoma is the presence in sentinel lymph node biopsy samples, which has been variably associated with a favorable prognosis. Some investigators assessed whether the presence of tumor-infiltrating lymphocytes was an independent predictor of sentinel lymph node biopsy status and survival or not [167, 168].

Microscopic satellites are defined as dermal or subcutaneous nodules. Microscopic satellites in primary melanomas are considered to be localized micrometastases developing in close proximity to the main tumoral portion of melanomas and show bad prognosis. In particular, the presence of angiotropism predicts the detection of microscopic satellites, and microscopic satellites probably develop as a result of extravascular migration. Consequently the linkage between microscopic satellites and angiotropism provides additional support for extravascu‐ lar migratory metastasis as a mechanism of melanoma metastasis. Finally, ongoing investiga‐ tions to develop a more specific biomarker for angiotropism and extravascular migratory metastasis are essential for the more precise recognition of extravascular migratory metastases and the explaining of its biological and prognostic significance. This pericytic angiotropism of melanoma cells, without any sign of intravasation, suggests that melanoma cells may migrate along the external surface of vessels, a mechanism we have termed extravascular migratory

Common cell types are epithelioid and spindle cells, although mixed cells may also be seen.

The incidence of malignant melanoma appears to be increasing at an alarming rate throughout the world over the past 35-40 years and continues to increase in the USA, Canada, Asia, Australia, and Europe. The behavior of head and neck melanoma is aggressive, and it has an overall poorer prognosis than that of other skin sites. Correlations between different factors were found, e.g. tumour localisation predominating on the back in males and on the legs in

metastasis (EVMM), as distinct from intravascular dissemination [51, 169].

Generally, spindle cells are associated with better prognosis than other cell types.

Melanoma is the most dangerous form of skin cancer [174]. The incidence of melanoma is increasing worldwide, more than other cancers. The clinicians has the greatest impact on reducing these cases. They educate patients about early detection, treatment and prevention methods [175]. UV light is the most important risk factor for melanoma development. The risk of developing melanom may be reduced by protecting from UV light exposure. We must educate others as to the importance of sun protection [174]. Patients should be educated to avoid intense intermittent sun exposure and minimize cumulative sun exposure [176]. Avoiding overexposure to direct sunlight during the peak daylight hours, wearing protective clothing, and applying sunscreen are the ways to protect the skin [177].

Clinicians must educate patients as to the importance of using sunscreens that protects against both UVA and UVB light and with an SPF 30 or greater [174, 175]. It is important to emphasize the correct application of the recommended amount of sunscreen and the need for reapplica‐ tion of sunscreen [176]. Sunscreen should be applied to exposed dry skin 15 to 30 minutes before sun exposure. The standard amount of sunscreen used in SPF testing is 2 mg/cm2 . Sunscreen should be reapplied every 2 hours or after swimming or heavy perspiration; many water-resistant sunscreens lose effectiveness after 40 minutes in the water [177]. Clinicians recommend patients sun protective clothing such as sunglasses, hats or long sleeve clothing. Patients should be avoided direct exposure to the sunlight between 9 AM - 3 PM and tanning beds [174]. There is great concern in regard to the total amount of sun exposure during infancy and early childhood [175]. The importance of sun protection in childhood should be empha‐ sized [176].

The importance of malignant melanoma as a potentially fatal skin cancer among Caucasian populations worldwide has received critical attention in recent years. As compared to other life-threatening malignancies such as breast or prostate carcinoma, melanoma may be diagnosed by simple inspection of the skin surface with 80 to 90% accuracy. Sun avoidance, regular self-examination are important measures that can easily be applied. Future investiga‐ tions is needed to establish whether education and modification of behavior such as reduced sun exposure and various methodologies of skin examination have a significant impact in

Current Management of Malignant Melanoma: State of the Art

http://dx.doi.org/10.5772/55304

113

, Burhan Engin, Server Serdaroğlu and Yalçın Tüzün

İstanbul University, Cerrahpaşa Medical Faculty, Department of Dermatology, İstanbul,

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\*Address all correspondence to: zekayikutlubay@hotmail.com

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reducing mortality from melanoma.

**Author details**

Zekayi Kutlubay\*

Turkey

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Self-examination of skin by informed patients in terms of suspicious nevi is an important contributory factor in the early diagnosis of melanoma [178].

Skin self examination has the potential to significantly reduce melanoma mortality. One retrospective study concluded that skin self examination has the potential to reduce melanoma mortality by 63% [179]. One study found that 44% of diagnosed recurrent melanoma was initially detected by patients based on symptoms that raised suspicion of metastasis [180]. For this reason, patients shoul be educated about the skin self examination. Patient education in skin self examination includes information on the warning signs of melanoma. Also it includes directions on how to perform a thorough whole-body skin examination [176]. Patients at higher risk should carefully examine their own skin monthly and also be frequently examined by dermatologists professionally [174].

Older individuals are both more likely to acquire and to die from cutaneous melanoma; thus, elderly people should be a primary target for secondary melanoma prevention. We must be careful for the early detection and patient routine screening. Also secondary melanoma prevention should be focused on targeted education to older men and their spouses for early detection and reduction of mortality in this extremely high-risk group [181].

Following the diagnosis of cutaneous melanoma, all patients should be educated on the risks of developing a second primary melanoma. In addition, counselling on the common clinical characteristics of cutaneous melanomas and instruction on how to perform a skin self exami‐ nation should be provided. In the event of the development of new pigmented lesions or changes in preexisting pigmented lesions, patients should be advised to seek medical attention. In addition, appropriate lifelong follow-up surveillance is critical for the detection of thinner, more curable melanomas [182].

Most of the studies suggested that many cancer patients want to get detailed information about their disease, treatment options and prognosis of the disease. The most common complaint of these patients is not to told what is wrong with them, during the treatment. Cancer care professionals are beginning to recognize that patients' information needs and preferences [183].

With growing evidence that well-informed patients are more satisfied with their care and do better clinically. Efforts are needed to improve the information provision to melanoma patients. Exploration of the patients' personal information needs must lead to a more patienttailored approach of informing melanoma patients. A good opportunity would be the implementation of a survivorship care plan, which aims at providing a cancer survivor with a summary of their course of treatment, management of late effects, and strategies for health promotion [184].

The importance of malignant melanoma as a potentially fatal skin cancer among Caucasian populations worldwide has received critical attention in recent years. As compared to other life-threatening malignancies such as breast or prostate carcinoma, melanoma may be diagnosed by simple inspection of the skin surface with 80 to 90% accuracy. Sun avoidance, regular self-examination are important measures that can easily be applied. Future investiga‐ tions is needed to establish whether education and modification of behavior such as reduced sun exposure and various methodologies of skin examination have a significant impact in reducing mortality from melanoma.
