Malignant Melanoma Information

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

Risk Factors For Malignant Melanoma

Diagnosing Malignant Melanoma

Symptoms of Malignant Melanoma

Prognosis

Living With Malignant Melanoma

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

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.