Categories
Diagnonistic Test

Skin Biopsy

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Definition:
A biopsy of a lesion of the skin, such as in mole removal or tumor removal, can help your doctor tell the difference between a skin cancer and a benign, or noncancerous, lesion. The skin sample obtained during a biopsy is sent to a laboratory for examination under a microscope.

For this test, abnormal areas of skin are removed to test for cancer or other skin diseases.

Doctors take biopsies of areas that look abnormal and use them to detect cancer, precancerous cells, infections, and other conditions. For some biopsies, the doctor inserts a needle into the skin and draws out a sample; in other cases, tissue is removed during a surgical procedure.

Your doctor may want to obtain a sample of skin in order to diagnose diseases of the skin, such as those caused by bacteria, fungi, or other chronic skin conditions. This procedure is called a skin biopsy.

.Skin Problem Slideshow->..
How the procedure is performed?
*In an excision biopsy, the entire area of suspect skin is cut out. Excision biopsy is normally done with a scalpel. Stitches are used to close the incision.

*In a punch biopsy, a sharp cookie cutter -like instrument is used to remove a small cylinder of skin. Sometimes stitches are necessary to close this type of biopsy wound.

*The outermost part of a lesion can also be shaved off with a scalpel. This is called a shave biopsy.

If you have a lesion on your skin that is fluid-filled and not solid, this can be evaluated with aspiration. Your doctor can put a small needle attached to a syringe into this lesion and suction out the fluid.

How do you prepare for the test?

*Skin biopsy is routinely done in the doctor’s office. You may be asked to change into a gown or remove an article of clothing so that the area of suspect skin can be more easily seen and removed.

*Tell your doctor if you have any allergies to medications, and especially if you have had any reactions to local anesthetics, such as lidocaine or Novocain, or to iodine cleaning solutions, such as Betadine.

*Inform your doctor if you are taking any medications, including over-the-counter drugs, street drugs, or herbal or nutritional supplements.

*Tell your doctor if you have any bleeding problems or if you are pregnant.

What risks are there from the test?
You should discuss with your doctor the following potential risks and complications of the biopsy procedure. You will need to sign a consent form before the procedure.

Possible risks include these:
*Bleeding from the biopsy site
*Pain
*Local reaction to the anesthetic
*If you had an excisional biopsy, you’ll have a scar shaped like a straight line.(Scars are rare following a punch biopsy.)
*Following any kind of incision into the skin, some people develop keloids-reddish lumps on the healing skin.
*Infection

Healing problems – If you tend to form large scars (keloids), you have an increased chance of forming a scar over the biopsy site. Smoking and some chronic medical conditions such as diabetes affect the healing ability of the skin.
What happens when the test is performed?
This procedure is done in a doctor’s office, often by a dermatologist. The doctor begins by injecting a local anesthetic near the biopsy site. Although the injection usually stings for a second, the rest of the procedure is painless. Depending on the size of the lesion, one of two methods will be used to remove or sample it.

For small lesions and tissue samples, your doctor might do a punch biopsy, in which he or she places an instrument shaped like a straw with a sharp end against your skin and twists it. The sharp end works like a cookie cutter to slice a small circle from the top layer of skin. The doctor lifts the tissue away with tweezers. A single stitch closes the opening in the skin.

Larger lesions and tissue samples are removed with an excisional biopsy. In this case, the doctor uses a blade to cut an oval opening around the area. The doctor will stop any bleeding with a cauterizer, a wand-shaped instrument that uses an electric current to seal the ends of bleeding blood vessels. You’ll also need stitches to close the incision.
The tissue that is removed is sent to the laboratory for analysis by a pathologist.

With both types of biopsies, the skin sample is then given to a pathologist and examined under a high-powered microscope.You’ll probably be able to go home right afterward.

For skin biopsies that are being tested for melanoma, the most serious form of skin cancer, your doctor will try to remove the entire area that looks abnormal. That way, the biopsy will not only determine if the lesion is malignant, it might also cure the cancer. The sample will be examined under a microscope to make sure the whole cancer has been removed. You might need additional skin surgery if the examination shows that the cancer extended to the margins of the skin sample.

After the Procedure:
*To Keep the healing wound clean and dry.Your doctor will put a bandage over your biopsy site. Keep this bandage dry. You may be advised to wash the wound, apply antibacterial ointment, and change the bandage daily.

*If you have stitches, you need to keep the area clean and dry. Follow instructions regarding when and how to wash the wound.
Stitches on the face are removed in 5-8 days. Stitches placed elsewhere on the body are removed in 10-14 days. Adhesive strips are left in place for 10-21 days.

*If you have pain at the biopsy site, talk with your doctor about medication to relieve it. In most cases, discomfort is minimal and requires nothing more than an over-the-counter pain medication.

Next Steps:
Your doctor needs to see you again to remove the stitches and to give you the results of the pathology report.

When to Seek Medical Care:
Call your doctor if you have worsening pain, spreading redness around the site, bleeding from the wound, fever (temperature greater than 100.4°F), or other concerns.

Go to a hospital’s emergency department if you have bleeding from the site that will not stop with gentle pressure, if you have a thick discharge (pus) from the wound, or if you have a high fever.

How long is it before the result of the test is known?
It can take several days to get your results.

Resources:
https://www.health.harvard.edu/diagnostic-tests/skin-biopsy.htm
http://www.emedicinehealth.com/skin_biopsy/article_em.htm

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Categories
Ailmemts & Remedies

Melanoma

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Definition:
Melanoma is a malignant tumor of melanocytes which are found predominantly in skin but also in the bowel and the eye (see uveal melanoma). It is one of the rarer types of skin cancer but causes the majority of skin cancer related deaths. Malignant melanoma is a serious type of skin cancer. It is due to uncontrolled growth of pigment cells, called melanocytes. Despite many years of intensive laboratory and clinical research, the sole effective cure is surgical resection of the primary tumor before it achieves a Breslow thickness greater than 1 mm.
..click to see the picture
Around 160,000 new cases of melanoma are diagnosed worldwide each year, and it is more frequent in males and caucasians. It is more common in caucasian populations living in sunny climates than other groups. According to a WHO Report about 48,000 melanoma related deaths occur worldwide per year.

click to see the pictures..>….…(01).(1)     .(2).……..(3)

Malignant melanoma accounts for 75 percent of all deaths associated with skin cancer.

The treatment includes surgical removal of the tumor; adjuvant treatment; chemo- and immunotherapy, or radiation therapy.
Causes:
Generally, an individual’s risk for developing melanoma depends on two groups of factors: intrinsic and environmental.”Intrinsic” factors are generally an individual’s family history and inherited genotype, while the most relevant environmental factor is sun exposure.

Epidemiologic studies suggest that exposure to ultraviolet radiation (UVA[13] and UVB) is one of the major contributors to the development of melanoma. UV radiation causes damage to the DNA of cells, typically thymine dimerization, which when unrepaired can create mutations in the cell’s genes. When the cell divides, these mutations are propagated to new generations of cells. If the mutations occur in protooncogenes or tumor suppressor genes, the rate of mitosis in the mutation-bearing cells can become uncontrolled, leading to the formation of a tumor. Data from patients suggest that aberrant levels of Activating Transcription Factor in the nucleus of melanoma cells are associated with increased metastatic activity of melanoma cells; studies from mice on skin cancer tend to confirm a role for Activating Transcription Factor-2 in cancer progression. Occasional extreme sun exposure (resulting in “sunburn“) is causally related to melanoma. Melanoma is most common on the back in men and on legs in women (areas of intermittent sun exposure). The risk appears to be strongly influenced by socio-economic conditions rather than indoor versus outdoor occupations; it is more common in professional and administrative workers than unskilled workers. Other factors are mutations in or total loss of tumor suppressor genes. Use of sunbeds (with deeply penetrating UVA rays) has been linked to the development of skin cancers, including melanoma.

Possible significant elements in determining risk include the intensity and duration of sun exposure, the age at which sun exposure occurs, and the degree of skin pigmentation. Exposure during childhood is a more important risk factor than exposure in adulthood. This is seen in migration studies in Australia[22] where people tend to retain the risk profile of their country of birth if they migrate to Australia as an adult. Individuals with blistering or peeling sunburns (especially in the first twenty years of life) have a significantly greater risk for melanoma. This does not mean that sunburn is the cause of melanoma. Instead it is merely statistically correlated. The cause is the exaggerated UV-exposure. It has been shown that sunscreen – while preventing the sunburn – does not protect from melanoma. Many researchers say that sunscreen can even increase the melanoma risk.

Fair and red-headed people, persons with multiple atypical nevi or dysplastic nevi and persons born with giant congenital melanocytic nevi are at increased risk.

A family history of melanoma greatly increases a person’s risk because mutations in CDKN2A, CDK4 and several other genes have been found in melanoma-prone families. Patients with a history of one melanoma are at increased risk of developing a second primary tumour.

The incidence of melanoma has increased in the recent years, but it is not clear to what extent changes in behavior, in the environment, or in early detection are involved.

To understand how sunscreen can reduce sunburn and at the same time cause melanoma it is necessary to distinguish between direct DNA damage and indirect DNA damage. Genetic analysis has shown that 92% of all melanoma are caused by the indirect DNA damage. Although some people believe that dark-skinned people such as African Americans cannot get sunburns, they are in fact susceptible, and should use sunscreen accordingly. The recommended amount of sunscreen for adults is 1 oz, which is enough to fill a shot glass.

Genetics:
Familial melanoma is genetically heterogeneous, and loci for familial melanoma have been identified on the chromosome arms 1p, 9p and 12q. Multiple genetic events have been related to the pathogenesis of melanoma. The multiple tumor suppressor 1 (CDKN2A/MTS1) gene encodes p16INK4a – a low-molecular weight protein inhibitor of cyclin-dependent protein kinases (CDKs) – which has been localised to the p21 region of human chromosome 9. Today, melanomas are diagnosed only after they become visible on the skin. In the future, however, physicians will hopefully be able detect melanomas based on a patient’s genotype, not just his or her phenotype. Recent genetic advances promise to help doctors to identify people with high-risk genotypes and to determine which of a person’s lesions have the greatest chance of becoming cancerous. A number of rare mutations, which often run in families, are known to greatly increase one’s susceptibility to melanoma. One class of mutations affects the gene CDKN2A. An alternative reading frame mutation in this gene leads to the destabilization of p53, a transcription factor involved in apoptosis and in fifty percent of human cancers. Another mutation in the same gene results in a non-functional inhibitor of CDK4, a [cyclin-dependent kinase] that promotes cell division. Mutations that cause the skin condition Xeroderma Pigmentosum (XP) also seriously predispose one to melanoma. Scattered throughout the genome, these mutations reduce a cell’s ability to repair DNA. Both CDKN2A and XP mutations are highly penetrant. Other mutations confer lower risk but are more prevalent in the population. People with mutations in the MC1R gene, for example, are two to four times more likely to develop melanoma than those with two wild-type copies of the gene. MC1R mutations are very common; in fact, all people with red hair have a mutated copy of the gene. Two-gene models of melanoma risk have already been created, and in the future, researchers hope to create genome-scale models that will allow them to predict a patient’s risk of developing melanoma based on his or her genotype. In addition to identifying high-risk patients, researchers also want to identify high-risk lesions within a given patient. Many new technologies, such as optical coherence tomography (OCT), are being developed to accomplish this. OCT allows pathologists to view 3-D reconstructions of the skin and offers more resolution than past techniques could provide. In vivo confocal microscopy and fluorescently tagged antibodies are also proving to be valuable diagnostic tools.

Symptoms and signs:
To detect melanomas (and increase survival rates), it is recommended to learn what they look like (see “ABCD” mnemonic below), to be aware of moles and check for changes (shape, size, color, itching or bleeding) and to show any suspicious moles to a doctor with an interest and skills in skin malignancy.

A popular method for remembering the signs and symptoms of melanoma is the mnemonic “ABCD”:

*Asymmetrical skin lesion.

*Border of the lesion is irregular.

*Color: melanomas usually have multiple colors.

*Diameter: moles greater than 6 mm are more likely to be melanomas than smaller moles.
.click to see

ABCD rule illustration. On the left side from top to bottom: melanomas showing (A) Asymmetry, (B) a border that is uneven, ragged, or notched, (C) coloring of different shades of brown, black, or tan and (D) diameter that had changed in size. The normal moles on the right side do not have abnormal characteristics (no asymmetry, even border, even color, no change in diametry).

A weakness in this system is the D. Many melanomas present themselves as lesions smaller than 6 mm in diameter; and likely all melanomas were melanomas on day 1 of growth, which is merely a dot. An astute physician will examine all abnormal moles, including ones less than 6 mm in diameter. Unfortunately for the average person, many seborrheic keratosis breaks most if not all of the ABCD rules, and can not be distinguished from a melanoma without a trained eye or dermatoscopy.

Some will advocate the system “ABCDE”, with E for evolution. Certainly moles which change and evolve will be a concern. Some will refer to E as elevation. But most melanomas detected today are in the very early stage, or in-situ stage. Elevation should absolutely not be a criterion to wait for, as it will be past in-situ and into the invasive stage.
A recent and novel method of melanoma detection is the “Ugly Duckling Sign” It is simple, easy to teach, and highly effective in detecting melanoma. Simply, correlation of common characteristics of a person’s skin lesion is made. Lesions which greatly deviate from the common characteristics are labeled as an “Ugly Duckling”, and further professional exam is required. The “Little Red Riding Hood” sign, suggests that individuals with fair skin and light colored hair might have difficult to diagnose melanomas. Extra care and caution should be rendered when examining such individuals as they might have multiple melanomas and severely dysplastic nevi. A dermatoscope must be used to detect “ugly ducklings”, as many melanomas in these individuals resemble non-melanomas or are considered to be “wolves in sheep clothing”. These fair skinned individuals often have lightly pigmented or amelanotic melanomas which will not present easy to observe color changes and variation in colors. The borders of these amelanotic melanomas are often indistinct, making visual identification without a dermatoscope (dermatoscopy) very difficult.

People with a personal or family history of skin cancer or of dysplastic nevus syndrome (multiple atypical moles) should see a dermatologist at least once a year to be sure they are not developing melanoma.
Diagnosis:
Moles that are irregular in color or shape are suspicious of a malignant or a premalignant melanoma. Following a visual examination and a dermatoscopic exam, used routinely by one in 4 dermatologists in the United States, or an examination using other in vivo diagnostic tools, such as a confocal microscope, the doctor may biopsy the suspicious mole. If it is malignant, the mole and an area around it needs excision.

..A dermatoscope.->

The diagnosis of melanoma requires experience, as early stages may look identical to harmless moles or not have any color at all. A skin biopsy performed under local anesthesia is often required to assist in making or confirming the diagnosis and in defining the severity of the melanoma. Amelanotic melanomas and melanomas arising in fair skinned individuals (see the “Little Red Riding Hood” sign) are very difficult to detect as they fail to show many of the characteristics in the ABCD rule, and breaks the “Ugly Duckling” sign. These melanomas are often light brown, or pink in color – and very hard to distinguish from acne scarring, insect bites, dermatofibromas, or lentigines. There is no blood test for detecting melanomas.

Excisional skin biopsy is the management of choice; this is where the suspect lesion is totally removed with an adequate (but minimal, usually 1 or 2 mm) ellipse of surrounding skin and tissue.[46] The preferred surgical margin for the initial biopsy should be narrow (1 mm) in order to prevent the disruption of the local lymphatic drainage. The biopsy will include the epidermal, dermal, and subcutaneous layers of the skin, enabling the histopathologist to determine the depth of penetration of the melanoma by microscopic examination. This is described by Clark’s level (involvement of skin structures) and Breslow’s depth (measured in millimeters). However, for large lesions such as suspected lentigo maligna, or for lesions in surgically difficult areas (face, toes, fingers, eyelids), a small punch biopsy (1.5 to 2 mm) in multiple representative areas will give adequate information and will not disrupt the final staging or depth determination. In no circumstances should the initial biopsy include the final surgical margin (0.5 cm, 1.0cm, or 2 cm), as a misdiagnosis can result in excessive scarring and morbidity from the procedure. Large initial excision will disrupt the local lymphatic drainage and can affect further lymphangiogram directed lymphnode dissection. A small punch biopsy can be utilized at anytime where for logistical and personal reasons a patient will refused more invasive excisional biopsy. Small punch biopsies are minimally invasive and heal quickly, usually without noticeable scarring.

Malignant melanoma in skin biopsy with H&E stain. This case may represent superficial spreading melanoma.

click to see

Lactate dehydrogenase (LDH) tests are often used to screen for metastases, although many patients with metastases (even end-stage) have a normal LDH; extraordinarily high LDH often indicates metastatic spread of the disease to the liver. It is common for patients diagnosed with melanoma to have chest X-rays and an LDH test, and in some cases CT, MRI, PET and/or PET/CT scans. Although controversial, sentinel lymph node biopsies and examination of the lymph nodes are also performed in patients to assess spread to the lymph nodes.

Sometimes the skin lesion may bleed, itch, or ulcerate, although this is a very late sign. A slow-healing lesion should be watched closely, as that may be a sign of melanoma. Be aware also that in circumstances that are still poorly understood, melanomas may “regress” or spontaneously become smaller or invisible – however the malignancy is still present. Amelanotic (colorless or flesh-colored) melanomas do not have pigment and may not even be visible. Lentigo maligna, a superficial melanoma confined to the topmost layers of the skin (found primarily in older patients) is often described as a “stain” on the skin. Some patients with metastatic melanoma do not have an obvious detectable primary tumor.

Treatment:-
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient’s needs. Treatment for melanoma depends on the extent of the disease, the patient’s age and general health, and other factors.

People with melanoma are often treated by a team of specialists. The team may include a dermatologist, surgeon, medical oncologist, radiation oncologist, and plastic surgeon.

Getting a second opinion

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor for a second opinion:

The patient’s doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.

The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.

A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors’ names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet at(You may Click on to see “Who’s Certified.”)

Preparing for treatment
People with melanoma often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a melanoma can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.

These are some questions a person may want to ask the doctor before treatment begins:

*What is my diagnosis?

*What is the stage of my disease?

*What are my treatment choices? Which do you recommend for me? Why?

*What are the benefits of each kind of treatment?

*What are the risks and possible side effects of each treatment?

*How will I feel after surgery?

*If I have pain, how will it be controlled?

*Will I need more treatment after surgery?

*Will there be a scar? Will I need a skin graft or plastic surgery?

*What is the treatment likely to cost?

*Will treatment affect my normal activities? If so, for how long?

*How often will I need checkups?

*Would a clinical trial (research study) be appropriate for me? Can you help me find one?

People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Methods of treatment:-

People with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.

At any stage of disease, people with melanoma may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called symptom management, supportive care, or palliative care.

The doctor is the best person to describe the treatment choices and discuss the expected results.

A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on “The Promise of Cancer Research” has more information about clinical trials.

Surgery
Surgery is the usual treatment for melanoma. The surgeon removes the tumor and some normal tissue around it. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin:

*The doctor may be able to completely remove a very thin melanoma during the biopsy. Further surgery may not be necessary.

*If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas. If the melanoma is thick, the doctor may need to remove a larger margin of tissue.

If a large area of tissue is removed, the surgeon may do a skin graft. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.

Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has also spread to other parts of the body. Two procedures are used to remove the lymph nodes:

*Sentinel lymph node biopsy—The sentinel lymph node biopsy is done after the biopsy of the melanoma but before the wider excision of the tumor. A radioactive substance is injected near the melanoma. The surgeon follows the movement of the substance on a computer screen. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping.) The surgeon removes the sentinel node(s) to check for cancer cells.

If a sentinel node contains cancer cells, the surgeon removes the rest of the lymph nodes in the area. However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.

*Lymph node dissection—The surgeon removes all the lymph nodes in the area of the melanoma.

Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. The patient may receive biological therapy.

Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods.

Chemotherapy
Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat melanoma. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor’s office, or at home). However, depending on which drugs are given and the patient’s general health, a short hospital stay may be needed.

People with melanoma may receive chemotherapy in one of the following ways:

*By mouth or injection—Either way, the drugs enter the bloodstream and travel throughout the body.

*Isolated limb perfusion (also called isolated arterial perfusion)—For melanoma on an arm or leg, chemotherapy drugs are put directly into the bloodstream of that limb. The flow of blood to and from the limb is stopped for a while. This allows most of the drug to reach the tumor directly. Most of the chemotherapy remains in that limb.

The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.

Biological therapy
Biological therapy (also called immunotherapy) is a form of treatment that uses the body’s immune system, either directly or indirectly, to fight cancer or to reduce side effects caused by some cancer treatments. Biological therapy for melanoma uses substances called cytokines. The body normally produces cytokines in small amounts in response to infections and other diseases. Using modern laboratory techniques, scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.

Radiation therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. The patient usually has treatment at a hospital or clinic, five days a week for several weeks. Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.

Treatment choices by stage:

The following are brief descriptions of the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

Stage 0
People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.

Stage I
People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.

Stage II or stage III

People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.

Stage IV
People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better—physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.

The patient may have one of the following:
Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body

Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

People with advanced melanoma can find helpful information in the National Cancer Institute booklet Pain Control: A Guide for People with Cancer and Their Families.

Recurrent melanoma
Treatment for recurrent melanoma depends on where the cancer came back, which treatments the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.

The patient may have one of the following:
*Surgery to remove the tumor
*Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

Heated chemotherapy drugs injected directly into the tumor

Treatment Sideeffects:
Because treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections “National Cancer Institute Information Resources” and “National Cancer Institute Booklets” for other sources of information about side effects.

Surgery
The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.

Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can (while still protecting against recurrence). In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, the doctor must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large growths, these scars will still be quite noticeable.

Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, insect bites, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.

Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:

*Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.

*Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.

*Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.

Biological therapy
The side effects of biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also get a skin rash. These problems can be severe, but they go away after treatment stops.

Radiation therapy
The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur in the treated area include red or dry skin and hair loss. Radiation therapy also may cause fatigue. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.

Nutrition
People with melanoma may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. Nevertheless, patients should try to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.

The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful ideas and recipes. The “National Cancer Institute Booklets” section tells how to get this publication.

For more knowledge You may click to see:
*What about followup care after treatment for melanoma?
*Are there support groups for people with melanoma?
*What steps are involved in performing a skin self-exam?
*Where can patients get more information about melanoma?

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Prevention:-
Minimizing exposure to sources of ultraviolet radiation (the sun and sunbeds), following sun protection measures and wearing sun protective clothing (long-sleeved shirts, long trousers, and broad-brimmed hats) can offer protection. In the past it was recommended to use sunscreens with an SPF rating of 30 or higher on exposed areas as older sunscreen more effectively blocked UVA with higher SPF. Currently, newer sunscreen ingredients (avobenzone, zinc, and titanium) effectively block both UVA and UVB even at lower SPFs. However, there are questions about the ability of sunscreen to prevent melanoma.This controversy is well discussed in numerous review articles, and is refuted by most dermatologists. This correlation might be due to the confounding variable that individuals who used sunscreen to prevent burn, might have a higher lifetime exposure to either UVA or UVB. Please see Sunscreen controversy for further references and discussions. Tanning, once believed to help prevent skin cancers, actually can lead to increase incidence of melanomas Even though tanning beds emits mostly UVA, which causes tanning, it by itself might be enough to induce melanomas.

Rough rules of thumb to decreasing ultraviolet light exposure include avoiding the sun between the hours of 9 a.m. and 3 p.m. or avoiding the sun when your shadow is shorter than your height. These are rough rules of thumbs, and varies depending on your locality and your skin cancer risk.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose
Resources:
http://en.wikipedia.org/wiki/Melanoma
http://www.medicinenet.com/melanoma/article.htm

 

 

 

 

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Sun Power

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Mankind knows that the sun is the centre of the universe and that it sustains life. But some ancient civilisations were a little confused: did the sun go around the earth? Or was it the other way around? All of them (the Chinese, Aztecs, Greeks, Romans and Indians) respected the sun and had elaborate rituals to appease its mighty power. Many of these movements were later incorporated into exercise forms, to be performed early in the morning clad in scanty clothing as the first rays of the sun appeared on the horizon.
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The sun emits light with varying spectra. The UVB (the B band of ultra violet rays) stimulates the production of vitamin D. These rays are maximal at sunrise and sunset, when the sunlight hits the body at an angle, and not when the sun is directly overhead. The beneficial rays are also screened out by window panes, clouds, fog and smog. This is why exercise is best performed outdoors and at such times.

As the sunlight falls on the skin, it helps the body manufacture vitamin D. In 30 minutes, around 3000IU (international units) of vitamin D is formed and absorbed into the body. Vitamin D is essential for calcium to enter our bones. This prevents rickets in children, and osteoporosis and osteomalacia in adults. Most people require only five minutes of exposure to obtain their daily requirements of this important vitamin.

Many people take vitamin D supplements or capsules of natural cod liver oil to prevent a deficiency. But these rarely contain more than 90IU while children require 200IU/day and adults 400IU/day.

Sunlight affects the pineal gland in the brain and exposure reduces the formation and release of a hormone called melatonin. An increase in melatonin levels leads to depression. That is why the “blues” set in (even in tropical countries) during winter when the days are shorter, or during the dark cloudy monsoon days. Post-natal depression too is aggravated in women confined indoors in dark rooms after childbirth.

Regular and longer exposure to sunlight elevates the mood naturally. People who walk or jog outdoors in daylight regularly have a more positive approach to life, less stress and better ability to cope. Roman gladiators were exposed to the sun regularly as part of their training. The trainers discovered that this toughened them mentally, and enlarged and strengthened the muscles, giving them an edge over their opponents.

Fretful children, who sleep poorly, build up fatigue and tension in their hapless parents. These children will sleep longer and more soundly if they are exposed to sunlight between noon and 4 p.m. in the veranda or some other shaded area.

Sometimes babies are jaundiced after birth. Whatever the cause, exposure of the affected unclothed baby to sunlight (UVB) for 10 minutes daily, early in the morning, brings down the jaundice. In severe cases (in intensive care facilities and nurseries), infants are exposed to artificial UVB lights for longer periods to produce the same effect.

The incidence of certain cancers, like those of the breast, prostate, reproductive organs and colon, is increased in individuals who are not regularly exposed to the sun.

The sun is a good antiseptic. Before the modern antibiotic era, fresh air and sunshine were used to heal wounds and treat tuberculosis.

Bed bugs can be eliminated by regular exposure of mattresses and linen to sunlight. This prevents human exposure to toxic chemical pesticides.

In resource-limited settings, where fuel is scarce and expensive, families often consume contaminated water without boiling it. This causes diarrhoea, eventually leading to chronic ill health and malnutrition. Exposure of the water to sunlight in transparent plastic drums for an hour significantly reduces the bacterial load and the incidence of diarrhoeal diseases.

Beneficial sunlight enters our body through our eyes. It has a profound effect on hormones, reproduction and our natural internal circadian (sleep) rhythm. The amount allowed inside is naturally adjusted (without sunglasses) by the pupils and according to the colour of our eyes. In Scandinavian countries where the sunlight is less the eyes are light coloured, allowing in more light, while the converse is true closer to the equator.

The ill effects of exposure to sunlight and the danger of developing skin cancer have been widely publicised. Skin cancer usually develops as a result of inappropriate exposure to excessive sunlight, usually around mid-day in lightly pigmented individuals. Too much of anything is bad, and the same is true of the sun too.

The sun is a boundless source of energy and health. We need to expose ourselves to its slanting rays regularly in the morning or evening, to keep our moods elevated, our muscles strong, our circadian rhythms intact and our body cancer free. It helps to start the day with a suryanamaskar, our very own traditional salute to the sun.

Sources: The Telegraph (Kolkata, India)

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Ailmemts & Remedies

Melasma

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Alternative Names : Chloasma; Mask of pregnancy; Pregnancy mask

Definition:-
Melasma is a dark skin discoloration found on sun-exposed areas of the face.
Melasma (also known as chloasma or the mask of pregnancy when present in pregnant women) is a tan or dark facial skin discoloration. Although it can affect anyone, melasma is particularly common in women, especially pregnant women and those who are taking oral or patch contraceptives or hormone replacement therapy (HRT) medications. It is also prevalent in men and women of Native American descent (on the forearms) and in men and women of German/Russian Jewish descent (on the face).

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Symptoms:-

Melasma doesn’t cause any other symptoms besides skin discoloration but may be of great cosmetic concern.A uniform brown color is usually seen over the cheeks, forehead, nose, or upper lip. It is most often symmetrical (matching on both sides of the face).
The symptoms of melasma are dark, irregular patches commonly found on the upper cheek, nose, lips, upper lip, and forehead. These patches often develop gradually over time. Melasma does not cause any other symptoms beyond the cosmetic discoloration.

Cause:-

Melasma is a very common skin disorder. Though it can affect anyone, young women with brownish skin tones are at greatest risk.

Melasma is often associated with the female hormones estrogen and progesterone. It is especially common in pregnant women, women who are taking oral contraceptives (“the pill”), and women taking hormone replacement therapy during menopause.

Sun exposure is also a strong risk factor for melasma. It is particularly common in tropical climates.
Melasma is thought to be the stimulation of melanocytes or pigment-producing cells by the female sex hormones estrogen and progesterone to produce more melanin pigments when the skin is exposed to sun. Women with a light brown skin type who are living in regions with intense sun exposure are particularly susceptible to developing this condition.

Genetic predisposition is also a major factor in determining whether someone will develop melasma.

The incidence of melasma also increases in patients with thyroid disease. It is thought that the overproduction of melanocyte-stimulating hormone (MSH) brought on by stress can cause outbreaks of this condition. Other rare causes of melasma include allergic reaction to medications and cosmetics.

Melasma Suprarenale (Latin – of the adrenals) is a symptom of Addison’s disease, particularly when caused by pressure or minor injury to the skin, as discovered by Dr. FJJ Schmidt of Rotterdam in 1859.

Diagnosis:-
Your health care provider can usually diagnose melasma based upon the appearance of your skin. A closer examination using a Wood’s lamp may help guide your treatment.Melasma is usually diagnosed visually or with assistance of a Wood’s lamp (340 – 400 nm wavelength). Under Wood’s lamp, excess melanin in the epidermis can be distinguished from that of the dermis.

Treatment:-
The discoloration usually disappears spontaneously over a period of several months after giving birth or stopping the oral contraceptives or hormone replacement therapy.

Treatments to hasten the fading of the discolored patches include:

*Topical depigmenting agents, such as hydroquinone (HQ) either in over-the-counter (2%) or prescription (4%) strength. HQ is a chemical that inhibits tyrosinase, an enzyme involved in the production of melanin.

*Tretinoin, an acid that increases skin cell (keratinocyte) turnover. This treatment cannot be used during pregnancy.
Azelaic acid (20%), thought to decrease the activity of melanocytes.

*Facial peel with alpha hydroxyacids or chemical peels with glycolic acid.

*Laser treatment. A Wood’s lamp test should be used to determine whether the melasma is epidermal or dermal. If the melasma is dermal, laser (or “IPL”) will acually DARKEN and worsen the appearance of the spots. Dermal melasma is generally unresponsive to most treaments, and has only been found to lighten with products containing mandelic acid.

In all of these treatments the effects are gradual and a strict avoidance of sunlight is required. The use of broad-spectrum sunscreens with physical blockers, such as titanium dioxide and zinc dioxide is preferred over that with only chemical blockers. This is because UV-A, UV-B and visible lights are all capable of stimulating pigment production.

Cosmetic cover-ups can also be used to reduce the appearance of melasma.

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Prognosis:
Melasma often fades over several months after stopping oral contraceptives or hormone replacement therapy or after delivering a child. It may return with additional pregnancies or use of these medications.

Prevention :
Daily sunscreen use not only helps prevent melasma but is crucial in the prevention of skin cancer and wrinkles.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Melasma
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000836.htm

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Ailmemts & Remedies

Skin Cancer

basal cell carcinoma removal scar
Image by safoocat via Flickr

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Definition:
Skin cancer is the uncontrolled growth of abnormal skin cells. If left unchecked, these cancer cells can spread from the skin into other tissues and organs.It is a malignant growth on the skin which can have many causes. Skin cancer generally develops in the epidermis (the outermost layer of skin), so a tumor is usually clearly visible. This makes most skin cancers detectable in the early stages. There are three common types of skin cancer, each of which is named after the type of skin cell from which it arises. Cancers caused by UV exposure may be prevented by avoiding exposure to sunlight or other UV sources, and wearing sun-protective clothes. The use of sunscreen is recommended by medical organizations as a measure that helps to protect against skin cancer (see sunscreen).

Unlike many other cancers, including those originating in the lung, pancreas, and stomach, only a small minority of those afflicted will actually die of the disease.[citation needed] Skin cancers are the fastest growing type of cancer in the United States. Skin cancer represents the most commonly diagnosed malignancy, surpassing lung, breast, colorectal and prostate cancer. Melanoma is the least common skin cancer but it is potentially the most serious: there are over 8,000 new cases each year in the UK and 1,800 deaths. More people now die of Melanoma in the UK than in Australia. It is the second most common cancer in the young population (20 – 39 age group). It is estimated that approximately 85% of cases are caused by too much sun. Non-melanoma skin cancers are the commonest skin cancers. The majority of these are called Basal Cell Carcinomas. These are usually localised growths caused by excessive cumulative exposure to the sun and do not tend to spread.

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Types:-
There are different types of skin cancer. Basal cell carcinoma is the most common. Melanoma is less common, but more dangerous.

More rare types of skin cancer include:
*Dermatofibrosarcoma protuberans
*Merkel cell carcinoma
*Kaposi’s sarcoma

The BCC and the SCC often carry a UV-signature mutation indicating that these cancers are caused by UV-B radiation via the direct DNA damage. However the malignant melanoma is predominantly caused by UV-A radiation via the indirect DNA damage.[citation needed] The indirect DNA damage is caused by free radicals and reactive oxygen species. It has been shown, that the absorption of three sunscreen ingredients into the skin, combined with a 60-minute exposure to UV, leads to an increase of free radicals in the skin.

Skin cancer as a group:-
Many laymen and even professionals consider the basal cell carcinoma (BCC), the squamous cell carcinoma (SCC) and the malignant melanoma as one group – namely skin cancer. This grouping is problematic for two reasons:

*the mechanism that generates the first two forms is different from the mechanism that generates the melanoma. The direct DNA damage is responsible for BCC and SCC while the indirect DNA damage causes melanoma.

*the mortality rate of BCC and SCC is around 0.3 causing 2000 deaths per year in the US. In comparison the mortality rate of melanoma is 15-20% and it causes 138001 deaths per year.

Even though it is rare, malignant melanoma is responsible for 75 % of all skin cancer related death cases.

While sunscreen has been shown to protect against BCC and SCC it may not protect against malignant melanoma. When sunscreen penetrates into the skin it generates reactive chemicals. It has been found that sunscreen use is correlated with malignant melanoma. The lab-experiments and the epidemiological studies indicate that sunscreen use causes melanoma.

Causes:
The outer layer of skin, the epidermis, is made up of different types of cells. Skin cancers are classified by the types of epidermal cells involved:

Basal cell carcinoma develops from abnormal growth of the cells in the lowest layer of the epidermis and is the most common type of skin cancer.
Squamous cell carcinoma involves changes in the squamous cells, found in the middle layer of the epidermis.
Melanoma occurs in the melanocytes (cells that produce pigment) and is less common than squamous or basal cell carcinoma, but more dangerous. It is the leading cause of death from skin disease.
Skin cancers are sometimes classified as either melanoma or nonmelanoma. Basal cell carcinoma and squamous cell carcinoma are the most common nonmelanoma skin cancers. Other nonmelanoma skin cancers are Kaposi’s sarcoma, Merkel cell carcinoma, and cutaneous lymphoma.

Skin cancer is the most common form of cancer in the Unites States. Known risk factors for skin cancer include the following:

*Complexion: Skin cancers are more common in people with light-colored skin, hair, and eyes.
*Genetics: Having a family history of melanoma increases the risk of developing this cancer.
*Age: Nonmelanoma skin cancers are more common after age 40.
*Sun exposure and sunburn: Most skin cancers occur on areas of the skin that are regularly exposed to sunlight or other

*ultraviolet radiation. This is considered the primary cause of all skin cancers.

Skin cancer can develop in anyone, not only people with these risk factors. Young, healthy people — even those with with dark skin, hair, and eyes — can develop skin cancer.

Symptoms:
Skin cancers may have many different appearances. They can be small, shiny, waxy, scaly and rough, firm and red, crusty or bleeding, or have other features. Therefore, anything suspicious should be looked at by a physician. See the articles on specific skin cancers for more information.

Here are some features to look for:

*Asymmetry: one half of the abnormal skin area is different than the other half
*Borders: irregular borders
*Color: varies from one area to another with shades of tan, brown, or black (sometimes white, red, blue)
*Diameter: usually (but not always) larger than 6 mm in size (diameter of a pencil eraser)

Any skin growth that bleeds or will not heal
Use a mirror or have someone help you look on your back, shoulders, and other hard-to-see areas.

Risk factors:-
Skin cancer is most closely associated with chronic inflammation of the skin. This includes:

1.Overexposure to UV-radiation can cause skin cancer either via the direct DNA damage or via the indirect DNA damage mechanism. UVA & UVB have both been implicated in causing DNA damage resulting in cancer. Sun exposure between 10AM and 4PM is most intense and therefore most harmful. Natural (sun) & artificial UV exposure (tanning salons) are associated with skin cancer.[citation needed] Since sunbeds cause mostly indirect DNA damage (free radicals) their use is associated with the deadliest form of skin cancer, malignant melanoma.

2.UVA rays affect the skin at a deeper level than UVB rays, reaching through the epidermis and the dermis to the hypodermis where connective tissues and blood vessels are located. UVA activates the melanin of the epidermis causing changes in pigmentation as well as loss of elasticity of the skin, which contributes to premature wrinkling, sagging and aging of the skin.

3.UVB rays primarily affect the epidermis causing sunburns, redness, and blistering of the skin. The melanin of the epidermis is activated with UVB just as with UVA; however, the effects are longer lasting with pigmentation continuing over 24 hours.
Chronic non-healing wounds, especially burns. These are called Marjolin’s ulcers based on their appearance, and can develop into squamous cell carcinoma.

4.Genetic predisposition, including “Congenital Melanocytic Nevi Syndrome”. CMNS is characterized by the presence of “nevi” or moles of varying size that either appear at or within 6 months of birth. Nevi larger than 20 mm (3/4″) in size are at higher risk for becoming cancerous.

5.Skin cancer is one of the potential dangers of ultraviolet germicidal irradiation.
Skin can be protected by avoiding sunlight entirely, or wearing protective clothing while outdoors. Skin cancer is usually caused by exposing skin to UV rays excessively.

Treatment:-
Most skin cancers can be treated by removal of the lesion, making sure that the edges (margins) are free of the tumor cells. These excisions provide the best cure for both early and high-risk disease.

For low-risk disease, radiation therapy and cryotherapy (freezing the cancer off) can provide adequate control of the disease; both, however, have lower overall cure rates than surgery.

Mohs’ micrographic surgery is a technique used to remove the cancer with the least amount of surrounding tissue and the edges are checked immediately to see if tumor is found. This provides the opportunity to remove the least amount of tissue and provide the best cosmetically favorable results. This is especially important for areas where excess skin is limited, such as the face. Cure rates are equivalent to wide excision. Special training is required to perform this technique.

In the case of disease that has spread (metastasized), further surgical procedures or chemotherapy may be required.

Scientists have recently been conducting experiments on what they have termed “immune- priming”. This therapy is still in its infancy but has been shown to effectively attack foreign threats like viruses and also latch onto and attack skin cancers. More recently researchers have focused their efforts on strengthening the body’s own naturally produced “helper T cells” that identify and lock onto cancer cells and help guide the killer cells to the cancer. Researchers infused patients with roughly 5 billion of the helper T cells without any harsh drugs or chemotherapy. This type of treatment if shown to be effective has no side effects and could change the way cancer patients are treated.

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Prognosis:-
The outlook depends on a number of factors, including the type of cancer and how quickly it was diagnosed. Basal cell carcinoma and squamous cell carcinoma rarely spread to other parts of the body. However, melanoma is more likely to spread. See the specific skin cancer articles for additional information.

Prevention :-
Minimizing sun exposure is the best way to prevent skin damage, including many types of skin cancer:

*Protect your skin from the sun when you can — wear protective clothing such as hats, long-sleeved shirts, long skirts, or pants.
*Try to avoid exposure during midday, when the sun is most intense.
*Use sunscreen with an SPF of at least 15. Apply sunscreen at least one-half hour before sun exposure, and reapply frequently.
*Apply sunscreen during winter months as well.
*Reapply sun block every 2 hours and after swimming

Although it is generally accepted that UV exposure is the greatest risk factor in melanoma development, some sceptics say that there is no proven data that links moderate sun exposure with the appearance of melanoma.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.nlm.nih.gov/medlineplus/ency/article/001442.htm
http://en.wikipedia.org/wiki/Skin_cancer

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