Melanoma

What is Melanoma?

Melanoma is a cancer of the pigment producing cells in the epidermis, or upper surface of the skin. Melanoma generally appears as an irregular brown, black, and/or red spot on your skin. Existing moles can also become cancerous and begin to change color, size, or shape. 

As a malignant form of skin cancer, melanoma is likely to metastasize (spread) to the lymph nodes and major organs. Malignant melanoma is derived from the melanocytes, or the cells in the epidermis that produce the pigment to give color to our skin. These are the cells which cause pigment production after exposure to the sun, leading to the tanning color. These cancers are more likely to have malignant cells migrate a distance from the border of the visible cancer, and are much more capable of spreading to the lymph nodes or other organs in the body. If caught early, melanoma can be curable. 

At Yale Plastic and Reconstructive Surgery, we understand that being diagnosed with melanoma can be frightening. We also understand that you may be equally concerned with the possibility of scars or disfigurement from the cancer and its removal. Our surgeons use specialized surgical techniques to remove the melanoma from all parts of the body surface while preserving your appearance. If necessary, our surgeons can perform reconstruction at the same time that the melanoma is removed.

Types of Melanoma

Melanoma
There are three types of melanoma: cutaneous, mucosal, and ocular.

Cutaneous Melanoma
There are four major types of cutaneous melanoma: 
• Lentigo maligna melanoma appears as large, flat lesions, frequently presenting as a large freckle and most commonly found on the faces of light-skinned women over the age of 50. This form of melanoma has a lower risk of metastasis than other types. 
• Superficial spreading melanoma is the most common form of the disease. It generally originates in a pre-existing mole and is flat, or slightly raised, and a bit more uniform in color. 
• Nodular melanoma is an elevated and often rounded growth of the cancer. It is more aggressive and usually develop more rapidly than superficial melanomas. 
• Acral lentiginous melanoma occurs on the palms, soles of the feet or in the cuticle or the nail beds. They are extremely aggressive and large, with an average diameter of three centimeters.

Mucosal Melanoma
Mucosal melanomas are rare, making up only about 1 percent of all diagnosed melanoma cases. This disease occurs in mucosal tissue, which lines body cavities and hollow organs. The most common sites for mucosal melanoma are the head and neck region (including the nasal cavity, mouth, and esophagus), as well as the rectum, urinary tract, and vagina.   

Ocular Melanoma
Because the eyes contain melanocytes, or pigment-producing cells, they can be susceptible to melanoma. There are two types: uveal and conjunctival:  
• Uveal melanoma is a cancer of the uvea portion of the eye, which includes the iris, ciliary body, or the choroid. Tumors arise in the pigment cells of the uvea.   
• Conjunctival melanoma is a dangerous but slow-growing tumor that develops over months or years in the conjunctiva and eyelids.

Stages of Melanoma

When you are diagnosed with melanoma, knowing the stage is important in determining the course of treatment. "Stage" refers to the severity of the cancer, categorized by the location of the cancer, its size, and if it has spread to the lymph nodes and other body parts. The following describes the stages of melanoma: 

Stage 0 (Melanoma in situ)
  • Does not reach below the surface of the skin.
Stage I Melanoma
  • Stage IA melanoma is less than one millimeter thick and has not ulcerated. It is most likely present only in the top layer of the skin.
  • Stage IB melanoma also may be less than one millimeter thick but has ulcerated (become an open sore) and may have grown into deeper layers of the skin.
Stage II Melanoma
  • Stage IIA melanoma is either one to two millimeters thick with ulceration or two to four millimeters thick with no ulceration.
  • Stage IIB melanoma is either two to four millimeters thick with ulceration or more than four millimeters thick without ulceration.
  • Stage IIC melanoma is more than four millimeters thick with ulceration.
Stage III Melanoma
  • Stage III melanoma has spread to the lymph system or directly into the lymph nodes near the cancer, and may also have spread directly from the original tumor to areas more than four centimeters away (but not to farther lymph nodes).
Stage IV Melanoma
  • Stage IV melanoma has metastasized to more distant lymph nodes and/or to other organs.

Symptoms of Melanoma

Melanoma can appear anywhere on the body, but it most frequently occurs on the trunk area in fair-skinned men and on the lower leg in fair-skinned women. In dark-skinned people, melanoma appears in areas with the least melanin, or color, such as the palms, the soles of the feet, and the skin under nails.

If you have melanoma, you may notice changes to moles. These changes may be a thickening, scaling, itching, redness surrounding the mole, or bleeding. The American Cancer Society has adopted the "A B C D E" warning signs to watch for: 
Asymmetry - any changes in the uniformity of the shape of the mole. 
Border - any irregularity in the margins of the mole, or blurring of the borders. 
Color - various colors, with irregular shades of brown, blue, black, or loss of pigmentation of a portion of the mole. 
Diameter - an increase in the size of a mole, with a diameter greater than 6 millimeters, or a quarter of an inch (size of eraserhead of a pencil).
Evolving - Any change — in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching or crusting. 

This list should be used as a guideline. Not every symptom is included. If you have one or more of these symptoms, it does not mean that you have melanoma. If you are concerned that you may have melanoma, please make an appointment with your doctor.

Risk Factors of Melanoma

What are the Causes of Melanoma?
The incidence, or annual risk of developing this form of cancer, in the United States has been increasing each year. It is believed that the number one cause of melanoma and other skin cancers is exposure to sunlight or tanning bed UV lights. It is for that reason that the most common locations of this cancer are the exposed parts of the skin, particularly the face and neck. If you have a history of severe sunburns, you might be at an increased risk of getting melanoma.

People with fair complexions have a higher risk of getting melanoma because they often are prone to sunburns.

If you have had melanoma, the risk of developing a second melanoma is 3 to 7 percent.

People who have benign and atypical moles might be at an increased risk of developing melanoma because they might indicate a family predisposition to getting skin cancer. Currently, there are at least three distinct genes that play a role in contributing to hereditary melanoma.

Reducing Your Risk:
Minimizing your exposure to the sun and avoiding UV tanning lights can significantly reduce your risk of developing melanoma. The following are some other ways to reduce your risk:
  • Use sunscreen. Choose an SPF 15 or higher and apply it liberally 30 minutes before going outside. Remember to reapply according to product directions.
  • Stay in the shade. In addition to wearing sunscreen, stay in the shade. Try to stay out of the sun when it is strongest, between 10:00 a.m. and 4:00 p.m.
  • Cover up. Wear a shirt or other cover-up to protect your skin from the sun. An average t-shirt has an SPF factor of only 8. Clothing with a high SPF factor is becoming more popular. 
  • Wear a hat. Pick one with a large brim to protect the ears and neck. Again, there are companies that specifically make hats with a high SPF. 
  • Wear sunglasses. This will minimize your risk of ocular cancer. 
  • Protect your children. Babies under six months of age should be completely shielded from direct sun exposure; they cannot wear sunscreen. Apply sunscreen to infants over six months of age and teach older children to make applying sunscreen a regular habit before they go out to play.
Screening
At home, look for changes in existing moles as well as new growths. Here are some questions to ask yourself while doing a self-exam: 
  • Are both sides of the lesion different?
  • Are the edges notched as opposed to smooth?
  • Is the lesion a mixture of black, blue, red, and white?
  • Is the diameter greater than six millimeters? (Most melanomas are larger than the head of a pencil.)
  • Is the lesion growing in width or height?
  • Has the sensation around a mole or spot changed?
  • Is there a sore that does not heal?
It is very important to have all changing moles and growths examined by a physician so that the suspicious ones can be removed and examined under the microscope. All tumors that are diagnosed to be melanomas will require a wider re-excision of the skin at the location of the tumor, and an evaluation of potential spread to the local lymph nodes.

These recommendations serve as a guide. If you are concerned with a lesion on your skin, you should be seen by a doctor promptly.

Diagnosis of Melanoma

A prompt diagnosis for melanoma is important so that treatment can start as soon as possible. At Yale Plastic and Reconstructive Surgery, our team rapidly diagnoses and determines the stage and severity of melanoma.

Early diagnosis plays an important role in controlling this form of cancer. It is for that reason that everyone should pay close attention to the appearance of moles on the skin for possible changes that might suggest transformation to a cancer. 

Our specialists can diagnose if you have melanoma by using a device called a dermascope. A dermascope magnifies and illuminates the skin. If an area looks suspicious, we take skin tissue from the area. Our pathologists will examine the sample and provide results within one to two days. 

Sometimes, cells from the melanoma can enter the lymph system and begin to grow there. The first lymph nodes that the cells from the tumor go into are called the sentinel lymph nodes. Using a sentinel lymph node biopsy on any site of the body, we can determine the stage of melanoma and how far it has spread. A sentinel lymph node biopsy is the most accurate way of finding out how far the melanoma may have spread. This type of biopsy helps to avoid unnecessary removal of lymph node. If melanoma has not spread to the sentinel lymph node, it is highly unlikely that the melanoma has spread to surrounding lymph nodes. 

X-rays, CT scans, PET scans, and blood tests are other ways that can help determine if the cancer has spread.