Melanoma is one of the top 3 dermatologic malignancies and the one of the most serious and deadly skin cancers. As opposed to more commonly occurring basal cell carcinomas and squamous cell carcinomas, melanomas can exhibit a much more unpredictable and dangerous behavior that can lead to significant morbidity and death. Melanomas are much more likely to change rapidly, invade quickly, and metastasize to other organs. Even those melanomas that are small, less invasive, and caught early, can have an unpredictable course. Fortunately, it still is true that catching a melanoma early and performing a rapid and complete surgical removal is a highly successful way to treat and survive melanoma.
Melanomas are derived from melanocytes, the skin color-producing cells in the skin. These cells are not only in the skin, but also in the eye, since both areas derive their cells from melanocytes precursors. Melanocytes give our skin its color, and, also are grouped together in moles. Melanoma is the result of a malignant (cancerous) transformation of melanocytes. As there is melanoma of skin, there is also an ocular melanoma. Risk factors for melanoma include family history and sun exposure. Melanomas can initiate from previous moles or can start de novo (on it’s own without a previous mole present). A vast majority of new melanomas are the risk of cumulative sun exposure on sun exposed skin, especially if that sun exposure included a history or strong or intense sunburns. A first degree relative (parents, siblings, children) with melanoma also increases risk.
Melanomas are best identified through routine skin exams, both at home and in your primary MD / dermatologist’s office. Skin exams should be performed monthly with particular attention to any mole that seems new, different than other moles (ugly duckling sign), or is changing in any way (ABCDEs). The ABCDEs are as follows:
Asymmetry: one half of the mole looks different than the other half
Borders: moles should be round and brown; if the edges are scalloped, or if the mole looks like a country, that would be suspicious
Color: any other color other than brown or dark brown (red, blue, black, white, purple) is suspicious
Diameter: not used as often. Melanomas can be small or large.
Evolving: any mole or growth that is changing in any way (size, shape, borders, color) is suspicious
Helpful tips in skin exams include looking between your toes and paying attention in non sun exposed areas (buttocks, genitals), asking a friend or family member to look at your back, and doing self full body photography including more detailed pictures of moles that seem more concerning and you’d like to watch / follow. In the digital age, it’s fairly easy and much less inconvenient to take full body pictures as home on your smartphone. Make sure to upload these photos to a cloud service such as Google Photos, so that they are always saved and available. Should a new lesion arise that concerns you, take new pictures and compare to the previous pictures. Should there be any questions or issues, please make sure to see your physician immediately.
The treatment for melanoma depends on the depth of the tumor, lymph node involvement, and metastasis. All primary melanomas without evidence of obvious metastasis are treated with surgery. Thinner melanomas are excised with a very high 5-year survival rate. Deeper melanomas require a more extensive surgery and possible lymph node removal. Likewise, invasive melanomas may also require more intensive screening (x-rays, CT scans, labs, etc). In all cases, routine followup is strongly recommended.
Melanoma prevention and early detection is essential. Prevention involves using protective clothing, an SPF 30 or higher, and direct sun avoidance. Early detection can involve doctor office visits, self photography, and routine monthly self skin exams.
Dermatologists can aid in the education, prevention, and detection of melanoma. Dermatologists will biopsy any suspicious lesion first, and then will recommend the correct treatment based on the depth and characteristics of the lesion once confirmed. Routine excision and closures for melanomas can be done in the dermatologist’s office for those confirmed melanomas of less that 0.75mm in depth on microscopic exam. Those deeper than 0.75mm may need a sentinel lymph node biopsy (the first lymph node that the area drains to) and are usually referred to general surgeons for the excision and this procedure. Additional screening can be done by your dermatologist or the general surgeon. There are now tests to indicate metastasis risk (DecisionDx – Castle Biosciences), so that screening is adjusted more or less aggressively depending on this result.