Melanoma 101: Introduction to a Deadly Skin Cancer

  • Medical Author: Jeffrey John Meffert, MD
  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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What tests do health-care professionals use to diagnose melanoma?

Most doctors diagnose melanoma by examining the spot causing concern and doing a biopsy. A skin biopsy refers to removing all or part of the skin spot under local anesthesia and sending the specimen to a pathologist for analysis. A small shave or punch biopsy which may be adequate for the diagnosis of other types of skin cancer is not the best for melanoma. To diagnose melanoma, the best biopsy is one that removes all or most of the tumor at the time of biopsy such as an excisional biopsy in which all visible tumor is cut out initially. Fine-needle aspiration may have a role in evaluating a swollen lymph node or a liver nodule but is not appropriate for the initial diagnosis of a suspicious skin lesion.

It is no longer recommended to do large batteries of screening tests on patients with thin, uncomplicated melanoma excisions, but patients who have had thicker tumors diagnosed or who already have signs and symptoms of metastatic melanoma may be recommended to have MRIs, PET scans, CT scans, chest X-rays, or other X-rays of bones when there is a concern of metastasis, blood tests of liver, and any other studies that will assist in staging (determining the extent of spread of the tumor).

The biopsy report may show any of the following:

  • A totally benign condition requiring no further treatment, such as a regular mole
  • An atypical mole which, depending on the judgment of the doctor and the pathologist, may need a conservative removal (taking off a little bit of normal skin all around just to make sure that the spot is completely out).
  • A thin melanoma requiring surgery
  • A thicker melanoma requires more extensive surgery or extra tests in which the lymph nodes are examined. Sentinel node biopsy is a procedure in which a radioactive dye is injected into the tumor site and then draining lymph nodes are identified and removed for microscopic examination. A negative result suggests there has not yet been spread through the lymphatic chain for that area of skin. A positive result suggests there may other lymph nodes involved and will usually be followed by removal of all the lymph nodes in that drainage area. Removing lymph nodes causes physical problems even when there is no tumor present and, for that reason, is not recommended for thinner melanomas.

Some doctors are skilled in a clinical technique called epiluminescence microscopy (also called dermatoscopy or dermoscopy). They may use a variety of instruments to evaluate the pigment and blood vessel pattern of a mole without having to remove it. Sometimes the findings support the diagnosis of possible melanoma, and at other times, the findings are reassuring that the spot is nothing to worry about. The gold standard for a conclusive diagnosis, however, remains a skin biopsy.

What is the treatment for melanoma?

In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove 1 centimeter (less than ½ inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery.

Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph nodes may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like immunotherapy or chemotherapy are sometimes recommended. Many of these treatments are still experimental and, for that reason, their use may be limited to patients willing to participate in a research study.

An Internet search will name a variety of home remedies and natural products for the treatment of skin cancers, including melanoma. These include the usual topical and systemic antioxidants and naturopathic immune stimulators. There is no scientific data supporting any of these, and their use may lead to unnecessary delay in better established treatments, possibly with tragic results.

How do doctors determine the staging and prognosis (outlook) of a melanoma?

The most useful criterion for determining prognosis is tumor thickness. Tumor thickness is measured in fractions of millimeters and is called the Breslow's depth. A related prognostic measure is the Clark's level, which describes how many skin layers the melanoma penetrates. The lower the Clark's level and the smaller the Breslow's depth, the better the prognosis. Any spread to lymph nodes or other body locations dramatically worsens the prognosis.

Thin melanomas, those measuring less than 1 millimeter, have excellent cure rates, generally with local surgery alone. The thicker the melanoma, the less optimistic the prognosis. Early diagnosis and treatment are essential.

Melanoma may be staged as any other tumor according to thickness and other factors. The staging of a cancer refers to the extent to which it has spread at the time of diagnosis, and staging is used to determine the appropriate treatment. Stages 1 and 2 are confined to the skin only and are treated with surgical removal with the size of margins of normal skin to be removed determined by the thickness of the melanoma. Stage 3 refers to a melanoma that has spread locally or through the usual lymphatic drainage. Stage 4 refers to distant metastases to other organs, generally by spread through the bloodstream.

What is recurrent melanoma?

Recurrent melanoma can be a recurrence of new tumor at the site of a previous tumor, such as in, around, or under the surgical scar. It may also refer to the appearance of metastatic melanoma in other body sites such as skin, lymph nodes, brain, or liver after the initial tumor has already been treated. Recurrence is most likely to occur within the first five years, but new tumors felt to be recurrences may show up decades later. Sometimes it is difficult to distinguish recurrences from new primary tumors.

Medically Reviewed by a Doctor on 6/30/2016

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