What is Melanoma?

Melanoma is a type of skin cancer. While it is far less common than other skin cancers like a basal cell or squamous cell, it is the most aggressive and life-threatening. It is usually found in uneven black or brown moles that are new, or existing moles that have changed with time. It can also appear as a bruise or marks under fingernails. Cancer is the result of cells in the body that begin to grow out of control. Melanoma begins in Melanocytes, one of the 3 main types of cells found in the skin. Melanocytes create brown pigments, more commonly known as melanin.

This is what makes your skin appear tan or brown in color. Melanin is an essential part of your skin’s defense, as it protects other layers of skin from harmful ultraviolet rays. When the melanocytes become cancerous, they are referred to as melanoma. Other common names for this particular type of cancer are malignant melanoma and cutaneous melanoma.

The mutations can occur anywhere on your skin, but they are more likely to be on a man’s chest and back or a woman’s legs. They are also common on the face and neck. Basically, anywhere that has had a lot of exposure to the sun has an increased risk for melanoma.

However, it is possible for melanoma to develop on the eyes, mouth, and genitals, although this is much less likely. While melanoma will only start on the skin, it is possible for it to spread to other organs, and even to your bones. Melanoma cells are still capable of making melanin, which is why the tumors are more often than not a black or brown color. There are some cells, however, that do not produce melanin and the resulting tumors can be white, pink, or tan. There are three different categories of melanoma: Cutaneous Melanoma, Mucosal Melanoma, and Ocular Melanoma.

Cutaneous Melanoma is when melanoma is found on the skin and is the most common form of melanoma.

Within this category, there are 3 more groupings:

• Superficial Spreading – Superficial spreading melanoma makes up nearly 70% of all melanoma cases. This melanoma can look a lot like freckles when it first starts, but then what appeared to be new freckles begin to grow vertically. Because it is present on the surface of the skin, those who are aware of existing moles and watch for new or changing conditions often detect them themselves.
• Mucosal Melanoma- Very rare, mucosal melanoma is only 1% of melanoma diagnosis. Most common in the head and neck region, it also presents in the anorectal region, in female genitals, the esophagus, gallbladder, bowel, conjunctiva, and urethra. Because of the locations and how rare it is, melanomas are often not discovered until they are quite advanced.
• Ocular Melanoma – This is a rare form of melanoma that develops in the eye. Even though it is the most common eye cancer, ocular melanoma is still very rare. It does not develop on parts of the eye that you would notice if you were checking for spots in the mirror, but can be detected during an eye exam by an ophthalmologist.

History

Melanoma is cancer with an ancient history. First recorded by Hippocrates in the 5th century BC, he described it as melas oma, which in Greek means a dark tumor. From the 5th century to now, we have made great progressions in our understanding of these tumors.

In Peru, archeologists found mummies dating to the 4th century that had evidence of melanoma on their skeletons. These mummies were estimated to be 2400 years old. In 1787, John Hunter became the first man to operate on melanoma. He was not sure exactly what he was dealing with but knew it was cancerous. He successfully removed the tumor and had it preserved.

Because he was able to preserve it, it was examined almost 200 years later in 1968 and identified as metastatic melanoma. 1804 brought the understanding that melanoma was different than other cancers.

Rene Laennec observed the differences, which prompted the introduction of the term melanoma by Sir Robert Carswell in 1838.

Samuel Cooper, in 1844 was the first to formally address issues with melanoma that we still know to be true today. He realized that if a melanoma was caught early enough, moves could be made to remove it. Also, it was left to reach an advanced state, treatment and recovery were much less likely or successful. The belief that removal of the tumor alone was not enough to cure a patient, and that lymph nodes should also be removed was introduced in 1892 by Herbert Snow. He had correctly observed that the cancer was not always limited to a specific location and that sometimes it spread to nearby lymph nodes.

William Handley continued research of the connections with the lymph nodes when he analyzed a woman’s infected leg in 1905. Because the lymph nodes were also infected, he suggested their removal alongside the removal of the tumor itself. This was the basis for all surgical treatments of melanoma for the next 50 years. The contribution of UV radiation to an increased prevalence of melanoma was first realized in 1956 by Henry Lancaster. It was about this time that researchers were starting to realize that certain skin characteristics were more common when melanoma was involved.

These included:

Certain textures of skin

• Hair color
• Skin color
• The skin’s reaction to the sun
• Eye color

The correlation between those who had fair skin and a lot of exposure to ultraviolet radiation was also made. Today, there are areas of melanoma that we have a pretty thorough understanding of. For instance, the connection between melanoma and exposure to ultraviolet light exposure is understood. We know that ultraviolet light is what causes melanocytes to break down, and become cancerous. We also know that there are certain people who have a higher risk of development, due to characteristics of the skin and genetic contributions.

However, there are a few things that we still do not understand, such as how a melanocyte breaks down and becomes a melanoma.

That is the reason that we do not understand how to prevent melanoma from occurring in the first place. This is an area that researchers are continuing to invest time and research.

Risk Factors

A risk factor is anything that is considered a contributor to the likelihood that someone will develop a disease.

It is important to remember that just because someone has risk factors, it is not conclusive that the person will develop the disease, in this case, melanoma.

However, understanding risk factors can help an individual with awareness, so that they can be educated and vigilant in watching for warning signs and include their doctor with their concerns.

Risk factors for melanoma include:

• Fair Complexion. This encompasses having fair, freckled skin that burns easily or does not tan, blue or green eyes, red or blond hair.
• Exposing the skin to either natural or artificial sunlight over a long period of time.
• Exposure to environmental factors, such as radiation, solvents, vinyl chloride, and PCB’s. One could be exposed to these environmental factors and more from the air, homes, workplaces, or even food and water.
• A childhood history of blistering sunburns.
• The presence of either a lot of small moles or several large ones.
• A family history of unusual moles or melanoma. Nearly 10% of those diagnosed with melanoma have family members who have also been diagnosed.
• A personal history of cancer. If you have had a melanoma or even other cancers in the past, you are at increased risk of developing melanoma again.
• Being white.
• Men are more likely to develop melanoma than are women.
• A weak immune system. A healthy immune system will help the body fight cancer cells before they get out of control.
• Any gene changes that relate to melanoma.

Being aware of risk factors can also help you to lessen your risk.

While some risk factors like family history and race you can do nothing to influence, you can avoid the things you do have control over, such as avoiding tanning beds and applying sunscreen when you are going to be outdoors. Although it is much more common for those who are white or very fair to develop melanoma, those who are dark-skinned are subject to the same risks.

Just as having many risk factors does not mean you will develop melanoma, and having few to no risk factors does not automatically mean you will not develop it.

Screening

Because anyone can develop melanoma, and it is an especially aggressive cancer; it is important to ensure that it is caught early before it is allowed to progress to stages that do not have excellent survival rates.

In order to be thoroughly aware of moles and growths, it is important to perform monthly self-examinations. Doing this ensures that should change or new growths occur, you will be on top of it early. Additionally, annual visits to a dermatologist are helpful. A dermatologist not only better knows what to look for, but will be able to assist with checks to less common and harder to see areas of the body. Having the assistance of a professional can also help to ease your mind, and know that should anything be a concern, you know where to go for immediate help.

When you attend your yearly exam, a doctor will check all moles, growths, and look for suspicious spots on your entire body. This includes the scalp, fingers, toes, fingernails, toenails, and more.

They may even take pictures of certain moles or growths so that they have a physical record to compare any changes to at your next visit.

In order to perform a monthly at-home self-check, follow these steps:

• Using full-length and hand mirrors, thoroughly examine your entire head and scalp. Because hair can hide a lot, you may find it helpful to use a comb and blow dryer to part your hair for maximum visibility.
• Check hands, including your fingernails. Using mirrors, look under your armpits, on and under elbows, arms, and underarms.
• Check your neck, behind both ears, chest, and stomach. For women, be sure to check under the breasts.
• Again using your mirrors, check the back of your neck, your back, and shoulders, buttocks, and your legs.
• Inspect feet, insides and outsides, heels, and nails.
• Check genitals, using a mirror.

It is impossible to see any melanomas located in the eye just by looking in the mirror. So in order to catch ocular melanoma be sure to schedule and keep yearly visits with an optometrist. The tools that they use to look in your eye will allow them to see any unusual spots. Nearly all cases of ocular melanoma are caught at an optometrist appointment. It is important to do a self-examination every month.

Set aside a date on the calendar, such as the first day of the month, or the last Saturday, whatever will be easiest for you to remember. If it helps you to keep track of changes, keeping a health journal may be a good idea. Take pictures of anything you are concerned about, and record measurements or concerns that you wish to discuss with your dermatologist. Making skin checks a part of your regular routine can save your life, as melanoma that is caught early has a very high survival rate.

Symptoms

Melanoma signs are varied and may be quite different from person to person, or even location to location. Some look like moles that have grown or changed, others look like bruises or sores that have not healed with time. Sometimes, a blue or black streak under a finger or toenail is melanoma. Whatever the case, it is helpful to always have a good idea of what moles or bruises you have so that you can keep an eye on them and be aware of any changes as early as possible.

The first signs of the presence of melanoma are:

• An existing mole has changed, whether in size or color.
• A new mole or growth has developed.

Melanoma does not always start in a mole. It can also begin in otherwise healthy-looking skin. A convenient method for checking for what is considered unusual is to think of your ABC’s, more specifically, ABCD and E.

A– Stands for asymmetrical. Asymmetrical moles will have shapes that are irregular. If you draw a line through the very middle of the mole, the two sides will be different in shape.

B- Stands for the border. Cancerous moles often have borders that are notched, scalloped, or blurred.

C- Stands for color. If a mole has an unusual color, or if it is composed of several colors, it should be looked at further. It is normal for a mole to be black, brown, tan, or pink, but not normal for 2 or more of those colors to be present in the same mole.

D- Stands for diameter. Watch especially moles that have grown to ¼ of an inch, or 6 millimeters. Think about the size of a pencil eraser, that is close to ¼ inch.

E- Stands for evolving. This is where being aware of existing moles comes in handy. Watch for changes that occur over time, like moles that are growing, changing color, or changing shape.

Other melanoma symptoms that are not included in ABCDE include:

• Sores that do not clear up with time.
• Moles that have a red or infected looking border.
• Any pain, tenderness, or itchiness on or around a mole or growth.
• Moles with texture changes, like scales.
• Any bleeding or oozing from an existing mole.

Because melanoma is difficult to treat as it progresses, it is always a good idea to consult with your doctor if you have a mole or growth that has caused concern. A doctor will be better equipped to know if it is something that needs to be investigated further, and the correct course of action. They will also be able to help you check for changes in places that are harder to see and less often checked.

Diagnosis and Stages

If one has a family history of melanoma, or if they have some of the common makers for the development, they should keep an eye out for suspicious growths themselves and consider having annual screenings. This is especially important as growth caught early is the easiest to treat. There are instances when a doctor will be able to tell if a spot is cancerous just by looking at it. To ensure accuracy, any suspicious mole will need to undergo a biopsy. In order to do a biopsy, the mole or other growth is removed and examined by a pathologist.

There are a few different ways a biopsy is performed, including:

• Punch Biopsy: Using a circular bladed tool, a doctor will press into the skin around a mole and remove a round piece of skin.
• Excisional Biopsy: This biopsy removes all the mole or growth, including some of the surrounding skin that still appears normal.
• Incisional Biopsy: In this procedure, only the part of the mole that appears most irregular is removed and analyzed in a laboratory.

The biopsy procedure chosen will depend on the specifics of the mole or growth in question. Most doctors prefer to remove the entire mole when it is possible. The main reason an incisional biopsy is performed is if the mole is very large or for some reason cannot be easily removed. Other methods of diagnosis may include the use of x-rays, MRIs, CT scans, PET/CETs, ultrasounds, or LDH testing.

Depending on the outcome of the biopsy, the lymph nodes may be examined. This is done to determine if any cancer cells have metastasized and spread beyond the original growth. If no melanoma is found within the lymph nodes, no further testing will need to be done. Lymph node involvement will help to classify the stage of the melanoma and help the doctor determine the appropriate treatment path.

Once biopsies of growths and lymph nodes have been completed, doctors will determine the stage of the melanoma to better determine what treatment should be pursued. Because melanoma is so aggressive, it is very important to determine the correct stage to be confident that the treatment will be effective. The staging method most commonly used was published in 2009 by the American Joint Commission on Cancer, called the TMN System.

The TMN System works as follows:

T stands for tumor. A number will follow the T and is used to convey tumor thickness.

N stands for the node, and the number following will refer to the extent of lymph node involvement

M metastasis, which means the tumor has spread. The corresponding number refers to the extent of the spreading.

The stages are generally determined by the thickness of the tumor, the extent to which it has spread, and its prognosis.

Stage 1 – Because a tumor at Stage 1 is unlikely to have spread, surgical removal leads to an excellent prognosis.

Stage 2 – At this stage, the melanoma is still curable, but maybe less successful than a Stage 1 melanoma due to the fact that some of the cancerous cells may have traveled to other locations not surgically removed.

Stage 3- In this stage, it is known that cancer has spread. It is at this stage that survival rates begin to lessen.

Stage 4 – This stage generally signifies a spreading of cancer that is beyond what simple removal procedures can help as it has spread to places like the lungs, liver, or brain. The chances of someone with this stage surviving 5 years are very small.

Treatments and Drugs

Treatment for melanoma largely depends on the stage. Other factors that will be considered are your current health besides melanoma and personal preference. For melanomas that are caught early, surgical removal may be all the treatment necessary. In fact, it is not uncommon for very shallow melanomas to be removed completely during a biopsy.

Typically, a very small amount of unaffected skin is also removed along with the mole or growth. Not all melanoma removals are this simple, however, and those with a higher stage can require much more invasive treatments. If melanoma has spread beyond a single point on the skin, these are a few of the courses of treatment that may be taken:

• Lymph Node Surgery: When the cancer is present in surrounding lymph nodes, your doctor will also work to remove them. Depending on the severity, your doctor may also recommend further treatments.
• Chemotherapy: Chemotherapy is the process of using drugs that can kill cells that are compromised. There are several ways that chemotherapy can be administered, including intravenously or in pill form. If the cancer is localized to a leg or arm, blood flow can be restricted to that area allowing a targeted treatment.
• Radiation: Radiation is the use of high-powered energy beams to target cancer cells. This is often used in conjunction with surgery to remove affected lymph nodes.
• Biological therapy: Biological therapy consists of treatments designed to boost the body’s immune system, better positioning it to fight cancerous cells itself. The treatments are either substances already made by the body or similar ones that are designed in a lab. Biological therapy treatments often produce side effects that are like having the flu, such as chills, fatigue, fever, headache, and muscle aches.
• Targeted Therapy: Targeted therapy utilizes different medications that specifically target any weaknesses specific to the cancer cells.

Treatment is largely determined by the stage of melanoma one is dealing with. The following list is a more specific breakdown of what treatments are likely to be considered because of a specific stage diagnosis.

Stage 1: Stage 1 melanomas will typically be surgically removed, including a small amount of surrounding skin tissue.

Stage 2: This stage also includes surgical removal, but one can expect more extensive amounts of the surrounding skin to be removed. This is determined by the thickness and size of the melanoma in question. Because this stage often includes lymph node involvement, they will be biopsied as well.

If cancer is found, all the surrounding lymph nodes may be removed in the following surgery. If this is the case, further drugs or vaccines may be recommended.

Stage 3: Because at this point lymph nodes are involved; the tumor and surrounding lymph nodes will be removed immediately. Drug therapies may be used to keep cancer from recurring. Radiation therapy and any applicable clinical trials may be introduced.

Stage 4: At this point, cancer has spread beyond the original tumor and well past surrounding lymph nodes. Depending on the location, any metastasized tumors will be surgically removed and others treated with radiation, chemotherapy, or targeted therapy.

Coping and Support

The discovery that you have cancer can be terrifying and can cause stress in many areas of your life. These stresses can range from emotional, physical, and financial.

No matter the stage or prognosis, your cancer treatment will include some level of side effects and it important for you to understand what you are going through and to know that you do not have to do it alone. At any point during finding out your diagnosis to post-treatment, it is normal to be stressed and scared, regardless of age, stage of cancer, or any side effects you may or may not have.

Emotions are complicated and are often hard to deal with and understand when you are coping with cancer. You may feel anger, anxiety, and frustration as you try to deal with your new reality. It can often be difficult to express how you feel to family or friends, and difficult for many to assume the role of a patient who will sometimes need to accept help. Other times, it can be difficult when those you love the most do not know how to talk to you because they do not understand everything you are dealing with. Your health care team is familiar with all of this and knows how to encourage family and friends to understand what all is happening.

They will also know how best to direct you to local emotional and social help that can be beneficial to helping you get through this difficult period. Cancer treatments are never pleasant, no matter what level of treatment your specific case requires. Understanding what your specific treatment path entail can help you to prepare for any side effects so that you can better control them.

Talk to your health care team about different massages, clothing choices, and medications that can help you with side effects. Have a spouse or loved one attend this meeting so that they understand how to help and why it is important. Financially, cancer treatments can be a huge burden. Regardless of insurance coverage, there are often many unplanned and unexpected costs that are related to care and recovery.

Some people even find that the high costs prevent them from continuing with treatments they need to recover. It is important to not let the fear of financial implications stop you from receiving treatments, and in fact, stopping now could lead to much more expensive costs in the future. There are many places that will help you to manage your money and plan for unexpected costs.

Or to budget for the bills you are already receiving. Regardless of what your melanoma situation is, it is important to remember that everyone deals with stress and needs to have help coping.

Thankfully, the help available is plentiful and readily available. If you do not know where to go to get started with help, talk to your health care team.

They understand the importance of your mental health to a full recovery and will work with you to ensure that you are not only receiving the best medical care possible but that you are coping with everything the best that you can.