We are on the threshold of expanded use of onycolytic viruses for a number of 

malignancies including malignant melanoma. An oncolytic virus is a virus that preferentially

infects and kills tumor cells.

                        The drug Talimogene laherparepvec (TVEC) is a type one herpes simplex virus

(HSB) genetically modified to preferentially replicate in the tumor cells of malignant melanoma.

                        As the infected cancer cells are destroyed by the virus,,the virus releases new

infectious virus particles called virions to help destroy the remaining tumor.

                       Oncolytic viruses are thought not only to cause direct destruction of the tumor

cells,but also to stimulate host antitumor immune responses.

                      In addition,researchers are now using a modified poliovirus to unleash the

body's ability to fight cancer.

                     Also,these cancer killing viruses may be utilized for a number of malignancies 

including a type of brain cancer called glioblastoma,a blood cancer called multiple myeloma,

a cancer of the lining of the lung cavity called mesothelioma,and carcinomas of the breast,

lung,prostate,kidney,liver,pancreas,bladder,ovary and head and neck.

                  Only time and additional research will tell if these oncolytic viruses will

increase cancer patient survival  time or cure rates.

            Merkel cell carcinoma (MCC) is a very aggressive skin cancer(please see my two previous blogs:

"Merkel Cell Carcinoma,"and Merkel cell carcinoma-a blood test to predict spread" posted on 04/13/2014.

           The incidence of MCC has increased markedly by 95 % during the past decade as compared to

malignant melanoma (57 %) and all solid tumors (15 %).

          Current estimates are for about 2500 new cases in the USA yearly and increase to 3250 cases

annually by 2025. Much of this increase is attributed to an older population,especially the aging of the

Baby Boomers.

          MCC is not only very prone to spread internally(ie,metastasize) but can be very difficult to diagnose

even by astute clinicians since it can appear simply as a firm red,purple or even skin-colored lump or

bump which could easily be mistaken for a cyst or blocked pore or hair follicle.

          Merkel cell carcinoma is caused in part by exposure to the sun and is found on the head or

neck in about 50 % of cases and on the extremities in about 40 % of patients.

         And, merkel cell carcinoma is aggressive and has a strong tendency to recur,to spread

to regional lymph nodes  and to metastasize.

           So,early detection is vital since when caught early the chance of cure increases dramatically

and is better than 90 %.

           An exciting new development in the treatment of metastatic MCC is the first FDA approved

treatment for adults and pediatric patients 12 years of age and older,including those who have not

yet received chemotherapy. 

           The medication called Avelumab is another advance in cancer treatments called biologics

or. monoclonal antibodies which help the body's immune system to fight the cancer.

                There has been increasing interest recently in the scientific literature about a sunscreen called

Polypodium leucotomos (PLE) derived from a South American fern known as calaguala which is

available over the counter(OTC) in capsule form of 240 mgs.

                 One capsule is designed to be ingested each AM at least 30 minutes before sun exposure

and a second capsule ingested a few hours later. Research results indicate that PLE inhibits both

sun-induced skin cancer and photoaging.

                Side effects have been reported as minor and may include mild episodic fatigue,bloating

and headaches.However,the package insert from PLE states that "there are no known side effects."

               However,to prevent both sun-induced skin cancer and photoaging,whether ingesting PLE

orally or applying a sunscreen topically(on the outside of your skin),one must still practice good

"sunsense." 

                This includes avoiding the midday sun,wearing a hat (floppy,hopefully, rather than a cap),

 the proper clothing and sunglasses,seeking shade,and not sitting in the sun for many hours on end.

                As for me, I shall still use the topical sunscreen rather than taking a "pill" internally and

especially continue to practice good "sunsense."

            Each year in the U.S. over 5.4 million cases of nonmelanoma skin cancer(NMSC) are treated in more than

3.3 million people.

           Each year there are more cases of skin cancer than the combined incidence of cancers of the breast,prostate,                                             

lung and colon and that over the past  3 decades more people have had skin cancer than all other cancers combined.

           According to the statistics basal cell carcinoma (BCC) is the most common form, of skin cance ( with more

than 4 million cases diagnosed in the U.S. annually,while squamous cell carcinoma( SCC) is the second most common

form-with more than 1 million cases diagnosed every year.

          However, I should like to point out that in my many years of practice,SCC has been far and away the most

common type of skin cancer diagnosed. And,in my opinion, SCC is harder to diagnose than BCC since it often

appears simply like dry skin areas and is easy to miss-unlike BCC which,in spite of the fact that there are several

different types,is easier to diagnose in my opinion.

         While actinic keratosis is the most common pre-cancerous skin lesion,about 90 % of NMSC are associated

with UV radiation from the sun. Other causes of skin cancer include  medical radiation ,chemotherapy (especially in already

immunosuppressed individuals suffering from internal cancer),non-healing ulcers,sores,vaccination marks and tatoos.

In addition,people drinking well water contaminated with arsenic from fertilizers used in sod farms,etc. are prone to

squamous cell carcinomas and if present in non-sun exposed areas of the skin can be more likely to spread

internally.

          Also, people who have had organ transplants have an incidence of squamous cell carcinoma about

100 X more than the general public-possibly due to the anti-rejection drugs (which depress the immune system)

they must take to prevent their body from attacking the  the organ transplant.

            One person dies of melanoma skin cancer every 54 minutes and that an estimated 87,000 + new cases of melanoma

will be diagnosed in the U.S.in 2017.And, that an estimated  9700 + will die of melanoma in 2017-the vast majority of which

are caused by the sun and that the risk of melanoma doubles if he or she has had more than 5 sunburns.

            And if you want to hear something really scarey,listen up: people who first use a tanning bed before age 35

increase their risk for melanoma by 75 %.

           In 2016 I diagnosed several people with malignant melanoma  over a six month period. My experience in

both internal medicine and dermatology over many years has been how certain diagnoses occur in clusters.

I could never figure out how as a young doctor working many a night in emergency rooms that one evening

everyone seemed to have chest pain,the next night breathing difficulty due to pulmonary problems,the next

night everyone needed sutures,the next night was pediatric night and on and on-almost as if there was a sign over the

emergency room entrance. 

           Even though I may not see a patient with malignant melanoma in many months,I know that if one

comes in,there will be at least 2 more in the near future since from my personal experience things seem to

always occur at least in 3's.

           It is also interesting to note that women aged 49 and under have a higher probability of developing

melanoma tha any other cancer except breast and thyroid cancer.

          And,it is very important to note that in darker skinned people such as blacks,Asians,Filipinos,Indonesians

and native Hawaiians ,melanomas are more likely to occur on non-sun exposed areas such as the ano-genital

area,palms of the hands,soles of the feet,mucous membranes and fingernail and toenail areas. Therefore,it is

encumbent on the clinician to examine these areas.

          And,SCC,the most common skin cancer in black and Asian peoples,tends to be more aggressive

(perhaps,because of delayed diagnosis in non-sun exposed areas) in black people with a 20 to 40 % chance

of metastasis(spreading internally).

         And,although malignant melanoma accounts for only up to 3 percent of all pediatric cancers,its treatment

is often delayed due to misdiagnosis of pigmented lesions,which occurs up to 40 percent of the time.Parents

should ask their child's pediatrician for a sunscreen SPF recommendation.

         In conclusion, regular use of a sunscreen with an SPF of at least 30 applied at least 30 minutes before

exposure and reapplied after bathing and at least every 2 hours while avoiding excessive sun exposure

during the heat of the day 10 AM-4 PM can markedly cut the risk of skin cancer and show 24 percent less

skin aging than those who do not use sunscreens daily.

        Also,one should get regular skin exams and check their own skin on a regular basis and report any 

changes to their clinician.

       Did you know that non-melanoma skin cancer is the most common malignancy in the United States ?

       Breast cancer followed by lung cancer rank # 2 and # 3 respectively.

       And primary lung cancer,or bronchogenic carcinoma,is the leading cause of cancer deaths in both

men and women. 

       About 85 % of lung cancers of all types are linked to smoking.

      The majority of the other 15 % of lung cancers not related to smoking are found in women for 

reasons not clearly known,although exposure of the chest cavity to radiation as well as exposure

to environmental toxins such as asbestos and radon are also linked to an increase risk of developing

lung cancer.

       Now,getting back to skin cancer,I find it extremely interesting that a type of skin cancer called the

Merkel cell carcinoma and, which is extremely aggressive, is of neuroendocrine origin(please see my previous

post on merkel cell carcinoma) as is a type of lung cancer,previously known as oat-cell)and now called

small cell cancer which has an eighty percent rate of metastasis at the time of diagnosis.And,is obviously

also extremely aggressive.

      In my opinion,a diagnosis of merkel cell skin cancer is one of the most serious diagnoses in

dermatology- in many cases more so than malignant melanoma,depending on the latter's depth and

staging at the time of diagnosis.

     The FDA has recently approved the drug Bavenicio( known chemically as avelumab) to treat metastatic

merkel cell carcinoma(which means it has spread to other parts of the body). And,about 1600 people in

the USA are diagnosed with merkel cell carcinoma annually.