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Melanoma

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Melanocytes produce the skin coloring or pigment known as melanin, which gives skin its tan or brown color and helps protect the deeper layers of the skin from the harmful effects of the sun.

Melanoma is a cancer that originates from a melanocyte (melanin-producing skin cell), and is associated with over exposure to the sun or UV radiation. It usually appears in the form of a mole or lesion, but it can be hidden and almost undetectable. Although melanoma accounts for only 4% of skin cancer diagnoses, it is the most dangerous form of skin cancer and accounts for 75% of skin cancer related deaths. Each year 50,000 people are diagnosed with melanoma, [1] and one American dies each hour from the cancer [2]. When caught early and treated correctly though, the cure rate is 95% [2]. Anybody can be diagnosed with skin cancer, but as you grow older your chances increase. Melanoma though, is one of the caners that can be diagnosed in young people. As society pushes the use of tanning beds and the importance of a "tan" body, we see the number of youth diagnosed with melanoma increase dramatically.

Contents

Symptoms

Melanoma usually develops on the areas of skin which are most exposed to the sun: the arms, legs, face, and upper trunk; these parts should be payed the most attention to. A melanoma can develop anywhere on the body, even on those areas that rarely see the sun. Melanoma of any type can become a very serious skin disease, but if caught and treated early, the survival rate of melanoma is very high. Two key warning signs of melanoma are: a change of color or shape in a previously existing mole or the development of a growth on the skin. Melanoma can also be skin colored and lay flat against the skin though, making it not easily noticed. Symptoms that also need to be considered are scaliness, pain, itchiness, ulceration, bleeding, oozing, and the development of bumps or hard nodules around the area. Not all moles are cancerous, and there are a few keys as to deciding whether or not a mole is most likely benign or cancerous [3].

An average adult will have approximately ten to forty moles, and the majority of these will develop before early adulthood. However, some may
A normal, non cancerous mole
change slightly in color, shape, or size though [3].

Characteristics of a normal mole:

  • Moles are all one color, usually brown, tan, or black
  • They are symmetrical in shape, usually shaped like a circle or oval
This mole is asymmetrical, has irregular borders, multiple colors, and a very large diameter
A melanoma mole exhibiting several ABCDE characteristics
  • Their diameter is approximately six mm or less, about the size of a pencil eraser

The American Academy of Dermatology has developed an A-B-C-D-E guide to determine moles or lesions which may be related to melanomas or other skin cancers [3].

  • A: Asymmetrical in shape

This mole has a very different shape, not at all like an oval or circle. It may have two very different looking halves.

  • B: Irregular border

Unlike normal moles which have a naturally definitive and distinct border, this mole's border is uneven, ragged, or toothed.

  • C: Change in color

Although normal moles may experience a very slight change in color, these moles experience a much larger change in color. These moles may have several colors which can include pink, blue, gray, tan, brown , and black or they have unevenly distributed pigment.

  • D: Diameter

A mole that has recently grown in diameter to a size larger than 6mm (.25 inches) or the size of that of a pencil eraser may possibly be melanoma.

  • E: Evolving

Any mole which evolves or changes over time should be carefully watched. These include changes in size, shape, color, or texture or symptoms such as bleeding, ulceration, broken skin, or itchiness [3].

Types

There are four basic types of melanoma: superficial spreading melanoma, lentigo maligna, acral lentiginous melanoma, and nodular melanoma; the first three types are found in the uppermost layer of skin, the epidermis, and are noninvasive. The last type can go into the deeper layers, like the dermis and hypodermis, and start to affect other parts of the body, thus becoming invasive [4].

Superficial spreading melanoma
  • Superficial spreading melanoma Around seventy percent of the melanoma cases diagnosed in the United States are superficial spreading (SSM) , making it the most common type of melanoma in the US. This type of melanoma spreads through the top layer of skin, the most "superficial" layer, for a while before making its way down to the deeper levels. The first sign of superficial spreading melanoma would be a mildly discolored patch, either flat or slightly raised on the skin, with irregular borders, and not geometric in shape. SSM can even occur in a once harmless mole [4]. People of any age and gender can be diagnosed with SSM, but this type is the most commonly found one in teenagers and young adults; it is the leading cause of death from cancer for this age group as well. SSM is also found a little more often in females than in males. When found in females it is most often found on the legs and when found in males it is most often found in the trunk region, between the pelvic area and neck [1].
Lentigo Maligna
  • Lenitgo Maligna Lenitgo maligna mainly affects those with habitual and chronic sun exposure and is most often found in the elderly. Although responsible for only ten percent of the melanoma diagnoses [1], this is the type most often found in Hawaii. Lentigo maligna resembles superficial spreading melanoma in appearance, both characterized by their slight discoloration and their proximity to the uppermost layer of skin, but differs in where it is found on the body. This type of melanoma most often presents itself on areas where sun exposure is the greatest; these areas include: the face, as well as the ears, the shoulders and back, and the arms. Lentigo maligna is referred to as such until it becomes invasive, penetrating the deeper layers of skin and making its way to other parts of the body, it then gains the name of lentigo maligna melanoma (LMM) [4]. As LLM advances, the irregular spot will darken, this change in color will be accompanied by an increased thickness and even hard nodules. Lenitgo maligna is very often mistaken as a sun spot in the middle aged and elderly, but as it grows it can become very dangerous [1]
Melanoma in the eye, acral lentiginous melanoma
  • Acral lentiginous melanoma Also known as the "hidden melanoma" this type is the least common in the United States, affecting only five percent of those with melanoma diagnoses. Acral lentiginous melanoma (ALM) is the most common type of melanoma affecting Asians, African-Americans, and people of darker skin color, responsible for fifty percent of the melanoma diagnoses in these people. ALM is often hard to find, because it develops on hard to examine places of the body and the areas in which you would least expect. It can occur on the fingernails or toenails and appear as a white streak or bruise, on the palm of the hand or sole of the foot, and on mucous membranes, including the mouth, nose, female genitalia, urinary tract, and the membrane of the anus. ALM can appear as an irregularly shaped and colored lesion, but can also be flat and colorless. Symptoms of ALM include: nosebleeds, streaks on the nail bed, or a colored mass on the inside of the mouth. Like the previous two types of melanoma this type remains on the most superficial layer of skin, the epidermis, for a while until penetrating to the dermis, thus becoming invasive [1].
Nodular Melanoma
  • Nodular melanoma is most often invasive at the time of diagnoses [4]. It accounts for ten to fifteen percent of the cases of melanoma in the US, but is the most aggressive form. Nodular Melanoma (NM), like the previous three types, can be found in a person of any age or gender, but is most often found in the elderly and more often seen in males than in females. NM most often arises not out of a previously benign mole, but usually from an area where there was no previous lesion or discolored spot. Nodular Melanoma presents itself as a dark lesion, but can be fair or colorless and usually grows in depth as opposed to width. The lesion can often be bleeding or ulcerated. NM can be hard to spot, because you can't readily see its growth and it may take a while to notice the newly appeared spot until it is well advanced [1]. NM most often appears on the trunk, arms, legs, and the scalps of males [4].

Stages

Stage 0:
The melanoma is only in the uppermost layer of the skin, the epidermis, and has not gone any deeper. Stage 0 is also referred to as "in situ" melanoma meaning it is non invasive[5]
.

Stage I:
Stage 1A
The layer of skin over this melanoma has not been broken, is not ulcerated, and the depth of the lesion is less than that of 1mm. The disease is still only in the skin and has not spread to any other parts of the body, including the lymph nodes [5].
Stage IB
The melanoma is either less than 1mm thick and has an ulceration, or it is 1-2 mm thick with no ulceration. The melanoma may have likely spread below the skin and into the dermis or other tissues [5].

Stage II:
Stage IIA
The melanoma can be either 1-2 mm with ulceration or 2-4 mm without ulceration[5].
Stage IIB
The melanoma tumor is either 2-4 mm thick with ulceration or 4 or more mm thick with no ulceration[5].
Stage IIC
The tumor has reached a depth greater than 4 mm and there is ulceration in the tumor as well[5].

Stage III:
The tumor may be of any thickness, with or without ulceration, but at least one of the following qualities must be present:

  • Has spread to the lymphatic system, not necessarily the lymph nodes
  • Has spread into the lymph nodes, either the movable or matted ones
  • Additional growths, satellite tumors, are present no more than 2 cm away from the original tumor, and the lymph nodes are somehow involved[5]

Stage IV:
The melanoma has become very aggressive, has spread to distant areas of the body, infected other organs, or infected the lymph nodes[5].

Recurrent malignant melanoma

Recurrent Melanoma
This melanoma has come back even after being treated. The tumor may have come back to another area of the body, or the original spot it was removed from [5].

Cause and Risks

The exact cause of melanoma remains unknown to scientists, but there are several risk factors, some controllable and others non controllable, which do increase your chances of getting melanoma. Although risk factors help predict who is most likely to get a certain disease they themselves do not ultimately decide. Some who get melanoma have very few risk factors, but others with several risk factors may go through life never facing that disease.

Tanning beds can increase your chances of getting melanoma
The main contributing risk factor to melanoma is chronic exposure to ultraviolet (UV) light either through direct sunlight or tanning beds, booths, and lamps. DNA can be damaged by UV radiation, including the DNA in melanoma cells, thus producing problems in that cells ability to divide and multiply. Much of the sun damage that occurs happens throughout one's childhood, teenage years, and early adulthood, but melanoma may not occur until much later in life. Frequent childhood sunburns, especially blistering ones, have also been linked to melanoma [6].
Redheads with freckles are the most susceptible to melanoma
The number of moles a person has can also be a contributing factor. Those with many moles, especially more than fifty, are more likely to have melanoma. There is very little chance that any single mole will be cancerous, but the more moles someone has the greater their chances are [7].

One of the uncontrollable risk factors is a person's heritage and skin tone. Those with lighter skin are ten times more likely to get melanoma than those with darker skin, like African-Americans and Asians. Any Caucasian with light eyes, fair skin, and either red or blond hair is more prone to melanoma, but redheads are the most vulnerable [6].
A family history of melanoma is also a risk factor. If a father, sister, or grandmother has had the disease your chances are much greater. Inherited gene mutations are possible, but not very likely; they are passed down through generations and inherited from your parents. The most common gene mutations occur in the genes CDKN2A (also known as p16) and CDK4. These mutations can cause problems and result in cells that do not properly divide and multiply [7].
Older people are also more susceptible to melanoma, and overall a slightly larger number of men than women are diagnosed with melanoma. Those with weakened immune systems are also more vulnerable. [7].

Diagnosis

In order for a doctor to diagnosis a mole or lesion as melanoma a medical examination, dermoscopy, and skin biopsy conducted by a dermatologist usually take place. Questions concerning one's personal medical history, family medical history, and the appearance and evolvement of the mole or lesion are asked in order to better assess the situation. Next, a skin sample is taken from the mole to be examined. If possible an excisional biopsy will take place in which the entire tumor is removed and examined, especially in the case where melanoma is highly suspected. If certain reasons prohibit an excisional biopsy an incisional biopsy will take place, where only part of the tumor is removed and examined. These biopsies can be conducted while the patient is under local anesthesia; the patient will feel no pain, only the needle and a slight burning sensation for about a minute [8].

Treatment and Care

Stitches left at the site of a removed pre cancer mole
Depending on the type of melanoma and the staging, very methods may be used to remove the cancer and tumor. If the cancer has spread to another part of the body or to the lymph nodes different things will be done than if the melanoma is in stage I and has remained in the epidermis. The most basic form of removal for a cancerous mole is through surgical excision, the removal of the whole mole, which may be done at the time of diagnosis. Local anesthesia is administered and the patient feels little pain. Surgeons and dermatologists today have come a long way and the margins, the area of tumor and healthy skin that is removed, are a lot smaller than they used to be. If the tumor is not yet invasive only .5 cm of skin will be removed. If the thickness of the tumor has become that of more than 1 mm between 1 cm and 3cm of skin will be removed. Patients are left with some discoloration and scarring after the surgery. If needed a flap of skin from nearby on the body can be taken to cover up the wound or a skin graft can be done [9].

Chemotherapy, which is the use of drugs to kill cancer cells, is also an option for cancer patients, including those who have already had the melanoma removed. Chemo used after surgery can help lower one's chances of the cancer returning. Different methods of chemotherapy are used on different patients depending on their staging and the growth of the melanoma. In Systematic chemotherapy you take the drugs either by mouth or through injection and they spread throughout the bloodstream affecting all areas of the body. Regional chemotherapy is when the drugs are placed directly into a body cavity, the spinal column, or an organ to reach that specific area of the body [10]

Radiation therapy can also be used to treat melanoma. It treats cancer by killing the cancer cells or stopping them from growing through the use of high energy x-rays or other forms of radiation. It can be used externally or internally, depending on the case and the patient. External radiation therapy uses a radiation machine outside of the body, but internal radiation therapy uses needles, catheters, or other objects with radioactive substances in them. These items are then placed inside the body either in or near the cancer [10]. Biologic therapy is a process in which the immune system is built up in hopes that it will fight and destroy the cancer. The products or substances they use can either be produced by the body or in a laboratory [10].

Those suffering from melanoma may also want to consider clinical trials. These are where the newest medicines and techniques for defeating cancer are tested. With clinical trials though, there is no promise of results, but it will always help in the quest to find the cure for cancer [10].

Prevention

Although out during peak hours, this man has shade and his sun screen with him
The most important thing one can do to protect themselves from melanoma is to limit their exposure to the sun and UV radiation. Outdoor activities in the sun should be limited between 10AM and 3PM, as that is when the sun is its strongest. If it is necessary to go outside during these times one should take the precautions to protect their skin, especially their face; try to wear broad rimmed hats, loose long sleeved shirts, long pants, and UV absorbing sunglasses. Also try to seek out the shade. Whether in summer or in winter a sun block of at least 15 SPF should also be consistently used. You will be protecting yourself not only from melanoma, but also the painful sunburn associated with too much exposure to the sun [11].

The next most important thing you can do is know your risk factor. If you have light skin and a light hair color your chances of developing melanoma are much higher compared to that of an African American with dark hair and dark eyes. Be on alert if you have had several blistering or bad sunburns during childhood or teen years. Most importantly, know if someone in your family has had melanoma, or if the disease runs in the family. Around ten percent of those diagnosed with melanoma have a family member who have or had the disease as well [11].
The last thing can you do is perform regular skin self-examinations and keep in contact with your doctor. This is especially important for those who have many risk factors for melanoma. Best to do after taking a bath or shower, examine your body and look at your moles, blemishes, and birthmarks. Take notice and write it down if you see anything unusual or anything that has recently changed. Remember the A-B-C-D-E guide and look for anything specifically that doesn't fit this mold. A change in color or texture is just as important as a change in shape. Make sure to check all the areas of the body, including your scalp, nose, mouth, under fingernails, buttocks, and genitals as melanoma can develop on all these parts of the body. If you perform these examinations regularly you will become much more familiar with your body and be much more likely to notice when a mole changes or appears cancerous. If you ever notice something that looks or feels different or you have concerns about, immediately talk to your doctor. Melanoma can be very dangerous, but easily cured if found and treated early [12]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Four Types of Melanoma American Academy of Dermatology. Skin Net.
  2. 2.0 2.1 Melanoma Fact Sheet American Academy of Dermatology.
  3. 3.0 3.1 3.2 3.3 Melanoma Mayo Foundation for Medical Education and Research
  4. 4.0 4.1 4.2 4.3 4.4 Types of melanoma Skin Cancer Foundation
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Stages of Melanoma eMedTV.
  6. 6.0 6.1 Do we know what causes melanoma? American Cancer Society.
  7. 7.0 7.1 7.2 What causes melanoma skin cancer? American Cancer Society
  8. Diagnosis and Staging of Melanoma Stanford Medicine.
  9. Melanoma Treatment American Skin Cancer Foundation.
  10. 10.0 10.1 10.2 10.3 Treatment Option Overview National Cancer Institute.
  11. 11.0 11.1 Causes, Risk Factors, and Prevention CancerLinksUSA.
  12. How to do a skin self-exam CancerLinksUSA.
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