Disease: Melanoma 101: Introduction to a Deadly Skin Cancer

    Melanoma facts

    • Melanoma is a cancer that develops in pigment cells called melanocytes.
    • Patients themselves are the first to detect many melanomas.
    • Caught early, most melanomas can be cured with relatively minor surgery.
    • Melanoma can be more serious than the other forms of skin cancer because it may spread (metastasize) to other parts of the body and cause serious illness and death.
    • Spots suspicious for melanoma usually show one or more of the following symptoms and signs (the ABCDs):
      • Asymmetry,
      • Border irregularity,
      • Color changes or too many colors in one mole,
      • Diameter more than 6mm (the size of a pencil eraser).
      • Some now add a fifth letter: E for Evolving.
    • Elevated risk factors for melanoma include Caucasian (white) ancestry, fair skin, light hair and light-colored eyes, a history of intense sun exposure, close blood relatives with melanoma, and moles that are unusually numerous, large, irregular, or "funny looking."
    • Doctors diagnose melanoma by performing a biopsy in which they remove a piece of skin for analysis. Whenever possible, it is best to remove the entire lesion in question.
    • The most common forms of melanoma are superficial spreading melanoma, nodular melanoma, and lentigo maligna.
    • Treatment of melanoma is primarily by surgical removal.
    • Changing or suspicious spots on the skin should be brought to medical attention right away.

    What is melanoma?

    Melanoma is a cancer that develops in melanocytes, the pigment cells present in the skin. It can be more serious than the other forms of skin cancer because it may spread to other parts of the body (metastasize) and cause serious illness and death. About 50,000 new cases of melanoma are diagnosed in the United States every year.

    Because most melanomas occur on the skin where they can be seen, patients themselves are often the first to detect many melanomas. Early detection and diagnosis are crucial. Caught early, most melanomas can be cured with relatively minor surgery.

    This article is written from the standpoint of the patient. In other words, instead of describing the disease in exhaustive detail, I will try to help answer the questions: "How do I know if I have melanoma?" and "Should I should be checked for it?"

    Spots on the skin

    Guideline # 1: Nobody can conclusively diagnose him- or herself. If someone sees a spot that looks as though it is new or changing, he or she should show it to a doctor. When it comes to spots on the skin, it is always better to be safe than sorry.

    Everybody gets spots on their skin. The older we are, the more spots of different types we have. Most of these spots are benign. That means they are neither cancerous nor on the way to becoming cancerous. These may include freckles, benign moles, collections of blood vessels called cherry angiomas, or raised, irregular bumps on the skin called seborrheic keratoses that appear to be stuck on to the skin.

    Moles

    Guideline # 2: The vast majority of moles stay as moles and do not turn into anything else. Most melanomas do not arise in preexisting moles. For that reason, having all of one's moles removed to "prevent melanoma" does not make clinical sense.

    Some people are born with moles (the medical name is "nevus," plural "nevi"). Almost everyone develops them, starting in childhood. On average, people have about 25 moles, though some have fewer and others many more. Moles may be flat or raised, and they may range in color from tan to light brown to black. Moles may lose their color and end up flesh colored. It is unusual to develop new pigmented moles after age 35.

    What does melanoma look like? What are melanoma symptoms and signs?

    Guideline # 3: A changing spot may be a problem, but not every change means cancer. A mole may appear and then get bigger or become raised but still be only a mole. It is normal for many moles to start flat and dark, become raised and dark, and then later lose much of their color. This process takes many years.

    Most public-health information about melanoma stresses the so-called ABCDEs:

    • Asymmetry: One half of the mole is different from the other half.
    • Border irregularity: The spot has borders which are not smooth and regular but uneven or notched.
    • Color: The spot has several colors in an irregular pattern or is a very different color than the rest of one's moles.
    • Diameter: The spot is larger than the size of a pencil eraser (6 mm).
    • Evolving: The mole is changing in size, shape, color, or overall texture. This may also include new bleeding.

    These guidelines are somewhat helpful, but the problem is that many normal moles are not completely symmetrical in their shape or color. This means that many spots, which seem to have one or more of the ABCDEs, are in fact just ordinary moles and not melanomas. Additionally, some melanomas do not fit this description but may still be spotted by a primary-care physician or dermatologist. Not all melanomas have color or are raised on the skin. Amelanotic melanomas have little or no color to the naked eye and may be confused with traumatized benign nevi or basal cell carcinoma. Desmoplastic melanoma may appear to be a thickened area of skin like a scar. These are treated the same way as more typical melanomas but, in the latter case, may be more difficult to determine the exact margins of the tumor.

    As a rule, melanoma is not painful unless traumatized. They sometimes itch, but this has no diagnostic or prognostic importance.

    What if the skin changes are rapid or dramatic?

    Guideline # 4: The more rapid and dramatic the change, the less serious the problem.

    When changes such as pain, swelling, or even bleeding come on rapidly, within a day or two, they are likely to be caused by minor trauma, often a kind one doesn't remember (like scratching the spot while sleeping). If a spot changes rapidly and then goes back to the way it was within a couple of weeks, or falls off altogether, it is not likely to represent anything serious. Nevertheless, this would be a good time to say once again: Nobody can diagnose him- or herself. If one sees a spot that looks as though it is new or changing, show it to a doctor. If one see a spot that doesn't look like one's other spots, it should be evaluated.

    What are the causes and risk factors for melanoma?

    Guideline # 5: Individual sunburns do raise one's risk of melanoma. However, slow daily sun exposure, even without burning, may also substantially raise someone's risk of skin cancer.

    Factors that raise one's risk for melanoma include the following:

    • Caucasian (white) ancestry
    • Fair skin, light hair, and light-colored eyes
    • A history of intense, intermittent sun exposure, especially in childhood
    • Many (more than 100) moles
    • Large, irregular, or "funny looking" moles
    • Close blood relatives -- parents, siblings, and children -- with melanoma

    The presence of close (first-degree) family with melanoma is a high risk factor, although looking at all cases of melanoma, only 10% of cases run in families.

    Having a history of other sun-induced skin cancers, such as the much more common basal cell or squamous cell carcinomas, indirectly raises one's risk because they are markers of long-term sun exposure. The basic cell type is different, however, and a basal cell or squamous cell carcinoma cannot "turn into melanoma" or vice versa.

    How can people estimate their level of risk for melanoma?

    The best way to know one's risk level is to have a dermatologist perform a full body examination. That way one will find out whether the spots one has are moles and, if so, whether they are funny looking in the medical sense.

    The medical term for such moles is atypical. This is a somewhat confusing term, because among other things the criteria for defining it are not clear, and it's not certain that an atypical mole is necessarily precancerous. Patients who have lots of "atypical moles" (more than 24) do have a higher risk for developing melanoma but not necessarily within one of their existing funny-looking moles. It may be a challenge to find the "baby melanoma" in the middle of a back full of large, dark, or irregular moles. If someone has such moles, a doctor will recommend regular surveillance and may recommend biopsy of the most unusual or worrisome looking moles.

    Sometimes, one learns at a routine skin evaluation that one does not necessarily need annual routine checkups. In other situations, a doctor may recommend regular checks at six-month or yearly intervals.

    What are the types of melanoma?

    The main types of melanoma are as follows:

    1. Superficial spreading melanoma: This type accounts for about 70% of all cases of melanoma. The most common locations are the legs of women and the backs of men, and they occur most commonly between the ages of 30-50. (Note: Melanomas can occur in other locations and at other ages, as well.) These melanomas are flat or barely raised and have a variety of colors. Such melanomas evolve over one to five years and can be readily caught at an early stage if they are detected and removed. An "in situ" melanoma refers to a very thin superficial spreading melanoma that does not extend beyond the junction of the dermis and epidermis, the normal location for melanocytes.
    2. Nodular melanoma: About 20% of melanomas begin as deeper, blue-black to purplish lumps. They may evolve faster and may also be more likely to spread. Untreated superficial spreading melanomas may become nodular and invasive.
    3. Lentigo maligna: Unlike other forms of melanoma, lentigo maligna tends to occur on places like the face, which are exposed to the sun constantly rather than intermittently. Lentigo maligna looks like a large, irregularly shaped or colored freckle and develops slowly. It may take many years to evolve into a more dangerous melanoma or may never become a more invasive form. Because of the unpredictability of future behavior, removal is recommended.

    There are also other rarer forms of melanoma that may occur, for example, under the nails (subungual), on the palms and soles (acral lentiginous), uveal or choroidal (ocular), oral or vulvar mucosa, or sometimes even inside the body.

    How is melanoma diagnosed?

    Most doctors diagnose melanoma by examining the spot causing concern and doing a biopsy. A skin biopsy refers to removing all or part of the skin spot under local anesthesia and sending the specimen to a pathologist for analysis.

    The biopsy report may show any of the following:

    • A totally benign condition requiring no further treatment, such as a regular mole
    • An atypical mole which, depending on the judgment of the doctor and the pathologist, may need a conservative removal (taking off a little bit of normal skin all around just to make sure that the spot is completely out).
    • A thin melanoma requiring surgery
    • A thicker melanoma requires more extensive surgery or extra tests in which the lymph nodes are examined. Removing lymph nodes causes physical problems even when there is no tumor present and, for that reason, is not recommended for thinner melanomas.

    Some doctors are skilled in a clinical technique called epiluminescence microscopy (also called dermatoscopy or dermoscopy). They may use a variety of instruments to evaluate the pigment and blood vessel pattern of a mole without having to remove it. Sometimes the findings support the diagnosis of possible melanoma, and at other times, the findings are reassuring that the spot is nothing to worry about. The gold standard for a conclusive diagnosis, however, remains a skin biopsy.

    What is the treatment for melanoma?

    In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove 1 centimeter (less than ½ inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery.

    Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph nodes may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like immunotherapy or chemotherapy are sometimes recommended. Many of these treatments are still experimental and, for that reason, their use may be limited to patients willing to participate in a research study.

    How do doctors determine the prognosis (outlook) of a melanoma?

    The most useful criterion for determining prognosis is tumor thickness. Tumor thickness is measured in fractions of millimeters and is called the Breslow's depth. A related prognostic measure is the Clark's level, which describes how many skin layers the melanoma penetrates. The lower the Clark's level and the smaller the Breslow's depth, the better the prognosis. Any spread to lymph nodes or other body locations dramatically worsens the prognosis.

    Thin melanomas, those measuring less than 1 millimeter, have excellent cure rates. The thicker the melanoma, the less optimistic the prognosis. Early diagnosis and treatment are essential.

    What methods are available to help prevent melanoma?

    1. Reducing sun exposure: Avoidance of sun exposure is the best means of helping to prevent melanoma, followed by wearing hats and tightly woven clothing, and then followed by broad-spectrum waterproof sunscreens applied liberally and often. The consensus among dermatologists is that sunscreens are at least partially helpful and are certainly preferable to unprotected sun exposure. (Despite sensational articles in the popular press, there is no credible evidence that sunscreens can cause melanoma. Data to indicate increased melanoma risk did not take into consideration that the sunscreens used by the subjects [at least as well as they could remember after decades] were far inferior to current products, which usually have much higher ultraviolet B SPF protection as well as ultraviolet A protection.)
    2. Early detection: Get one's skin checked at least once. Then, if it is recommended, have one's skin checked on a regular basis. The American Academy of Dermatology sponsors free skin cancer screening clinics every May all over the country. Special "Pigmented Lesion Clinics" have also been established in many medical centers to permit close clinical and photographic follow-up of patients at high risk.
    3. Screening of high-risk individuals: Anyone at high risk, such as anyone with a close relative who has melanoma, should be screened by a doctor for melanoma.

    Conclusions

    When it comes to spots on the skin, it is always better to be safe than sorry. Melanoma is a potentially serious form of skin cancer. Diagnosed early and treated properly, it can very often be cured with relatively minor surgery alone.

    What research is being done on melanoma?

    Research in melanoma is headed in three directions: prevention, more precise diagnosis, and better treatment for advanced disease.

    • Prevention: Public education and more widely available screening clinics can increase public awareness of the need for sun avoidance, sunscreen use, and early detection of suspicious spots.
    • More precise diagnosis: Newer experimental techniques, such as the confocal scanning laser microscope, may help doctors make more certain calls on borderline or suspicious spots without having to biopsy.
    • Better treatment for advanced disease: Because conventional chemotherapy has been disappointing with melanoma, researchers have turned their attention to biologic treatments of advanced melanoma to stimulate the body's own immune response against the tumor. These biologic treatments include interferon, interleukins, monoclonal antibodies, and tumor vaccines. Many of these treatments are still investigational and intended for patients with widespread, recurrent life-threatening disease.

    What does melanoma look like? What are melanoma symptoms and signs?

    Guideline # 3: A changing spot may be a problem, but not every change means cancer. A mole may appear and then get bigger or become raised but still be only a mole. It is normal for many moles to start flat and dark, become raised and dark, and then later lose much of their color. This process takes many years.

    Most public-health information about melanoma stresses the so-called ABCDEs:

    • Asymmetry: One half of the mole is different from the other half.
    • Border irregularity: The spot has borders which are not smooth and regular but uneven or notched.
    • Color: The spot has several colors in an irregular pattern or is a very different color than the rest of one's moles.
    • Diameter: The spot is larger than the size of a pencil eraser (6 mm).
    • Evolving: The mole is changing in size, shape, color, or overall texture. This may also include new bleeding.

    These guidelines are somewhat helpful, but the problem is that many normal moles are not completely symmetrical in their shape or color. This means that many spots, which seem to have one or more of the ABCDEs, are in fact just ordinary moles and not melanomas. Additionally, some melanomas do not fit this description but may still be spotted by a primary-care physician or dermatologist. Not all melanomas have color or are raised on the skin. Amelanotic melanomas have little or no color to the naked eye and may be confused with traumatized benign nevi or basal cell carcinoma. Desmoplastic melanoma may appear to be a thickened area of skin like a scar. These are treated the same way as more typical melanomas but, in the latter case, may be more difficult to determine the exact margins of the tumor.

    As a rule, melanoma is not painful unless traumatized. They sometimes itch, but this has no diagnostic or prognostic importance.

    What if the skin changes are rapid or dramatic?

    Guideline # 4: The more rapid and dramatic the change, the less serious the problem.

    When changes such as pain, swelling, or even bleeding come on rapidly, within a day or two, they are likely to be caused by minor trauma, often a kind one doesn't remember (like scratching the spot while sleeping). If a spot changes rapidly and then goes back to the way it was within a couple of weeks, or falls off altogether, it is not likely to represent anything serious. Nevertheless, this would be a good time to say once again: Nobody can diagnose him- or herself. If one sees a spot that looks as though it is new or changing, show it to a doctor. If one see a spot that doesn't look like one's other spots, it should be evaluated.

    What are the causes and risk factors for melanoma?

    Guideline # 5: Individual sunburns do raise one's risk of melanoma. However, slow daily sun exposure, even without burning, may also substantially raise someone's risk of skin cancer.

    Factors that raise one's risk for melanoma include the following:

    • Caucasian (white) ancestry
    • Fair skin, light hair, and light-colored eyes
    • A history of intense, intermittent sun exposure, especially in childhood
    • Many (more than 100) moles
    • Large, irregular, or "funny looking" moles
    • Close blood relatives -- parents, siblings, and children -- with melanoma

    The presence of close (first-degree) family with melanoma is a high risk factor, although looking at all cases of melanoma, only 10% of cases run in families.

    Having a history of other sun-induced skin cancers, such as the much more common basal cell or squamous cell carcinomas, indirectly raises one's risk because they are markers of long-term sun exposure. The basic cell type is different, however, and a basal cell or squamous cell carcinoma cannot "turn into melanoma" or vice versa.

    How can people estimate their level of risk for melanoma?

    The best way to know one's risk level is to have a dermatologist perform a full body examination. That way one will find out whether the spots one has are moles and, if so, whether they are funny looking in the medical sense.

    The medical term for such moles is atypical. This is a somewhat confusing term, because among other things the criteria for defining it are not clear, and it's not certain that an atypical mole is necessarily precancerous. Patients who have lots of "atypical moles" (more than 24) do have a higher risk for developing melanoma but not necessarily within one of their existing funny-looking moles. It may be a challenge to find the "baby melanoma" in the middle of a back full of large, dark, or irregular moles. If someone has such moles, a doctor will recommend regular surveillance and may recommend biopsy of the most unusual or worrisome looking moles.

    Sometimes, one learns at a routine skin evaluation that one does not necessarily need annual routine checkups. In other situations, a doctor may recommend regular checks at six-month or yearly intervals.

    What are the types of melanoma?

    The main types of melanoma are as follows:

    1. Superficial spreading melanoma: This type accounts for about 70% of all cases of melanoma. The most common locations are the legs of women and the backs of men, and they occur most commonly between the ages of 30-50. (Note: Melanomas can occur in other locations and at other ages, as well.) These melanomas are flat or barely raised and have a variety of colors. Such melanomas evolve over one to five years and can be readily caught at an early stage if they are detected and removed. An "in situ" melanoma refers to a very thin superficial spreading melanoma that does not extend beyond the junction of the dermis and epidermis, the normal location for melanocytes.
    2. Nodular melanoma: About 20% of melanomas begin as deeper, blue-black to purplish lumps. They may evolve faster and may also be more likely to spread. Untreated superficial spreading melanomas may become nodular and invasive.
    3. Lentigo maligna: Unlike other forms of melanoma, lentigo maligna tends to occur on places like the face, which are exposed to the sun constantly rather than intermittently. Lentigo maligna looks like a large, irregularly shaped or colored freckle and develops slowly. It may take many years to evolve into a more dangerous melanoma or may never become a more invasive form. Because of the unpredictability of future behavior, removal is recommended.

    There are also other rarer forms of melanoma that may occur, for example, under the nails (subungual), on the palms and soles (acral lentiginous), uveal or choroidal (ocular), oral or vulvar mucosa, or sometimes even inside the body.

    How is melanoma diagnosed?

    Most doctors diagnose melanoma by examining the spot causing concern and doing a biopsy. A skin biopsy refers to removing all or part of the skin spot under local anesthesia and sending the specimen to a pathologist for analysis.

    The biopsy report may show any of the following:

    • A totally benign condition requiring no further treatment, such as a regular mole
    • An atypical mole which, depending on the judgment of the doctor and the pathologist, may need a conservative removal (taking off a little bit of normal skin all around just to make sure that the spot is completely out).
    • A thin melanoma requiring surgery
    • A thicker melanoma requires more extensive surgery or extra tests in which the lymph nodes are examined. Removing lymph nodes causes physical problems even when there is no tumor present and, for that reason, is not recommended for thinner melanomas.

    Some doctors are skilled in a clinical technique called epiluminescence microscopy (also called dermatoscopy or dermoscopy). They may use a variety of instruments to evaluate the pigment and blood vessel pattern of a mole without having to remove it. Sometimes the findings support the diagnosis of possible melanoma, and at other times, the findings are reassuring that the spot is nothing to worry about. The gold standard for a conclusive diagnosis, however, remains a skin biopsy.

    What is the treatment for melanoma?

    In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove 1 centimeter (less than ½ inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery.

    Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph nodes may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like immunotherapy or chemotherapy are sometimes recommended. Many of these treatments are still experimental and, for that reason, their use may be limited to patients willing to participate in a research study.

    How do doctors determine the prognosis (outlook) of a melanoma?

    The most useful criterion for determining prognosis is tumor thickness. Tumor thickness is measured in fractions of millimeters and is called the Breslow's depth. A related prognostic measure is the Clark's level, which describes how many skin layers the melanoma penetrates. The lower the Clark's level and the smaller the Breslow's depth, the better the prognosis. Any spread to lymph nodes or other body locations dramatically worsens the prognosis.

    Thin melanomas, those measuring less than 1 millimeter, have excellent cure rates. The thicker the melanoma, the less optimistic the prognosis. Early diagnosis and treatment are essential.

    What methods are available to help prevent melanoma?

    1. Reducing sun exposure: Avoidance of sun exposure is the best means of helping to prevent melanoma, followed by wearing hats and tightly woven clothing, and then followed by broad-spectrum waterproof sunscreens applied liberally and often. The consensus among dermatologists is that sunscreens are at least partially helpful and are certainly preferable to unprotected sun exposure. (Despite sensational articles in the popular press, there is no credible evidence that sunscreens can cause melanoma. Data to indicate increased melanoma risk did not take into consideration that the sunscreens used by the subjects [at least as well as they could remember after decades] were far inferior to current products, which usually have much higher ultraviolet B SPF protection as well as ultraviolet A protection.)
    2. Early detection: Get one's skin checked at least once. Then, if it is recommended, have one's skin checked on a regular basis. The American Academy of Dermatology sponsors free skin cancer screening clinics every May all over the country. Special "Pigmented Lesion Clinics" have also been established in many medical centers to permit close clinical and photographic follow-up of patients at high risk.
    3. Screening of high-risk individuals: Anyone at high risk, such as anyone with a close relative who has melanoma, should be screened by a doctor for melanoma.

    Conclusions

    When it comes to spots on the skin, it is always better to be safe than sorry. Melanoma is a potentially serious form of skin cancer. Diagnosed early and treated properly, it can very often be cured with relatively minor surgery alone.

    What research is being done on melanoma?

    Research in melanoma is headed in three directions: prevention, more precise diagnosis, and better treatment for advanced disease.

    • Prevention: Public education and more widely available screening clinics can increase public awareness of the need for sun avoidance, sunscreen use, and early detection of suspicious spots.
    • More precise diagnosis: Newer experimental techniques, such as the confocal scanning laser microscope, may help doctors make more certain calls on borderline or suspicious spots without having to biopsy.
    • Better treatment for advanced disease: Because conventional chemotherapy has been disappointing with melanoma, researchers have turned their attention to biologic treatments of advanced melanoma to stimulate the body's own immune response against the tumor. These biologic treatments include interferon, interleukins, monoclonal antibodies, and tumor vaccines. Many of these treatments are still investigational and intended for patients with widespread, recurrent life-threatening disease.

    Source: http://www.rxlist.com

    Guideline # 4: The more rapid and dramatic the change, the less serious the problem.

    When changes such as pain, swelling, or even bleeding come on rapidly, within a day or two, they are likely to be caused by minor trauma, often a kind one doesn't remember (like scratching the spot while sleeping). If a spot changes rapidly and then goes back to the way it was within a couple of weeks, or falls off altogether, it is not likely to represent anything serious. Nevertheless, this would be a good time to say once again: Nobody can diagnose him- or herself. If one sees a spot that looks as though it is new or changing, show it to a doctor. If one see a spot that doesn't look like one's other spots, it should be evaluated.

    Source: http://www.rxlist.com

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