Skin Cancer/Melanoma Team

Patients with melanoma may be referred to the Skin Cancer Team at Scott & White by contacting the Team Coordinator at 254-724-3675 or 800-882-4366.

About Melanoma

Cancer of the skin is the most common of cancers, probably accounting for at least half of all cancers. Melanoma accounts for less than 5% of skin cancer cases but causes a larger majority of skin cancer deaths. The American Cancer Society estimates that about 68,720 new melanomas will be diagnosed in the United States during 2009. Incidence rates for melanoma increased sharply at about 6% per year in the 1970s. During the 1980s and 1990s, the rate of increase slowed to a little less than 3% per year. Since 2000, the rate has been fairly stable. Of the three forms of skin cancer (basal cell cancer, squamous cell cancer and melanoma), melanoma is the most serious since it is more likely to metastasize (spread to distant areas of the body such as lymph nodes, lung, bone or brain) and become potentially fatal.

What Are the Risk Factors?

Although anyone can get melanoma, there are many risk factors that increase a person’s chance of developing one:

1. Light colored skin/freckles
2. History of severe sunburn during childhood
3. Multiple dysplastic nevi (a syndrome in which one has greater than 100 unusual moles)
4. Congenital nevi (moles present at birth that are larger than a quarter)
5. Family history of melanoma

How do I know if my mole is suspicious for melanoma?

The ABCDs of melanoma are the warning signs:

A symmetry	– if the mole is divided in half, the two halves do not look the same
B orders	– a suspicious mole has irregular (not smooth) borders
C olor	– a suspicious mole will have different shades of color within the same lesion
D iameter	– a suspicious mole will be greater than 6mm (pencil eraser size) in diameter

Other warning signs include:

1. A mole that has been present for years that starts changing in size or color
2. Change in the skin surrounding a mole including redness or new moles
3. Change in the texture of a mole including ulcerations or bleeding

Basically, if a mole is changing in any way, it should be checked by a physician.

What are the different kinds of melanoma?

Superficial spreading – This form of melanoma accounts for 70 percent of all melanomas. It is flat, although it may contain lumpy areas and has irregular borders.

Nodular – This form of melanoma accounts for 15 percent of all melanomas. It is a rapidly growing form that metastasizes early. It is a raised berry-like nodule that is dark in color.

Acral lentiginous – This melanoma accounts for 10 percent of all melanomas. It is flat and is found on the palms of the hands, soles of the feet and under nails.

Lentigo Maligna – This form of melanoma accounts for 5 percent of all melanomas. It is usually a dark brown to black lesion inside a background of lighter brown and is a slow growing form of melanoma. It is frequently found on the face.

What is the prognosis?
There are predictions that can be made about the prognosis (length of survival) in melanoma based on the depth of the lesion into the skin.

There are two methods used today:

Clark Level	Breslow Thickness
I. – in situ (not invasive)	Up to 0.75mm
II. – Involves epidermis and papillary dermis	0.76mm – 1.5mm
III. – Invades to the papillary - reticular dermal junction	1.5mm – 4.0mm
IV. – Invades the reticular dermis	> 4.0mm
V. – Invades the structures deep to the skin (fat, muscle)

The level of a melanoma is determined at the time of surgical excision. Melanoma can spread through the bloodstream to the lungs, liver or bone. Melanoma can also spread through the lymphatic system to the lymph nodes. If either of these events have occurred, the prognosis is poor.

What is the treatment?

All melanomas must be surgically removed. Additional treatments depend on the stage of the melanoma. Although Clark level and Breslow thickness are determined to help predict prognosis, treatment is based on the clinical stage of the melanoma. Here is a simple staging system:

Stage I
The tumor is less than 1.5mm thick and is confined to the outer layer of the skin (epidermis) or the upper part of the inner layer of skin (dermis).

Stage II
The tumor is 1.5mm to 4mm thick and involves the lower portion of the dermis but not tissues deep to the skin or surrounding lymph nodes.

Stage III
The tumor may be greater or less than 4mm, but has at least one of the following:

• Satellite tumors (other tumor growths within one inch of the original tumor)
• Involvement of tissues adjacent to the skin (underlying fat or muscle)
• Involvement of nearby lymph nodes

Stage IV
The tumor has spread to distant areas of the body such as brain or lung.

Treatment

Surgical removal is the primary treatment for all stages of melanoma. Typically, 1-2 cm margins around the tumor are taken at the time of surgery. Reconstruction of the defect that is created may be necessary. This may involve the use of skin grafts or transfer of muscle to cover the area where the melanoma was removed.

• A procedure called sentinel lymph node mapping is now being performed in order to look for melanoma cells in the lymph node basin that drains the tumor, which would indicate spread of the cancer. In this procedure, the tumor is injected with blue dye and/or radiolabled material. Then, during the operation, the surgeon looks at the lymph nodes that drain the area of the body where the tumor is located and finds the lymph node that contains blue dye and radioactive material (using a sensor probe). This is called the sentinel node since it is the node that the tumor drains into first. This node is then studied by the pathologist and evaluated for cancer cells. If there are no cancer cells present, then the melanoma most likely has not spread to the lymph nodes or other areas of the body. If there are cancer cells present, then all of the lymph nodes in that area are removed.
• If the melanoma has metastasized, or spread to distant areas of the body, surgical removal of these lesions is sometimes performed, although it is usually not curative. Surgical removal of metastases may prolong survival and improve quality of life.
• Chemotherapy is often used for metastatic or recurrent melanoma. Again, chemotherapy is not intended as a cure, but can improve quality of life or prolong survival.
• Immunotherapy and vaccines are also being used in the treatment of melanoma. Interleukins and interferons are drugs that boost the patient’s immune system and may aid the body in fighting off cancer cells. Vaccines use proteins from the cancer cells themselves in order to stimulate the body's immune system to attack cancer cells. Both of these therapies show promise in increasing survival for melanoma patients.
• Radiation therapy is not a primary treatment in melanoma since this form of cancer is highly resistant to radiation effects. However it is sometimes used in metastatic melanoma to relieve pain.

How can I reduce my risk? Although the development of melanoma cannot be completely attributed to one source, one fact is certain - sun exposure increases the risk more than any other risk factor. Heredity seems to play a definite role; but in terms of prevention, avoidance of the ultraviolet rays found in sunlight and tanning beds is the best way to reduce your risk of developing a melanoma. Using a sunscreen that is greater than SPF 15 or wearing protective clothing/hats can also reduce the risk.

Most importantly, if you have a mole that you think might be suspicious, do not delay in visiting your physician to have it checked. Early diagnosis and surgical removal are the best ways to increase your chance of surviving melanoma.

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