CONDITIONS

Malignant Melanoma

What Is Malignant Melanoma

Melanoma (or malignant melanoma) is a skin cancer that originates from the pigment-producing cells of the skin, known as melanocytes. Although often arising from moles, or nevi, they usually appear black or brown. However, melanomas may also appear skin color, pink, red, blue and white. Rarely, melanoma may begin in the eyes and even the internal organs, such as the intestine. Melanoma accounts for only 2% of all skin cancers, but is responsible for the vast majority of skin cancer deaths.  As the most dangerous type of skin cancer, melanoma affects more than 120,000 people per year and kills 9,710 people annually in the United States—however, if melanoma is found and treated early, it is almost always curable.  If the disease is not caught early, it can spread to other parts of the body, becoming harder to treat, and can be fatal.

This is a disease that affects people of all ages—in fact, people under 45 account for 25% of all melanoma cases. As the leading cause of cancer deaths in women 25 to 30, this is a disease that can be prevented from being fatal through vigilance and observation.

Melanoma is classified by the following sub-types:

  • Cutaneous melanoma – melanoma originating from the skin
  • Mucosal melanoma – melanoma originating from the mucosal areas of the throat, nasal passages, anus, or vagina
  • Ocular melanoma – also known as uveal melanoma, or disease in the eye
  • Metastatic melanoma – melanoma that has spread to lymph nodes or other more distant organs from its site of origin

After melanoma is diagnosed, tests will be done to find out if cancer cells have spread—or metastasized—within the skin or to other parts of the body; and allow your doctor to stage the cancer, which is critical in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • Physical exam and history
  • Lymph node mapping and sentinel lymph node biopsy
  • CT or CAT scans
  • PET scans
  • MRI scans with gadolinium
  • Blood chemistry tests

The results of these tests are viewed together with the results of the tumor biopsy to find out the stage of the melanoma.

Cancer spreads in three ways within the body: through tissue, the lymph system and blood. When cancer spreads, or metastasizes, the metastatic tumor is the same type of cancer as the primary tumor. For instance, if melanoma spreads to the stomach, the cancer cells in the stomach are actually melanoma cells. The disease is metastatic melanoma, not stomach cancer.


The staging of melanoma depends on the following:

  • Thickness of the tumor
  • Whether the tumor is ulcerated (has broken through the skin)
  • Whether the tumor has spread to the lymph nodes
  • Whether the tumor has spread or metastasized to other parts of the body

The following stages are used for melanoma:

Stage 0 (Melanoma in Situ):  In stage 0, abnormal melanocytes, which may become cancerous, are found on the outer layers of the skin or epidermis.

Stage 1:  In stage 1, cancer has formed. This stage is divided into stages 1A and 1B.

  • Stage IA: In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration.
  • Stage IB: In stage IB, the tumor is either:
    • Not more than 1 millimeter thick, with ulceration; or
    • More than 1, but not more than 2 millimeters thick, with no ulceration.

Stage II: Stage II is divided into stages IIA, IIB, and IIC.

  • Stage IIA: In stage IIA, the tumor is either:
    • More than 1, but not more than 2 millimeters thick, with ulceration; or
    • More than 2, but not more than 4 millimeters thick, with no ulceration.
  • Stage IIB: In stage IIB, the tumor is either:
    • More than 2, but not more than 4 millimeters thick, with ulceration; or
    • More than 4 millimeters thick, with no ulceration.
  • Stage IIC: In stage IIC, the tumor is more than 4 millimeters thick, with ulceration.

Stage III:  In stage III, the tumor may be any thickness, with or without ulceration. One or more of the following is true:

  • Cancer has spread to one or more lymph nodes
  • Lymph nodes are joined or matted
  • Cancer is found in a lymph vessel between primary tumor and nearby lymph nodes, more than 2 cm away from the primary tumor
  • Very small tumors are found on or under the skin, not more than 2 cm away from the primary tumor

Stage IV: In stage IV, cancer has metastasized to other places in the body, far from where it first started, like the brain, lungs, bones, and more.

What Causes Malignant Melanoma

Melanomas are caused by an overgrowth of melanocytes, which are pigment producing cells located in the basal layer of the skin. This unrelenting growth of cells is usually caused by damage to the genetic portion of the cells, known as DNA. When damage to the DNA occurs, generally caused by exposure to ultraviolet (UV) radiation from the sun or tanning beds, the cells no longer have limiting mechanisms on division.  As a result, these cells rapidly divide and begin to form tumors that invade surrounding normal tissue. Hereditary is also thought to play a role in the development of melanoma.

Risk Factors For Malignant Melanoma

The American Academy of Dermatology states the following risk factors for developing melanoma:

  • Skin Type. This is the primary risk factor for melanoma. Those with fair skin are at much greater risk than those with darker skin. And people with red or blond hair or green or blue eyes have a further increased risk. This is because people with darker skin produce more melanin, which is the pigment that gives color to skin and hair, and protects the skin from damaging UV radiation.  While melanoma affects people of all races, Caucasians are 20 times more likely to develop melanoma than African Americans.
  • Sun-sensitive skin. Skin that rarely tans or burns easily, or that freckles easily, is more susceptible to all types of skin cancers, including melanoma.
  • Moles. Having more than 50 moles present on the skin, large moles, or unusual looking moles
  • Family history of melanoma. Risk of developing melanoma increases considerably if there is family history of melanoma among one or more of your first-degree family members, like a parent, sibling or child. 10% of those that develop melanoma have a family history of melanoma
  • A personal history of a previous skin cancer
  • UV Exposure. Excessive exposure to UV radiation—such as the sun or that from tanning beds—is the biggest risk factor for melanoma. Research has shown that repetitive and severe sunburns (particularly in childhood) put one at increased risk. Being exposed to intense sunlight intermittently is more strongly correlated with the development of melanoma than daily sun exposure.
  • Weakened immune system, secondary to infection, medications, or genetic diseases

Diagnosing Malignant Melanoma

Your doctor will likely ask you questions about the suspicious lesion, such as how long the mark has been there, if it has changed in appearance, and if it has caused any symptoms, such as pain, itching, or bleeding.

The doctor will then assess the appearance of the lesion. If the physician is a dermatologist, he or she may use a dermatoscope, which has magnification and allows a more careful inspection of the skin.

If the medical history and appearance leads the physician to suspect melanoma, he or she may elect to perform a skin biopsy to obtain a sample of the suspicious lesion to have it examined by a pathologist and to allow for a more certain diagnosis (4). Skin biopsies may be performed as a superficial shave biopsy, a slightly deeper punch biopsy, or as an incisional/excisional biopsy, during which part, or all, of the lesion is removed after local anesthesia. Once these tissue biopsies are obtained, they are sent to a pathologist for analysis, who can ascertain whether the lesion is normal tissue, benign tumor, or malignant melanoma.

If the melanoma is suspected to have spread, a chest X-ray may be utilized to view the lungs for disease, while computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) imaging may prove useful to diagnose melanoma involving other areas of the body.

Symptoms of Malignant Melanoma

The first signs or symptoms of melanoma are usually:

  • A change in an existing mole
  • The development of a new pigmented or unusual looking growth on your skin
  • Pain
  • Itching
  • Skin bleeding

Other warning signs are:

  • A sore that does not heal
  • Spread of pigment from the border of a spot into surrounding skin
  • Redness or a new swelling beyond the border of a mole
  • Change in sensation, like itchiness, tenderness, or pain
  • Change in the surface of a mole, like scaliness, oozing, bleeding; or the appearance of a bump or nodule

Prognosis

The prognosis of melanoma depends on how advanced or spread the cancer is within the body, which is termed the stage. If melanoma is diagnosed very early when it is small and localized to one area of the body (termed stage IA), the 5-year survival rate is 97%, while the 10-year survival rate is 95%. However, if the melanoma has spread throughout the body and is affecting many different organs, it is termed stage IV and has a 5-year survival rate of 15-20% and a 10-year survival rate of 10-15%. Early detection is key for effective treatment and long-term survival.

Living With Malignant Melanoma

If diagnosed with a malignant or advanced melanoma, you or your loved one will likely face physical and emotional challenges and encounter a wide range of feelings, including fear, shock, and isolation. As this can be extremely stressful, it is important to incorporate as many stress management techniques are possible. These include:

  • Exercising
  • Yoga
  • Listening to music
  • Joining support groups or participating in forum discussions
  • Massage
  • Meditation
  • Seeking the comfort of family and friends

Screening

Even if you have been careful with your sun exposure during the summer months, it’s still key to remain vigilant in fall, winter and spring. All year, you (or a loved one) should perform self-skin exams once a month, checking your body head to toe for any suspicious moles or lesions.  As early detection of melanoma is vital for early diagnosis, effective treatment, and improved outcomes, it is imperative you are screened for melanoma. If found and treated early, chances for long-term survival are excellent—five-year survival rates for those with Stage 1 melanoma are greater than 90% to 95%. The Melanoma Research Foundation recommends that you perform a self-skin examination each month. During this examination, you (or a loved one) should note any moles or discolorations that look new or different. It is important to not miss areas such as the back of your legs, scalp, and fingernail beds. Suspicious lesions are more likely to be asymmetric, have a scalloped border, irregular color, and an increased diameter, or size.

A useful mnemonic for assessing moles is ABCDE, which stands for:

  • Asymmetry—moles that are asymmetrical are at greater risk for being cancerous
  • Border—benign moles tend to have smooth, even borders, whereas the borders of an early melanoma tend to be uneven or scalloped.
  • Color—most moles are all one color. A mole that shows a variety of colors, like different shades of tan, brown, or black is a warning sign of melanoma. Sometimes a melanoma is red, white, or even blue.
  • Diameter—benign moles are usually smaller in diameter than malignant moles. Usually, melanomas are larger than the diameter of an eraser on a standard pencil—about ¼”, though they may be smaller when first detected.
  • Evolving—Regular moles look the same over time, but a mole that starts to evolve or change can be a warning sign of skin cancer. Any change—from size, to color, shape, thickness, or more, can be a warning sign. Also pay attention to any lesions that bleed, itch or crust.

Another concept that is used to assess moles is the “Ugly Duckling Concept.” Basically, moles on the same person tend to resemble one another, but a mole that may be melanoma often deviates from the look of the other moles—hence the “ugly duckling.”  The outlier mole may be larger or darker than surrounding moles, or even smaller if among larger moles.

Some skin cancers and melanomas do not fit the criteria described above, be sure to tell your doctor about any changes or growths that look different to you.

In addition to a monthly self-skin examination, you should also have a yearly skin examination performed by a health care professional. During this visit, the health care provider will check your entire body for suspicious looking lesions. In addition, some centers may take photographs of suspicious skin marks to follow their appearance over time.

Prevention

In addition to screening, prevention of melanoma is extremely important. According to the Skin Cancer Foundation, you should do the following to prevent melanoma:

  • Seek the shade, especially between 10am and 4pm
  • Do not burn
  • Avoid using tanning beds
  • Cover up with clothing, hats, and sunglasses to protect yourself from UV radiation
  • Use broad-spectrum UVA/UVB sunscreen of at least 15 or 30 SPF – and reapply often. Use 1 ounce (think a shot glass full) of sunscreen each time you apply. For extended outdoor time or if doing sports outside, use a water-resistant sunscreen
  • Keep newborns out of the sun—and for babies 6 months or over, use a special infant formula broad-spectrum sunscreen to protect their delicate skin
  • Do your skin screenings (self exams every month and health care provider exams every year)

Common Treatment

The first step in treatment of the melanoma is removal, also known as resection or excision.  In most cases, small melanomas are surgically removed in the doctor’s office, or outpatient facility. After local anesthesia, a small incision is made, the lesion is removed, and then the incision is closed with a few sutures. Confirmation that the entire lesion has been removed is done via by microscopic examination, which will determine if any edges, or margins, of the melanoma remain behind.

If the melanoma is larger, it may be necessary to use skin near the resection to graft onto the area where the melanoma was removed to close. This grafting skin may be used nearby the surgical field or, if necessary, may be sourced from other areas of the body, such as the leg. Grafting on larger resections will improve the cosmetic appearance of the melanoma site after surgery. In addition to the resection, a larger melanoma may spread beyond the initial site of growth. Often times, the melanoma will spread to the nearby lymph nodes. Determination of this spread with a lymph node biopsy (where a small sample of tissue is obtained) or a lymph node dissection (or surgical exploration) is important to determine the cancer staging, treatment, and prognosis. If this is the case, it may be necessary to perform these types of resections in a surgical center or hospital, which is capable of general anesthesia, not just local anesthesia.

In recent years, Mohs Micrographic Surgery has begun to be utilized for melanoma resection. During this process, one thin layer of tissue is removed at a time and then its margins are examined for the presence of cancer cells (melanoma). Once a layer is found to be free of melanoma, the surgery is completed with minimal amount of normal tissue having to be removed.

In addition to surgical treatment, extensive malignant melanomas (metastatic disease) may respond to medications, such as alpha-interferon and ipilimumab. However, these medications have significant side effects and have not yet been found to offer significant improvements in long-term outcomes for patients.

Complementary and Alternative Treatment

As the definitive treatment for melanoma remains surgery, alternative and complementary treatments for this condition should only be considered in conjunction with surgical or medical intervention.

Complementary therapies can help relieve symptoms and side effects of cancer treatments, and can include:

  • Acupuncture—to relieve pain and promote well-being
  • Massage—to reduce pain, anxiety, and stress, and ease muscle tension
  • Meditation—to relieve stress and help center a worried mind
  • Yoga—to do keep the body flexible and help reduce stress and muscle tension

These complementary therapies can also reduce chronic lower back pain, joint pain, headaches, and pain from treatments.

Care Guide

In addition to medical and surgical treatment it’s important to take care of yourself. This may include:

  • Learning about your condition and your treatment
  • Talking openly with your family and friends
  • Joining a support group to talk with other skin cancer survivors
  • Asking your doctor about medications that help with side effects such nausea and fatigue

You can also take better care of yourself with: 

  • Healthy eating habits
  • Gentle exercise, such as walking, swimming, or yoga
  • Stress management

When To Contact A Doctor

If you are experiencing any of the signs or symptoms of melanoma, or it is simply time for your yearly skin exam, you should contact a doctor. A primary care physician is a great resource to inquire about any type of skin concern, including melanomas. Along with a dermatologist, your primary care physician will be very knowledgeable regarding all types of skin cancer.

Questions For Your Doctor

Your medical team may consist of several healthcare professionals, including your primary care physician, a dermatologist, and even a hematology/oncology specialist.

The National Cancer Institute offers a Web site where you can find a cancer center near you.

Questions For A Doctor

When you go to see your doctor, it’s good to have a list of the questions you’d like to have answered. Take a moment to write down some of the things you want to know. Your questions for your doctor might include some of these:

  • How far advanced is my cancer?
  • What are my options for treatment?
  • What treatment would you recommend, and why?
  • What are the possible side effects?
  • Does my insurance cover these treatments?
  • What changes will I need to make in my day-to-day life?
  • Is there anything else I should know about my cancer?

Resources

Other useful resources to help you learn about malignant melanoma can be found at:

Skin Cancer Foundation

The Melanoma Research Foundation (MPR)

American Cancer Society

The National Cancer Institute