Melanoma

Melanoma is a disease in which malignant (cancer) cells form in the skin cells called melanocytes (cells that color the skin).

Melanocytes are found throughout the lower part of the epidermis. They make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to tan, or darken.

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Anatomy of the skin, showing the epidermis, dermis, and subcutaneous tissue.

The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. The skin has 2 main layers: the epidermis (upper or outer layer) and the dermis (lower or inner layer).

There are 3 types of skin cancer:

  • Melanoma.
  • Basal cell skin cancer.
  • Squamous cell skin cancer.

Melanoma is more aggressive than basal cell skin cancer or squamous cell skin cancer.

Melanoma can occur anywhere on the body.

In men, melanoma is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma often develops on the arms and legs. Melanoma usually occurs in adults, but it is sometimes found in children and adolescents.

Unusual moles, exposure to sunlight, and health history can affect the risk of developing melanoma.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for melanoma include the following:

  • Unusual moles.
  • Exposure to natural sunlight.
  • Exposure to artificial ultraviolet light (tanning booth).
  • Family or personal history of melanoma.
  • Being white and older than 20 years.
  • Red or blond hair.
  • White or light-colored skin and freckles.
  • Blue eyes.

Possible signs of melanoma include a change in the appearance of a mole or pigmented area.

These and other symptoms may be caused by melanoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

  • A mole that:
    • changes in size, shape, or color.
    • has irregular edges or borders.
    • is more than 1 color.
    • is asymmetrical (if the mole is divided in half, the 2 halves are different in size or shape).
    • itches.
    • oozes, bleeds, or is ulcerated (a hole forms in the skin when the top layer of cells breaks down and the underlying tissue shows through).
    • Change in pigmented (colored) skin.
      Satellite moles (new moles that grow near an existing mole).

Tests that examine the skin are used to detect (find) and diagnose melanoma.

If a mole or pigmented area of the skin changes or looks abnormal, the following tests and procedures can help detect and diagnose melanoma:

  • Skin examination: A doctor or nurse examines the skin to look for moles, birthmarks, or other pigmented areas that look abnormal in color, size, shape, or texture.
  • Biopsy: A local excision is done to remove as much of the suspicious mole or lesion as possible. A pathologist then looks at the tissue under a microscope to check for cancer cells. Because melanoma can be hard to diagnose, patients should consider having their biopsy sample checked by a second pathologist.

Suspicious areas should not be shaved off or cauterized (destroyed with a hot instrument, an electrical current, or a caustic substance).

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of melanoma (whether cancer is found in the outer layer of skin only, or has spread to the lymph nodes, or to other places in the body.
  • Whether there was bleeding or ulceration at the primary site.
  • The location and size of the tumor.
  • The patient’s general health.

Although many people are successfully treated, melanoma can recur (come back).

After melanoma has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

The process used to find out whether cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • Wide local excision: A surgical procedure to remove some of the normal tissue surrounding the area where melanoma was found, to check for cancer cells.
  • Lymph node mapping and sentinel lymph node biopsy: Procedures in which a radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to have spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist then checks the sentinel lymph nodes for cancer cells. If no cancer cells are detected, it may not be necessary to remove additional nodes.
  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For melanoma, pictures may be taken of the chest, abdomen, and pelvis.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
  • Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.

The results of these tests are viewed together with the results of the tumor biopsy to determine the melanoma stage.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The Clark levels are used for thin tumors to describe how deep the cancer has spread into the skin:

 

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Clark levels of melanoma. In Clark Level I, the cancer is in the epidermis only. In Clark Level II, the cancer has begun to spread into the papillary dermis (upper layer of the dermis). In Clark Level III, the cancer has spread through the papillary dermis into the papillary-reticular dermal interface but not into the reticular dermis (lower layer of the dermis). In Clark Level IV, the cancer has spread into the reticular dermis. In Clark Level V, the cancer has spread into the subcutaneous tissue.

Level I

The cancer is in the epidermis only.

Level II

The cancer has begun to spread into the papillary dermis (upper layer of the dermis).

Level III

The cancer has spread through the papillary dermis (upper layer of the dermis) into the papillary-reticular dermal interface (the layer between the papillary dermis and the reticular dermis).

Level IV

The cancer has spread into the reticular dermis (lower layer of the dermis).

Level V

The cancer has spread into the subcutaneous layer (below the skin).

The method used to stage melanoma is based mainly on the thickness of the tumor and whether cancer has spread to lymph nodes or other parts of the body.

 

The staging system is based on the following:

 

  • The thickness of the tumor. The thickness is described using the Breslow scale.
  • Whether the tumor is ulcerated (has broken the skin).
  • Whether the tumor has spread to the lymph nodes and if the lymph nodes are joined together (matted).
  • Whether the tumor has spread to other parts of the body.

The following stages are used for melanoma:

Stage 0 (Melanoma in Situ)

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Stage 0 melanoma. Abnormal melanocytes are in the epidermis (outer layer of the skin).

In stage 0, abnormal melanocytes are found in the epidermis (Clark level I). These abnormal melanocytes may become cancer and spread into nearby normal tissue. Stage 0 is also called melanoma in situ.

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Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil eraser is about 5 mm.

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Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin). In stage IB, the tumor is either not more than 1 millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick, with no ulceration. Skin thickness is different on different parts of the body.

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

  • Stage IA: In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration. The tumor is in the epidermis and the papillary dermis (Clark level II or III).
  • Stage IB: In stage IB, the tumor is either:
    • not more than 1 millimeter thick and it has ulceration or it has spread through the dermis or into the subcutaneous layer (Clark level IV or V) ; or
    • more than 1 but not more than 2 millimeters thick, with no ulceration.

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Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.

Stage II is divided into stages IIA, IIB, and IIC.

  • Stage IIA: In stage IIA, the tumor is either:
    • more than 1 but not more than 2 millimeters thick, with ulceration; or
    • more than 2 but not more than 4 millimeters thick, with no ulceration. Stage IIB: In stage IIB, the tumor is either:
    • more than 2 but not more than 4 millimeters thick, with ulceration; or
    • more than 4 millimeters thick, with no ulceration.

Stage IIC: In stage IIC, the tumor is more than 4 millimeters thick, with ulceration.

Stage III

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Stage III melanoma. The tumor may be any thickness with or without ulceration. It has spread either (a) into a nearby lymph vessel and may have spread to nearby lymph nodes; OR (b) to 1 or more lymph nodes, which may be matted (not moveable). Skin thickness is different on different parts of the body.

In stage III, the tumor may be any thickness, with or without ulceration, and either:

  • has spread into a nearby lymph vessel and may have spread into nearby lymph nodes; or
  • has spread to 1 or more lymph nodes, which may be matted (not moveable).

Stage IV

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In stage IV, the cancer has spread to other places in the body.

Recurrent Melanoma

Recurrent melanoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the original site or in other parts of the body, such as the lungs or liver.

There are different types of treatment for patients with melanoma.

Different types of treatment are available for patients with melanoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Four types of standard treatment are used:

Surgery

Surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:

  • Local excision: Taking out the melanoma and some of the normal tissue around it.
  • Wide local excision with or without removal of lymph nodes.
  • Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and examined to see whether they contain cancer.
  • Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed for biopsy. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.

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Sentinel lymph node biopsy of the skin. A radioactive substance and/or blue dye is injected near the tumor (first panel), the injected material is detected visually and/or with a probe (middle panel), and the sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel).

Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.

Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to increase the chances of a cure, is called adjuvant therapy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

In treating melanoma, anticancer drugs may be given as a hyperthermic isolated limb perfusion. This technique sends anticancer drugs directly to the arm or leg in which the cancer is located. The flow of blood to and from the limb is temporarily stopped with a tourniquet, and a warm solution containing anticancer drugs is put directly into the blood of the limb. This allows the patient to receive a high dose of drugs in the area where the cancer occurred.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.

Chemoimmunotherapy

Chemoimmunotherapy is the use of anticancer drugs combined with biologic therapy to boost the immune system to kill cancer cells.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

There are different types of treatment for patients with melanoma.

Different types of treatment are available for patients with melanoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Four types of standard treatment are used:

Surgery

Surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:

  • Local excision: Taking out the melanoma and some of the normal tissue around it.
  • Wide local excision with or without removal of lymph nodes.
  • Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and examined to see whether they contain cancer.
  • Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed for biopsy. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.

xmelanoma_img_8.jpg.pagespeed.ic.QHTnjdPs0e

Sentinel lymph node biopsy of the skin. A radioactive substance and/or blue dye is injected near the tumor (first panel), the injected material is detected visually and/or with a probe (middle panel), and the sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel).

Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.

Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to increase the chances of a cure, is called adjuvant therapy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

In treating melanoma, anticancer drugs may be given as a hyperthermic isolated limb perfusion. This technique sends anticancer drugs directly to the arm or leg in which the cancer is located. The flow of blood to and from the limb is temporarily stopped with a tourniquet, and a warm solution containing anticancer drugs is put directly into the blood of the limb. This allows the patient to receive a high dose of drugs in the area where the cancer occurred.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.

Chemoimmunotherapy

Chemoimmunotherapy is the use of anticancer drugs combined with biologic therapy to boost the immune system to kill cancer cells.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options for Recurrent Melanoma

Treatment of recurrent melanoma may include the following:

  • Surgery to remove the tumor.
  • Hyperthermic isolated limb perfusion.
  • Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
  • Palliative treatment with biologic therapy.
  • A clinical trial of biologic therapy and/or chemotherapy as palliative therapy to relieve symptoms and improve quality of life.

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