Melanoma Skin Cancer

Melanoma is a serious type of skin cancer. Most melanoma is treated surgically, and in many cases this surgery is curative. Through numerous clinical trials, the surgery that is required to treat melanoma has become less invasive. A number of these less radical procedures were pioneered at the Saint John’s Cancer Institute Melanoma Program.

Stages 1 and 2

Early melanomas (Stages 1 and 2) are localized, and more advanced melanomas (Stages 3 and 4) have spread (metastasized) to other parts of the body. There are also subdivisions within stages. The lower or earlier the stage the more likely it is that a patient will be cured of it. It is important to remember that there are many numbering systems within melanoma evaluation. These can be confusing, and it is often helpful to have a physician explain the meaning of all of the numbers. For example a Stage 3 melanoma is very different from a melanoma with Level III invasion.

Stage 3

In Stage 3 melanoma, cancer cells have spread from the primary tumor site through small channels in the tissue (“lymphatics”). These tumor cells can be detected as metastases in lymph nodes in the region of the primary melanoma, or as nodules of melanoma in the nearby skin (“in-transit metastases). If melanoma spreads this way, the risk of it spreading further in the body is greatly increased.

Stage 4

If the disease has advanced to Stage 4, the melanoma cells have traveled through the body via the bloodstream or lymph vessels and have settled into another area of the body, likely far from the original tumor site. These cells may have reached distant lymph nodes or invaded the internal organs. This can be in addition to or instead of the lymphatic spread.

Cutaneous melanomas usually begin in cells known as the epidermal melanocyte:

• Lesion asymmetry or border irregularity on moles
• Bleeding or crusting
• Recent changes in moles
• Variation of color on existing moles (though some are non-pigmented)
• Diameter over 7 millimeters
• Development of an elevated area (or palpable nodule)

If you’ve been identified as being at a higher risk for a melanoma diagnosis, you may be a candidate for melanoma screening if you:

• Have light skin
• Greater sensitivity to the sun
• Have multiple atypical nevi or moles
• Large congenital moles
• A family history of melanoma
• A history of blistering sunburns

Anything that increases your chance of getting melanoma is a risk factor. Sun damage, especially a history of peeling or blistering sunburns, is the main risk factor for melanoma. Artificial sunlight from tanning beds causes the same risk for melanoma as natural sunlight. Tanning in the sun or in tanning beds always involves radiation damage to the skin and increases the risk of skin cancer.

• Previous melanoma
• A large number of benign (non-cancerous) moles
• Family history of melanoma
• Atypical mole and melanoma syndrome (AMS)
• If you have AMS, you and your family members should be screened regularly

Not everyone with risk factors gets melanoma. Individuals are encouraged to visit with their primary care doctor or a dermatologist if there is any concern or suspicion about melanoma. Early detection is vital to treating and surviving cancer.

Diagnosis of melanoma is most often done by a simple skin exam. The exam should be thorough, as melanoma can occur in any part of the skin. Some tools can aid in the diagnosis, such as magnification or special types of light, and photographs are often helpful for follow up exams of the skin over time.

The most important part of the evaluation, though, is the experience of the examiner and the dedication to doing a thorough job. Most often, this is done by a dermatologist or primary care physician, and when in doubt a biopsy with evaluation by an experienced pathologist is recommended.

Once a melanoma has been found, a great deal of information can be obtained by a full assessment of the skin biopsy. At the Melanoma Program at Providence Saint John’s, our pathologists are very practiced in evaluating melanomas and provide all of the relevant information to help guide treatment decisions in a standard synoptic report.

If the initial biopsy was done elsewhere, they are able to provide an expert review rapidly upon receipt of the biopsy slides.

Biopsy

Skin cancer can’t be diagnosed just by looking at it. If a mole or pigmented area of the skin changes or looks abnormal, a doctor may biopsy the mark, taking a tissue sample for a pathologist to examine. Suspicious areas should not simply be shaved off or destroyed with a hot instrument, an electrical current or a caustic substance. A biopsy should be performed first to determine if the area is malignant.

Local excision/excisional biopsy

The entire suspicious area is removed with a scalpel under local anesthetic. This is usually done as an outpatient procedure.

Punch biopsy

The doctor uses a tool to punch through the suspicious area and remove a round cylinder of tissue.

Shave biopsy

The doctor shaves off a piece of the growth and checked for any abnormal results.

Abnormal results may include:

• Benign (non-cancerous) growths such as moles, warts and benign skin tumors
• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma
• Merkel Cell Carcinoma

Medical treatments for melanoma are rapidly evolving, and a great deal of progress has been made in recent years. Our physicians are at the forefront of many of these new therapies and can help patients sort through the complex and changing information about established treatments, such as interferon, and newer, recently developed drugs.