Woman looking at mole on back 2121 x 1414
Photo source: iStock Photos

Melanoma, also known as malignant melanoma or cutaneous melanoma, is an aggressive form of skin cancer. It arises from the cells that give skin its color, the pigment-producing cells present in the epidermis called melanocytes.

Melanomas can develop anywhere on the body. Because melanoma cells stem from pigment-producing cells, melanomas are most frequently brown or black in color. In rare instances, melanoma develops from pigmented cells that are not associated with the skin, such as the eye or other internal organs.

Graphic from Fayne Frye

Melanoma is the most serious form of skin cancer because if left untreated, can spread to other areas of the body. Like other skin cancers, however, when found and treated early, patients with melanomas can live long healthy lives.

Although melanoma is much less common than both basal cell and squamous cell carcinomas of the skin, it is the sixth most frequently diagnosed cancer in both men and women in the United States. 

Risk factors for melanoma

The risk factors for melanoma include the following:

  • Sun exposure: Both long term ultraviolet light exposure from sunlight and/or tanning lamps and a history of blistering sunburns early in life
  • Fair skin: Individuals with light colored hair, red hair, and light colored eyes
  • Moles: Individuals with 50 or more moles
  • History of skin cancer: Patients who have already been diagnosed with skin cancer, basal cell carcinoma, squamous cell carcinoma or melanoma
  • A family history of melanoma: Individuals with a first-degree relative, a parent, sibling, or child, who has been diagnosed with melanoma
  • Weakened immune system: patients with decreased immunity due to chemotherapy, organ transplant, infections such as HIV/AIDS, or certain cancers like lymphoma

The signs & symptoms of melanoma

Benign healthy moles are far more common than melanomas. But distinguishing between the two can be difficult. Any change in an existing mole or the development of a new pigmented or unusual looking new mole may be the first signs of melanoma.

Unlike melanoma, a healthy mole is generally uniform in color, light brown, tan or black. It is usually smaller than the size of a pencil eraser and the borders of the mole are easily distinguished from the normal skin surrounding the mole. 

An analytical method to help detect early melanoma is the ABCDE guideline. Some or all of these features are manifested in most melanomas:

  • Asymmetry – one half of the growth does not look like the other half
  • Border Irregularity- Edges of the mole are uneven or blurred
  • Color Variability –uneven coloring or multiple shades of color, like brown, black, and red
  • Diameter – Larger than 5 mm in size (the size of a pencil eraser)
  • Evolving or Changing – any change in appearance (size, shape or color) or if the growth bleeds or itches

Related Article by Dr. Frey:  How Do I Know if I Have Skin Cancer?

Types of Melanoma

There are several different types of melanoma. The most common type is superficial spreading melanoma.

Superficial spreading melanoma

Superficial spreading melanoma constitutes about 70% of melanoma diagnosed in patients. This form of melanoma grows gradually on the surface of the skin before it begins to invade the deeper layers. 

Superficial Spreading Melanoma 1124 x 714
Photo source: National Library of Dermatologic Teaching Slides of the American Academy of Dermatology via Dr. Fayne Frey

Nodular melanoma

Nodular melanoma can grow more quickly than other melanoma types and begins to invade into the deeper layers of skin as they develop. They comprise about 15% of melanoma cases.

Nodular melanoma 1046 x 712
Photo source: National Library of Dermatologic Teaching Slides of the American Academy of Dermatology via Dr. Fayne Frey

Lentigo maligna melanoma

Lentigo maligna melanoma is a less common form of melanoma found commonly on older individuals. This is a very slow growing melanoma that occurs in sun-exposed areas primarily on the head and neck.

Lentigo Maligna Melanoma 1068 x 686
Photo source: National Library of Dermatologic Teaching Slides of the American Academy of Dermatology via Dr. Fayne Frey

Acral-lentiginous melanoma

Acral-lentiginous melanoma is the rarest form of melanoma but is the most common form of melanoma in dark-skinned individuals. This tumor appears on the nail beds of the fingers and toes, on the palms of the hands and on the soles of the feet.

Acral Lentiginous Melanoma 1074 x 690
Photo source: National Library of Dermatologic Teaching Slides of the American Academy of Dermatology via Dr. Fayne Frey

Amelanotic melanoma variant

Although uncommon, any type of melanoma may present as amelanotic or lacking pigmentation. These melanomas appear skin-colored, pink, red, or white. For this reason, these tumors are often difficult to diagnose, as they can be clinically confused with other non-pigmented benign skin growths. This often leads to a delay in diagnosis.  

Amelanotic Melanoma 1084 x 692
Photo source: National Library of Dermatologic Teaching Slides of the American Academy of Dermatology via Dr. Fayne Frey

Staging of Malignant Melanoma

Staging of melanomas is based on the following characteristics:

  • The thickness of the melanoma at presentation
  • Whether ulceration is seen on pathology
  • Whether the tumor has spread to regional lymph nodes or to other organs or areas of the body.

The prognosis of melanoma patients depends on the stage of disease at the time of initial presentation.

Stage O: This stage is also called in-situ or non-invasive melanoma. Stage 0 tumors are limited to the epidermis, the most superficial layer of skin. In addition, there is no lymph node involvement and the tumor has not spread to other areas of the body. The 5-year survival rate of stage 0 melanoma approaches 100%

Stage I:

In Stage I melanoma, the cancer has spread into the dermis, the second layer of skin. The lymph nodes are not involved and the tumor has not spread to distant organs. The 5-year survival rate is over 90%

Stage II:

In this sage, the tumor is at least 1.01 millimeters in thickness but has not spread to lymph nodes or to distant organs. 5-year survival rates are between 50%-80% depending on tumor thickness and the presence of ulceration.

Stage III:

Regardless of tumor depth, Stage III tumors have spread to nearby lymph nodes. The 5-year survival rates range from 40%-70% depending on the presence of tumor ulceration, and the extent of lymph node involvement

Stage IV:

Stage IV tumors have evidence of spread to distant lymph nodes or organs far from the original site of the tumor. The 5-year survival rate is < 20%

Note: There are more specific subdivisions within each stage.

Treatment

The type of treatment for melanoma depends on the location, size, and stage of the cancer. It also depends on the patient’s health and, on patients’ personal preferences.

-Thin Primary Melanoma

  • Surgical wide local excision is the mainstay of treatment for early-stage melanomas. The melanoma, and underlying tissue, along with a margin of healthy skin, is removed in an elliptical fashion with a scalpel. The tissue is sent for pathological evaluation to confirm that the cancer is completely removed. The majority of thin melanomas can be removed under local anesthesia in a doctor’s office or outpatient facility using this technique. 
  • Mohs Micrographic Surgery (MOHS). Melanomas in difficult locations are often treated with MOHS. It involves removing skin cancer tissue, layer-by-layer, examining each layer at the time of removal until no evidence of tumor exists.

-Higher Risk Melanomas

Treatment options for patients with melanomas that have grown deeper into the skin or have spread beyond the original tumor site may include:

-Surgery

In addition to the surgical removal of the melanoma, local lymph nodes may be sampled to assess whether the melanoma has spread. The surgical removal of local lymph nodes to evaluate them for the presence or absence of cancer is a technique known as sentinel lymph node biopsy (SLNB), 

-Immunotherapy

Also known as biological therapy, these types of treatments involve specialized medical therapies that can boost the patients’ immune system. This helps the body fight cancer. These treatments are often used for patients with melanomas that have a high risk to reoccur or for metastatic disease. FDA approved immunotherapies include the following: 

    • Nivolumab
    • Pembrolizumab
    • T-VEC
    • Ipilimumab
    • Interleukin-2
    • Interferon alpha 2-b

-Targeted Therapy

Certain patients with metastatic melanoma may benefit from targeted therapy. This treatment involved the use of drugs that “target” the abnormal cancer cells without harming the normal cells. The FDA has approved the following targeted therapies for melanoma patients with a specific gene mutation:

  • Cobimetinib
  • Dabrafenib
  • Trametinib
  • Vermurafenib

-Chemotherapy

Chemotherapeutic drugs are given by intravenously or by mouth in order to destroy cancer cells. Chemotherapy has had limited success in treating melanoma. The FDA has approved Dacarbazine (DTIC) for treatment of metastatic melanoma.

-Radiation

High-energy rays may be used to shrink melanoma tumors. It can also be used to treat areas of melanoma that have a high risk of reoccurrence after initial treatment. Although not a common treatment option, radiation therapy may ease symptoms in patients with metastatic disease to the brain or bones.

-Clinical Trials

Clinical trials are research studies that test new or experimental melanoma treatments. They are available throughout the country. The best option for patients with late-stage disease may be participating in a clinical trial.

Related Article by Author:  Skin Cancer Increases the Risk of Other Types of Cancer

Prevention

To reduce the risk of melanoma and other skin cancer types:

-Avoid midday sun exposure: Sunlight intensity is strongest between 10 AM and 4 PM. Therefore, you should schedule daily activities in the early morning or later in the afternoon when possible. And remember to do this even in the winter and on cloudy days.

-Seek shade: especially midday when the sun’s rays are most intense.

-Sunscreen: Liberally apply a broad-spectrum sunscreen with an SPF of 30 or higher on all exposed surfaces year round. Be sure to reapply it often, especially after sweating or swimming.

-Avoid tanning lamps and tanning beds.

-Perform monthly self-exams: With the help of a hand-held mirror, examine the skin on all body parts. Look for new growths or changes in existing moles, freckles, or birthmarks.

 

The bottom line

To summarize, melanoma is an aggressive skin cancer but it is treatable – even curable – if caught early. As is true for all skin cancers, there are things you can do to reduce your risk of getting this cancer.

Fayne Frey, MD

Fayne Frey, M.D., is a board-certified clinical and surgical dermatologist practicing in West Nyack, New York, where she specializes in the diagnosis and treatment of skin cancer. She is a nationally recognized expert in the effectiveness and formulation of over-the-counter skincare products, and, as a speaker, has captivated audiences with her wry observations regarding the skincare industry. She has consulted for numerous media outlets, including NBC, USA Today, and, the Huffington Post, and has shared her expertise on both cable and major TV outlets.

Dr. Frey is the Founder of Fryface.com, an educational skincare information and product selection service website that clarifies and simplifies the overwhelming choice of effective, safe and affordable products encountered in the skincare aisles.

Dr. Frey is a graduate of the Weill Cornell Medical College and is a fellow of both the American Academy of Dermatology and the American Society for Dermatologic Surgery.

1 COMMENT

  1. Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well-prepared for your appointment.

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