MELANOMA

 

Meet Our Experts

Surgery - Marcus Tan (trunk and extremity melanoma)

Surgery - Lynn Dyess (trunk and extremity melanoma)

Surgery - Fred Silver (head and neck melanoma)

Medical Oncology (Tom Butler)

 

About Melanoma

In the United States in 2013, there will be approximately 75,000 new cases of melanoma, including about 1,300 cases in Alabama alone. It is the 5th most common cancer in males, and the 7th most common cancer in females. Unlike more common cancers such as breast cancer and colorectal cancer, the incidence of melanoma continues to rise.

Survival Statistics

If detected early, melanoma is a very curable cancer, with an overall 5 year survival of 91%. This is an improvement on the 82% 5 year overall survival in the mid-1970s.

If the melanoma has not spread to lymph nodes or to distant organs, 5 year survival is 98%. If the melanoma has spread to lymph nodes but not distant organs, then 5 year survival is 62%. When the melanoma has spread to distant organs, then 5 year survival is 15%.

Risk Factors  
  • Family or personal history of melanoma
  • Fair skin; blonde or red hair
  • 3 or more blistering sunburns before the age of 20 years
  • Presence of actinic keratosis
Symptoms

Most melanomas are pigmented lesions. They may occur in both sun-exposed areas of skin as well as skin that is usually covered (including toenails, fingernails). Melanomas can also occur in the eye and gastrointestinal tract.  Melanomas, compared with benign pigmented lesions, are more likely to have the following features: 

  • Size >6mm or recent increase in size
  • Asymmetry
  • Bleeding, itching, ulceration, pain
  • Different shades of pigmentation within the same lesion
  • Indistinct or irregular borders

Melanomas are not necessarily pigmented (dark). "Amelanotic" melanoma is a melanoma in which the cancer cells have lost the ability to produce pigment. If melanoma is not suspected, these non-pigmented lesions can go unnoticed and untreated for a long time.

Screening

All people should perform monthly total body skin self-examination and have a yearly skin examination by a physician (family physician, dermatologist, surgical oncologist).

Recommended links

Key statistics about melanoma from the American Cancer Society http://www.cancer.org/cancer/skincancer-melanoma/detailedguide/melanoma-skin-cancer-key-statistics

Melanoma website at the National Cancer Institute http://www.cancer.gov/cancertopics/types/melanoma

References

Siegel R, Naishadham D, Jemal A. Cancer Statistics. CA Cancer J Clin 2013; 63:11-30.

 

Diagnosis and Staging

The diagnosis of melanoma is made by biopsy of the suspicious lesion. We recommend either punch biopsy or excisional biopsy because these techniques reveal how deep the melanoma is. The depth or thickness of the melanoma is critical in determining further staging and prognosis.

Once the diagnosis has been made, certain tests will be performed to find out how advanced your tumor is. For melanoma, these tests may include:

  • Sentinel lymph node biopsy (SLNB). This may be performed once a melanoma is greater than a certain thickness or has other concerning microscopic features. It is usually performed at the same time as definitive excision of the melanoma. The purpose of SLNB is to identify the first lymph node (or nodes) that the cancer drains to. By removing this "sentinel" node, we can find out if there is cancer in that node. The presence (or absence) of cancer in this sentinel node provides important information about the likelihood of the cancer spreading elsewhere or returning after it has been removed.
  • CT scan
  • PET scan
  • Blood tests, including lactate dehydrogenase (LDH)
Stages of Melanoma

The stage of a cancer is a standardized description of how far it has spread. The higher the stage, the further it has spread. Importantly, with increasing thickness of the primary tumor, the likelihood of spread to lymph nodes (and distant organs) increases (see link to Prognostic tools, below).  Information required to determine the stage of the cancer includes:  

  • How deeply the melanoma has grown (tumor thickness)
  • Whether the melanoma is ulcerated
  • Whether the melanoma has spread to nearby lymph nodes (and if so, how many nodes)
  • Whether the melanoma has spread to other parts of the body (distant metastasis)

Staging describes three elements of a cancer's spread: 

  • Extent of the primary tumor (T stage)
  • Presence and extent of tumor spread to lymph nodes (N stage)
  • Presence of spread to other parts of the body ("metastasis;" M stage)

Complete information about the staging of melanoma can be found at the website listed below.  However, the essential details are: 

  • Stage 1 and 2: no tumor spread to lymph nodes, but increasing tumor thickness from stage 1a through to stage 2c
  • Stage 3: tumor is present in lymph nodes
  • Stage 4: tumor has spread to distant organs (distant metastasis).
Related links

Detailed melanoma staging http://www.cancer.gov/cancertopics/pdq/treatment/melanoma/Patient/page2

Prognostic tools http://www.lifemath.net/cancer/index.html

 

Treatment

Our team of physicians, consisting of surgeons, medical oncologists and radiation oncologists, work together to select the treatment strategy that is best for each individual patient.

Surgery  
  • Wide local excision is the primary treatment of most melanomas. The width of normal tissue around the tumor (surgical "margin") depends on the tumor thickness (depth of invasion). Melanomas less than 1mm thick are excised with a margin of 1cm; lesions thicker than 2mm and scalp lesions are excised with a 2cm margin.
  • Sentinel lymph node biopsy (SLNB, discussed above in staging) is usually performed for all tumors thicker than 1mm, and for select lesions 0.75-1.0mm thick.  If lymph nodes are found on physical exam or on SLNB, then an operation may be performed to remove all the lymph nodes in that region of the body (in the armpit or in the groin, typically). This operation is called a "lymph node dissection."
  • Resection of metastases. In select patients with metastatic melanoma, operations can be performed to remove sites of metastatic disease. Such operations can be to relieve intractable symptoms, or be curative.
  • Isolated limb perfusion or infusion. This therapy is an option for patients with locally advanced (but non-metastatic disease) which cannot be surgically resected. The circulation of the affected limb is isolated from the rest of the body through the use of special catheters, and then high dose chemotherapy is infused into the limb.
Chemotherapy

Chemotherapy (or systemic therapy) is a drug or combination of drugs that are given to kill cancer cells wherever they are in the body.  There have been a number of recent clinical trials that have given hope to patients with metastatic melanoma. These trials have used drugs that either stimulate the immune system (ipilimumab, nivolumab) or target a specific mutation (vemurafenib). Other, older drugs include temozolamide and interferon.

Radiation therapy

Radiation therapy is infrequently used in the treatment of melanoma. It may be used to decrease the risk of tumor recurrence after lymph node dissection.

Related links

NCCN Guidelines for melanoma http://www.nccn.org/patients/guidelines/melanoma/index.html

 

Email Newsletters

Connect With Us