VIRGINIA BEACH DERMATOLOGY ASSOCIATES, PLLC.

MELANOMA
“Out Damn Spot”

Melanoma. The Black Cancer. No other skin cancer is as deadly. What may start out as a harmless looking freckle may end up as a lethal cancer.

What is especially alarming is that the rate of melanoma is virtually skyrocketing. The number of melanoma cases is climbing more rapidly than any other form of cancer.

This form of cancers most commonly in a relatively young age group – often afflicting those in their most productive years of life.

Reading this article may be important. It may save you or one of your loved one’s life.

WHAT IS MELANOMA?

Melanoma is a cancer arising out of melanocytes. Melanocytes are the skin cells which form the pigment melanin. When these melanocytes divide uncontrollably melanoma results.

Since these malignant melanocytes usually do not lose their ability to make pigment, most melanomas are dark with mixed shades of brown, tan or black. Melanomas are disorganized and haphazard. Therefore the pigment they spit out is uneven, leading to variegation in color. Variegation in color is a hallmark of melanoma.

What makes melanomas so deadly is that they carry the potential to spread or metastasize. They can do this by invading the blood vessels or lymphatics. This gives them the opportunity to attack vital organs such as the liver, lung or brain.

Most melanomas arise from a preexisting nevus (mole). This makes it important that you know your skin and its moles. Armed with this knowledge you can seek treatment if you see a change in color, shape or size.

Some melanomas develop from a mole that has been present since birth (congenital nevi). This type of mole should be removed in late childhood or early adolescence.

Many people have atypical moles called dysplastic nevi. These sometimes run in families. Dysplastic nevi are somewhat larger moles with irregular features. People with dysplastic nevi have an increased incidence of melanoma. These dysplastic nevi have certain characteristics that should wave red flags to their bearers. Not only can these moles turn into melanomas, but they serve as markers which identify those at greater risk for melanomas forming elsewhere on the skin.

WHAT CAUSES MELANOMA?

Most experts in the field feel that the sun causes melanoma. However, most of these scientists feel that it is intense singular sun damage that may precipitate malignant transformation, rather than the accumulation of sun damage. Thus, sunburns may foment the melanocytes to become cancerous rather than gradual, unremitting exposure to the sun.

For instance, it is the secretary or business executive who goes on a vacation and gets burned who has a greater risk than the painter or farmer who is out in the sun all the time.

Melanoma is more likely to develop on skin that is not exposed to the sun. Thus we see more cases on the trunk. Basal cell and squamous cell skin cancers are mostly seen on the face, neck and lower arms.

WHO IS LIKELY TO DEVELOP MELANOMA?

Like the other forms of skin cancer, melanomas occur chiefly in those who have light complexions. The blond or redhead with blue or green eyes has the highest risk.

People who sunburn easily and have difficulty in tanning are also more susceptible. In fact, the leading risk factor turns out to be a bad sunburn in childhood. If you or a parent remember that you had a blistering sunburn as a child, you best be careful.

A family history of melanoma places a person at much greater degree of risk.

Those of African descent, while protected by increased pigmentation, may sometimes develop melanoma. Such cases occur on the palms of the hands, soles of the feet, under the nails, and in the mouth. Bob Marley, the great Reggae singer, succumbed to a melanoma which began on his feet.

WHAT ARE THE WARNING SIGNS OF MELANOMA?

I always like to tell a patient that any change in a pre-existing mole or a new mole should warrant a visit to a physician.

The American Academy of Dermatology likes to stress the ABCD’s of melanoma.

A – ASYMMETRY, when one half of the mole does not match the other half
B – BORDER, when the border or edges of the mole are ragged, blurred or irregular.
C – COLOR, when the color of the mole is not the same throughout or if it has shades of tan, brown, black, red, white or blue.
D – DIAMETER, if the diameter of a mole is larger than the eraser of a pencil.
This is good advice. However, a lesion may have all of these features yet be benign. Conversely, a mole may have none of these clues and be malignant.

Nonetheless, the ABCD’s of melanoma are a valuable tool.

I would also like to stress the value of a second opinion. If you have any question AT ALL that one of your moles may be malignant, get another opinion. You may even request a biopsy. In a biopsy, the physician will remove the mole. In removing that piece you may gain peace of mind.
One last thing. Delay does not help. Say you have noted a change in a mole. If you have it attended to right away there are two possibilities. Either you will find out it is benign or malignant. In the vast majority of cases it will be the former.

Now, pretend you delay. Say you wait eight months. Your spouse or friend has nagged you enough and you finally see your doctor. At that point there are again two possibilities. You will be told, either with or without a biopsy, that your mole is benign or malignant. If it is malignant, you have greatly lessened your chance for a cure. If it is benign you have had eight months of needless anxiety. Either way you lose. Better to have it checked out early.

SYMPTOMS OF MELANOMA

Unfortunately, melanomas usually do not have symptoms in their early, most curable period. Sometimes they may itch. This actually is probably the immune system trying to mount a defense.

Later a melanoma may scab, bleed or become red and inflamed.

The melanomas lack of symptoms makes the above advice even more important. If you see any change in a lesion, or a new lesion, whether pigmented or not, consult your physician.

WHAT ARE THE TYPES OF MELANOMA?

There are four main types of melanoma

Superficial Spreading Melanoma
This is the most common form, accounting for about 65% of melanomas. Fortunately, the most common type affords the highest cure rate. The superficial spreading type travels along the skin in a horizontal direction before descending deeper into the dermis where it can cause trouble. This form of growth is referred to as the radial growth phase.

A superficial spreading melanoma shows the most classical reflection of the ABCD warning signs. They usually are only slightly elevated, have an irregular border and color variegation. Left untreated, they may spread out for quite a distance.

Nodular Melanoma
Less common than the SSM, is the nodular melanoma. Since this melanoma has a short or even non-existent horizontal growth phase, this is the deadliest form of melanoma. The nodular melanoma possesses an early vertical growth phase . This means that it can delve into the dermis more quickly and invade blood vessels and lymphatics.

Occasionally, a nodular melanoma lacks pigment. These are called amelanotic melanoma. They actually tend to be a bit more aggressive.

Lentigo Maligna Melanoma
Sometimes still referred to by its ancient name of Hutchinson’s freckle. The lentigo maligna melanoma is the only melanoma that appears to be associated with chronic sun exposure. For this reason it occurs more frequently in the elderly. I have seen a few cases in those under forty however. These were all blond women with intense sun exposure.

This lesion may grow for many years as a non-invasive or in-situ lesion before developing the vertical growth phase. Once the lentigo maligna melanoma goes into this phase, however, it can be as aggressive as any of its cousins.

Acrolentiginous Melanoma
The acrolentiginous melanoma occurs on the palms, and under the nails. This turns out to be a fairly deadly form of melanoma since its early signs are often missed by both the patient and physician. The warning signs with the Acrolentiginous Melanoma are subtle, but basically are the same as propounded in the ABCD rules. This melanoma tends to stay flat for quite some time, while it stealthily does its dirty work.

HOW IS THE DIAGNOSIS MADE?

After examining the mole, if you physician feels that the mole is suspicious, a biopsy will be recommended. A biopsy can be done in a doctor’s office quickly and relatively painlessly. The mole is sent to the pathology laboratory, where a slide is made. The pathologist looks at the slide and determines whether the lesion is benign or a melanoma. Often other opinions are garnered before a final decision is made.

PROGNOSIS

By far the leading factor in judging the prognosis of the melanoma patient is the thickness of the melanoma. Thickness is measured in millimeters from the top to the deepest point it has invaded. If the melanoma is less than 0.76 mm. Thick the prognosis is excellent. If the melanoma is between 0.76 and l.5 mm. The chances of survival are still quite good. About half of the patients are dead within five years, however, if the melanoma has extended into the fat, more than 4 mm. thick.

Other factors which may influence prognosis are sex (females do better), body site (extremities do best followed by head, neck and trunk; palms, soles, back of the lower arms, and under the nails do the worst), and age (younger does better).

Other factors which can only be evaluated under the microscope, include mitotic rate ( less cell division the better), lymphocytic infiltration ( the more of a particular white cell called a lymphocyte the better as this shows an immune response), and whether the lesion is in a horizontal growth phase ( good) or vertical growth phase (bad).

All these prognostic factors can only be a rough approximation. There are people alive whose melanoma spread to lymph nodes and organs. There are unfortunately people who have died when everyone was convinced their melanoma was thin and not advanced.

TREATMENT

Treatment for melanoma is Surgery, Surgery and then other things. The surgeon will excise the melanoma. The margin, or the piece of normal tissue which is taken around the lesion, will be determined by the depth of invasion. It has been shown that the margin does not have to be as wide as once thought. Thus, we rarely see the “shark-bite” appearance that once laid waste to the melanoma patient’s flesh.

If the melanoma has invaded to a medium level, sentinel node lymphoscintography is often employed. Using this technique a radioactive dye is squirted into the melanoma site. The lymph node which collects this dye is removed and analyzed. If the lymph node is normal, the patient is reassured that they have a better prognosis. If that lymph node is riddled with tumor, the surrounding lymph nodes are excised.

Some surgeons will do what is termed an elective regional node dissection. In this procedure the lymph nodes which drain the site of the melanoma are removed as a precaution.

The melanoma patient may be evaluated by an oncologist. This cancer specialist will run a check on various organs to see whether the melanoma has spread.

There are some new weapons in the fight against melanoma. These include the use of various chemotherapeutic agents, immunotherapy, and melanoma vaccines. Radiation is sometimes used as palliation – to permit the melanoma patient to live longer and more comfortably.

PREVENTION

Since melanomas are caused by the sun, it makes good sense to keep you exposure to a minimum. Avoid direct sun exposure between 10 a.m. and 3 p.m.. Wear sunscreens, ideally ones with an SPF rated 15 or higher. Wear protective clothing.

Have your skin examined once a year by a physician. Have your spouse or friend examine your skin once a month. If you live alone learn how to examine your own skin.

If you see a suspicious lesion, have it examined by a physician.