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FAQ

faq

Today, the diagnostic standard, that is the battery of medical tests most effective in diagnosing and treating melanoma, consists of the following:

To find and diagnose melanoma:
1. A careful inspection of the patient’s skin conducted by a general practitioner during any health exam;
2. A careful inspection of the patient’s skin conducted by a dermatologist during a routine check-up (done at least once a year) and a following examination of suspicious skin lesions with a dermatoscope.
The latter helps to identify the traits of the lesions that cannot be seen “with the naked eye,” such as:
1) asymmetrical structure,
2) atypical pigment network,
3) blue-white veil
Presence of at least two out of the three indicates that the lesion most likely is a melanoma and should be removed). Diagnostic sensitivity of dermatoscopy can reach over 93%;
3. Histopathology (microscopic examination) of a suspicious lesion that has been removed. It helps to conclusively determine whether we are dealing with a melanoma or another type of lesion (e.g., a benign mark). If the lesion turns out to be a melanoma, the histopathology report includes a description of distinctive traits of the tumour, which helps to determine the stage of the disease and plan further course of action, including the choice of the right treatment.

Before and during treatment:
1. If the doctor deems the melanoma locally advanced (the primary tumour is quite large and/or it has spread to the neighbouring lymph nodes) or if the patient reports suspicious symptoms, additional tests are ordered to determine whether the cancer has metastasized. Those tests may include one or more of the following:
- ultrasonography (an ultrasound exam) of lymph nodes (e.g., in the neck, armpit, or groin),
- a chest X-ray and/or CT scan,
- an abdominal ultrasound and/or CT or MRI scan,
- a cranial (head) CT and/or MRI scan,
- positron emission tomography (PET),
- bone scintigraphy,
- a biopsy of a lesion suspected of being metastasis (e.g., a biopsy of a swollen lymph node or a biopsy of a liver tumour),
- other tests deemed appropriate in a given situation
The results of the tests determine the selection of further treatment.
2. If the melanoma has been detected in the early stages and the patient does not report any suspicious symptoms, there is no need for additional tests, as the risk of metastases is very low.

After treatment:
For the first 2 years after the treatment for melanoma, patients should visit their attending physicians for a routine check-up every 3-4 months. During the check-up, the doctor carefully inspects the area of the scar formed after the surgical removal of the melanoma, (possibly) the lymph nodes, and the patient’s whole body to rule out possible skin metastases or a new melanoma. The doctor may also order an ultrasound of lymph nodes and an abdomen and a chest X-ray.
Other tests are prescribed only if there is a suspicion of metastatic disease.
For the following 3 years the follow-up visits should occur every 6 months, and after that, once a year.
The highest risk of a recurrence of melanoma is during the first 3 years after the treatment.

The key prognostic factor is the stage of the cancer (on I-IV scale); therefore, determining it is the first step in the diagnostic and therapeutic process. The tests used to do that include: CT scan of the chest, bronchoscopy, scans that allow assessment of the remote organs that are the most common sites for metastases, and other tests deemed necessary in individual cases.

The treatment is planned according to the spread and histological type of the cancer. During bronchoscopy, a biopsy of suspicious lesions is performed, and the biopsy material is submitted for histopathology. A pathomorphologist ascertains whether the lesion is a lung cancer, then determines its malignancy level (grades G1-G4) and type. The most common types are three non-small cell lung cancers: adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, and small cell lung cancer.

The course of treatment is decided on the basis of all this information. The best outcome is when the patient qualifies for surgery, during which the whole or a part of a lung is removed together with the regional lymph nodes. The chances of full recovery can be increased for many patients with post-surgery treatment involving chemotherapy, radiotherapy, or both.

However, some patients are not eligible for either surgery or conservative treatment (chemotherapy, radiotherapy) because of a coexisting condition, such as cardiovascular disease, neurological disorders, kidney disease, respiratory disease, etc. What is more, a considerable number of the patients who underwent surgery experience a relapse within 2 years, which is usually non-operable. Such patients, apart from oncological treatment meant to lengthen their lifespans and improve the quality of live, receive also intensive palliative care focused on relieving pain, shortness of breath, depression, and other symptoms related to the progression of the disease.

In some patients, mutations of certain genes (e.g., ALK, EGFR) are discovered, making them eligible for a targeted therapy. Such therapy does not lead to full recovery but its results are better than those of the “classic” chemotherapy.

With a malignant cancer as fatal as lung cancer the biggest hope lies in clinical trials, during which new drugs and potentially effective diagnostic-therapeutic methods are tested in a way that is safe for the patients.

Currently, the diagnostic standard, that is, the battery of medical tests most effective in diagnosing and treating cervical cancer, consists of the following:

To find and diagnose cervical cancer:
1. pelvic examination – sometimes, lesions suspected of malignancy are visible during a standard pelvic exam. Unfortunately, such lesions are usually already advanced;
2. the Papanicolaou test (Pap test or Pap smear) – a very important screening test, whose sensitivity in detecting cervical cancer and precancerous changes (cervical dysplasia – i.e., an abnormal, “pathological” condition that can transform into malignant cancer) is between 77 and 98%.
Pap test is completely painless and very quick. It involves collecting a sample of cells from the os and canal of the cervix with a swab during a pelvic exam. Then, in a laboratory, the sample is inspected under a microscope to assess the state of epithelial and glandular (mucus-producing) cells of the cervix.
The results of the test are reported in terms of 5 cytology classes introduced by Papanicolaou. Classes I and II mean that the results are normal.
3. Colposcopic examination (colposcopy) – this test is used when the results of the Pap test are abnormal. However, a referral to colposcopy does not automatically mean that cancer is present! The vast majority of colposcopies do not result in this diagnosis.
Combined with Pap test, colposcopy increases the efficiency of confirming or ruling out cervical cancer almost to 100%. Therefore, it is an important follow-up to Pap test and a necessary step before starting treatment for either precancerous changes or a malignant cancer.
Colposcopy, similarly to Pap test, is a quick and painless procedure performed during a pelvic exam (however, a slight “burning” or “pinching” sensation is possible when a biopsy is taken for a histopathological examination).
4. histopathological examination – the biopsy of abnormal tissue taken during colposcopy is sent to a laboratory, where a pathomorphologist, after analysing the tissue, gives the final diagnosis: inflammatory changes, precancerous condition, or cervical cancer.
On the basis of this information, the gynaecologist makes a decision regarding further diagnostics and treatment.
If there is any suspicion that the cancer infiltrated the urinary bladder or rectum, the doctor will recommend cystoscopy and colonoscopy.

Before and during treatment
After cervical cancer diagnosis, the next necessary step is to determine the stage of the disease. Tests which help with that include:
- a full physical examination (including lymph nodes assessment),
- a chest X-ray,
- standard blood and urine tests,
- a transvaginal or abdominal ultrasound (not as common as the others).
If the cervical cancer is locally advanced (a big primary tumour or infiltration of the neighbouring lymph nodes) the battery of tests may involve also:
- CT or MRI scans of the pelvis and abdomen, or a PET scan (positron emission tomography),
- biopsy of suspicious lymph nodes,
- cystoscopy and colonoscopy (if infiltration of the bladder and rectus is suspected),
- other tests deemed appropriate in a given situation.
The results of the tests determine the selection of further treatment.
The tests used during treatment depend on the administered form of therapy (e.g., surgical treatment, chemotherapy, or radiotherapy used as a sole treatment or in combination).

After treatment
During the first 2 years after the end of active treatment for cervical cancer, the patient should visit her gynaecologist for a follow-up every 3 months. The visit will include:
- a complete gynaecological examination,
- a Pap test.
Other tests are used only when a local recurrence or a metastatic disease are suspected.
For the following 3 years, the follow-up visits should occur every 6 months, once a year after that.

The treatment for melanoma may involve:
1. Surgery
2. Radiotherapy
3. Chemotherapy, immunotherapy, targeted drugs.

Melanoma can be fully cured only with surgical treatment, by cutting out all cancer cells from the body of the patient. Other forms of treatment are used as adjuvant therapy (to lower the risk of a relapse) or palliative care (to relieve symptoms related to the progression of the disease and/or to increase life expectancy of the patients with melanoma too advanced to cure).
Melanoma should be treated only in institutions with adequate experience in treating this type of cancer (cancer centres).

Surgical treatment consists of several stages:
1. Excisional biopsy;
2. Radical scar excision and sentinel lymph node biopsy (only in certain cases);
3. Radical lymphadenectomy (only in certain cases);
4. Metastasectomy (only in certain cases).

1. Excisional biopsy
A patient eligible for excisional biopsy is any patient on whom a dermatologist found a skin lesion bearing characteristics of melanoma (more about dermatoscopy here: What Tests Will the Doctor Order?).
The procedure is performed by a surgical oncologist. The surgeon removes the lesion with a small (only 2-3 mm) margin of the healthy tissue, then sends it for a histopathology (microscopic examination), conducted by a pathomorphologist. The wait for the results can last even up to several weeks.
The pathomorphologist performs an in-depth characterization of the tumour and gives the final diagnosis. If it is melanoma the report of the test will include the following information:
- the Breslow thickness (the thickness of the tumour measured from its surface to its deepest part, or in more medical terms, from the granular layer of the epidermis or the floor of an ulceration to the most deeply infiltrating nests of melanocytes);
- presence or absence of ulceration on the surface of the tumour;
- mitotic rate (number of mitoses per square millimetre);
- presence of regression;
- presence or absence of blood vessel or lymphatic invasion;
- presence or absence of microscopic satellite lesions (clumps of melanocytes with diameter > 0,05 mm located more than 0,3 mm from the invasive component of the primary tumour);
- margins of the healthy tissue around and under the tumour.
All this information helps determine the stage of the disease (measured according to the scale where stage 0 is melanoma in situ, i.e., not yet able to metastasize, and stages I-IV are invasive melanomas) and estimate the level of its malignancy and the risk of its recurrence and spread. The information largely influences also the choice of further treatment and the individual prognosis.
Important prognostic factors (i.e., factors affecting the prognosis for the progression of the disease and for the chances of full recovery) include the Breslow thickness, presence of a (micro)ulceration of the primary tumour, and the mitotic rate.
Undergoing an excisional biopsy usually does not involve hospitalization, and the local anaesthesia used during the procedure makes it completely painless.

2. Radical scar excision and sentinel lymph node biopsy
If the histopathology report is positive for cancer, the surgical oncologist will always widen the margins of excision, as there is a risk that parts the tumour were not removed from the healthy tissue and some cancer cells remain in the area around the biopsy wound. Depending on the Breslow thickness of the melanoma, the biopsy scar is excised with the margin of healthy tissue of 1 cm to 2 cm.
During the procedure, a sentinel lymph node biopsy will be performed in patients whose histopathology after the excision biopsy showed at least one of the following:
- the Breslow thickness of the tumour ≥ 1mm;
- (micro)ulceration on the surface of the tumour;
- mitotic rate ≥ 1 per 1 mm²,
because among these patients the risk of metastasis to the nearest lymph node through the lymphatic vessels is very high.
During a sentinel lymph node biopsy, the surgeon first uses a special dye which shows which node lymph travels to from the site of the primary tumour, and then removes that node.
The entire matter removed during both procedures (the scar with the healthy tissue margin and the sentinel node) is submitted for a histopathology, the results of which determine what, if any, further treatment is necessary.

3. Radical lymphadenectomy
If the histopathology (microscopic examination) of the sentinel node shows a metastasis, the next step is lymphadenectomy, that is, removal of the whole group of nodes the sentinel node originally belonged to (e.g. the cervical nodes on either side of the neck, axillary nodes, or inguinal nodes) – the risk that the cancer has metastasized to other nodes in the group is high. Lymphadenectomy is called radical because – as it was mentioned earlier – a full recovery is possible only by removing every single melanoma cell from the body. Otherwise, a relapse and further metastases will quickly follow.
Presence or absence of metastases in lymph nodes is the most significant prognostic factor in melanoma. The chances of full recovery of a patient with metastases in lymph nodes lessen considerably but still exist. Even in this stage, conquering the disease is still possible (but not certain!), provided that the right surgical treatment is received immediately.

4. Metastasectomy
In some cases, a single metastasis (e.g., in the lungs, brain, liver, bowel, or skin) is identified at the same time as the primary tumour. Such situations are very rare – usually there are multiple metastases and surgical treatment is impossible, as it would considerably damage the affected organ or result in haemorrhaging and, in consequence, death of the patient.
A single metastasis, if deemed operable – that is, if its removal would not kill or seriously cripple the patient because of its size and location – should be operated on. Such procedure is called metastasectomy and involves excision of the metastasis of the malignant cancer.

Thanks to this procedure some patients’ lifespans are lengthened by many years and some patients are even completely cured (unfortunately not many).
The role of radiotherapy in melanoma treatment is not significant. It is used either as adjuvant therapy in addition to the surgical treatment – e.g., irradiation of the site of lymph node excision if the cancer in the removed node infiltrated the node’s capsule – or as palliative therapy in metastasized melanoma – e.g., in cases of non-operable brain or bone metastases. However, this kind of treatment does not affect the progression of the disease much.
Chemotherapy also has small impact on melanoma – on average, it stops the progression of the disease for about 2 months.
Targeted drug therapy (BRAF inhibitor) – approx. 50% of melanomas contain a mutation in the BRAF gene. Administering BRAF inhibitor is much more effective than chemotherapy, and it considerably lengthens lifespans of some patients with non-operable lesions.
Immunotherapy (in melanoma, administering a drug containing ipilimumab) lengthens the life expectancy by several years in approx. 20% of patients with a metastasized melanoma. However, it is a very expensive treatment: in Poland, the average cost of the treatment for one patient with a metastasized melanoma is PLN 350 000 (approx. € 90 000); in Poland, it is refunded to a very limited extent.

Remember:
Melanoma can be cured only with surgical treatment. Other forms of therapy have limited effectiveness, and not all of them are easily available.
You can fully recover from melanoma if you seek help early. The chances of curing melanoma in the early stages reach up to 90%.

The treatment for cervical cancer may include:
1. Surgery
2. Chemoradiotherapy
3. Radiotherapy
4. Chemotherapy

The first step in choosing and starting the right treatment is the right identification of the stage of the disease.

Staging of cervical cancer is based on the FIGO classification system, with stages graded I-IVB.
Stage I means that the cancer is limited only to the cervix.
Classification into sub-stages IA, IA1, IA2, IB, IB1, and IB2 depends mainly on the depth of the infiltration into cervical tissue and the size of the tumour (its diameter).
Stage II means that the cancer has grown beyond the cervix but has not yet invaded the walls of the pelvis. It could have spread to the vagina but only in its upper part (the upper 2/3).
Classification into sub-stages IIA, IIA1, IIA2, and IIB depends on the question whether the tumour is larger than 4 cm, and whether it has spread to the tissues next to the cervix (the parametria – groups of connective tissues acting as ligaments located around the uterus and behind the peritoneal cavity).
Stage III means that the cancer has spread to the walls of the pelvis or to the lower part of the vagina. Additionally, one of the kidneys might not be working, or a condition called hydronephrosis might occur. Either can happen when the tumour infiltrates or pinches a ureter and the urine cannot drain out of the kidney.
Classification into sub-stages IIIA and IIIB depends on which of these factors have occurred.
Stage IV means that the cancer has spread to other organs.
Sub-stage IVA means that the tumour has invaded the neighbouring organs (e.g., the bladder and rectum), while sub-stage IVB indicates metastases to remote organs (e.g., the liver or lungs).

Surgical treatment
Cervical cancer in the early stages – that is, a cancer limited to the cervix or a cancer that has spread slightly beyond it but has not invaded the parametria or grown beyond 4 cm – can be treated surgically. The procedure involves removal of the uterus and parametria as well as lymphadenectomy (removal of the lymph nodes located near the primary tumour).
The exception is the microinvasive cancer in stage IA1 (the tumour is not larger than 7 mm and it has not infiltrated the cervix deeper than 3 mm). In such cases, the procedure is limited to simple removal of the uterus. Sometimes, not even that is necessary. Women who want to retain fertility can undergo conization – i.e., partial removal – of the cervix.
Fertility can be retained also by some of the patients in the other early sub-stages of cervical cancer. The treatment in such cases involves complete removal of the cervix, parametria, and neighbouring lymph nodes; however, the uterus remains intact. Over 20% of patients who undergo such treatment are later able to get pregnant and have children.
The effectiveness of surgical treatment of cervical cancer in the early stages is high – approx. 80% of patients make full recovery.
Very rarely, e.g., in the case of a single, operable metastasis, metastasized cervical cancer can also be treated surgically.
In certain cases, if there are factors indicating that the risk of a relapse is particularly high for a patient, the doctor might recommend chemotherapy as adjuvant treatment.

Chemoradiotherapy
Except for the early stages and stage IVB (metastatic cancer), cervical cancer is treated predominantly with chemoradiotherapy, which combines three treatments:
- chemotherapy,
- standard radiotherapy (high, radical dose of ionizing radiation),
- brachytherapy (applying a radiation source inside a patient’s body; the source is placed in the direct vicinity of the cancerous lesion).
The therapy lasts about 8 weeks. It cures more than half of stage II cervical cancers, a third of those in stage III, and, unfortunately, only a few percent of those in stage IVA.
Patients whose overall physical condition prohibits them from undergoing chemotherapy receive only radiotherapy, the results of which are considerably worse.

Chemotherapy:
If the cancer has already metastasized, usually only chemotherapy is administered as palliative treatment – that is, treatment which can stop the progression of the disease for a while but can never cure it.
Cervical cancer is not a chemosensitive tumour; therefore, chemotherapy rarely produces good results.

Remember:
- Cervical cancer can be cured with surgery and chemoradiotherapy.
- Certain forms of surgical treatment allow young women with early-stage cervical cancer to retain fertility.
The chances of curing cervical cancer decrease proportionally to the progression of the disease. The earlier the diagnosis and treatment, the bigger chance there is for surviving cervical cancer.

Active surveillance is necessary after the treatment for melanoma. The main reason for that is the high risk of a recurrence, resulting from a possibility that a microspread of the cancer occurred before or during the surgical treatment – that is, melanoma cells might have “broken away” from the primary tumour, infiltrated blood or lymph vessels, and “settled” in a neighbouring lymph node or a remote organ, such as the lungs, liver, bones, or brain; with time, they might form a new tumour there. There is also a risk that some cancer cells remained around the scar after the primary tumour biopsy, which might result in the so called local recurrence.

What is more, the risk of developing a new primary melanoma is much higher for survivors of melanoma than for those who have never suffered from it before.

The highest risk of a recurrence of melanoma is during the first 3 years after active treatment ends.

For the first 2 years after the treatment for melanoma, patients should visit their attending physicians for a routine check-up every 3-4 months. During the check-up, the doctor carefully inspects the area of the scar formed after the surgical removal of the melanoma, (possibly) the lymph nodes, and the patient’s whole body to rule out possible skin metastases or a new melanoma. The doctor may also order an ultrasound of lymph nodes and an abdomen and a chest X-ray.
Other tests are prescribed only if there is a suspicion of metastatic disease.

For the following 3 years the follow-up visits should occur every 6 months, and after that, once a year.

Scrupulous use of preventive healthcare strategies is crucial (see: How to Prevent Melanoma?).

During the first 2 years after the end of active treatment for cervical cancer the patient should visit her gynaecologist for a follow-up every 3 months. The visit will include:
- a complete gynaecological examination,
- a Pap test.
Other tests are used only when a local recurrence or a metastatic disease are suspected.
For the following 3 years, the follow-up visits should occur every 6 months and after that, once a year.

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