Where Melanoma can spread

Melanoma

Normal Skin

The skin is the largest organ in the body. It covers and protects the organs inside the body. It also protects the body against germs and prevents the loss of too much water and other fluids. The skin sends messages to the brain about heat, cold, touch, and pain. 

The skin has 3 layers . From the outside in, they are:

• Epidermis
• Dermis
• Subcutis

The top layer of the skin, the epidermis, is very thin and serves to protect the deeper layers of skin and the organs. The epidermis itself has three layers:

• Upper
• Middle
• Bottom layer (composed of basal cells)

These basal cells divide to form keratinocytes, (also called squamous cells) which make a substance (keratin) that helps protect the body.

Another type of cell (melanocyte) is also present in the epidermis. These cells produce the pigment called melanin. Melanin gives the tan or brown color to skin and helps protect the deeper layers of the skin from the harmful effects of the sun.

A layer called the basement membrane separates the epidermis from the deeper layers of skin.

What Is Skin Cancer? 

Skin cancers are divided into nonmelanomas and melanomas.

• Nonmelanomas

Nonmelanomas (usually basal cell and squamous cell cancers ) are the most common cancers of the skin. They are called nonmelanoma because they develop from skin cells other than melanocytes. Because they rarely spread elsewhere in the body, they are less worrisome than melanomas. There are several types of non-cancerous (benign) tumors that develop from other types of skin cells. In fact, most tumors of the skin are not cancerous and rarely if ever turn into cancer.

• Melanomas

Melanoma is a cancer that begins in the melanocytes. Because most of these cells keep on making melanin, melanoma tumors are often brown or black, but this is not always the case. Melanoma most often appears on the trunk of fair-skinned men and on the lower legs of fair-skinned women, but it can appear other places as well. While having dark skin lowers the risk of melanoma, it does not mean that a person with dark skin will never develop melanoma.

Melanoma is almost always curable in its early stages. But it is also likely to spread to other parts of the body. Melanoma is much less common than basal cell and squamous cell skin cancers, but it is far more serious.

How Many People Get Melanoma Skin Cancer?
 
Cancer of the skin is the most common of all cancers. Melanoma accounts for about 4% of skin cancer cases, but it causes most skin cancer deaths. The number of new cases of melanoma in the United States is on the rise. The American Cancer Society estimates that in 2006 there will be 62,190 new cases of melanoma in this country. About 7,910 people will die of this disease.
 
What Causes Melanoma Skin Cancer?
 
We do not yet know exactly what causes melanoma skin cancer, but we do know that certain risk factors are linked to the disease. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed.

• Risk Factors for Melanoma Skin Cancer

Sunlight (UV radiation): Too much exposure to UV radiation is a risk factor for melanoma. The main source of such radiation is sunlight. Tanning lamps and booths are another source.

Moles: A mole (nevus) is a benign (not cancerous) skin tumor. Certain types of moles increase a person’s chance of getting melanoma. People with lots of moles, and those who have some large moles, have an increased risk for melanoma. These people should have frequent skin exams by a dermatologist (skin doctor). They should also examine their own skin every month and practice good sun protection.

Fair skin: People with fair skin, freckling, or red or blond hair have a higher risk of melanoma.

Family history: Around 10% of people with melanoma have a close relative (mother father, brother, sister, child) with the disease. This could be because the family tends to spend more time in the sun or because the members have fair skin, or both. Less often, it is because of a gene change (mutation) along with sun exposure. People with a strong family history of melanoma should have skin exams by a dermatologist and learn to examine their own skin as well. They need to be very careful about sun exposure.

Immune suppression: People who have been treated with medicines that suppress the immune system, such as transplant patients, have an increased risk of developing melanoma.

Age: Melanoma is more likely to happen to older people. But it is one of the few cancers that is also found in younger people.

Gender: Men have a higher rate of this cancer than women.

Xeroderma pigmentosum (XP): This is a rare, inherited condition. People with XP are less able to repair damage caused by sunlight and are thus at greater risk of melanoma.

Past history of melanoma: A person who has already had melanoma has a higher risk of getting another melanoma.

Can Melanoma Skin Cancer Be Prevented?
 
The best way to lower the risk of melanoma is to avoid too much exposure to the sun and other sources of UV light. The ideas below can help you prevent skin cancer:

• Avoid being outdoors in sunlight too long, especially in the middle of the day when UV light is most intense.
• Protect your skin with clothing, including a shirt with long sleeves and a hat with a broad brim.
• Use sunscreen and lip balm. They should have an SPF factor of 15 or more. Apply the sunscreen correctly. Many people do not use enough--a palmful is best. Put it on about 20 to 30 minutes before you go outside so your skin can absorb it. And you should put it on again every two hours. Use it even on hazy days or days with light or broken cloud cover. Don’t stay out in the sun longer just because you’re using sunscreen as that defeats the purpose.
• Wear sunglasses. Wrap-around sunglasses with at least 99% UV absorption give the best protection.
• Avoid other sources of UV light such as tanning beds and sun lamps.
• Be especially careful about sun protection for children. Teach your children to protect themselves from the sun as they get older. People who suffer severe, blistering sunburns, particularly in childhood or teenage years, are at increased risk of melanoma.
• Check suspicious moles with your doctor and have them removed if needed.

If any of the following apply to you, talk to your doctor about genetic counseling.

• You have had several melanomas already.
• Several people on one side of your family have had melanoma
• You have had melanoma at a young age.
• You have a certain kind of mole known as dysplastic nevi.
• There is a gene which has been found to have changed (mutated) in some families with high rates of melanoma. But the test for this gene is still under research. The test should be used only in special cases.

How Is Melanoma Skin Cancer Found?
 
Melanoma can be found early. Everyone can play an important role in finding this cancer.

• Skin exams

It's important to check your own skin about once a month. You should know the pattern of moles, freckles, and other marks on your skin so that you'll notice any changes. Self-exam is best done in front of a full-length mirror. A hand-held mirror can be used for areas that are hard to see. A family member can check areas such as your lower back or the back of your thighs.

Spots on the skin that change in size, shape, or color should be seen by a doctor right away. Any unusual sore, lump, blemish, marking, or change in the way an area of the skin looks or feels may be a sign of skin cancer.

Part of a routine cancer checkup should include a skin exam by a doctor or qualified health professional.

• Normal Moles

It's important to know the difference between melanoma and a harmless mole. A normal mole is most often an evenly colored brown, tan, or black spot on the skin. It can be either flat or raised. It can be round or oval. Moles are usually less than 1/4 inch in diameter, or about the width of a pencil eraser. Moles can be present at birth or they can appear later. Several moles can appear at the same time.

Once a mole has developed, it will usually stay the same size, shape, and color for many years. Moles may fade away in older people.

Most people have moles, and almost all moles are harmless. But it is important to spot changes in a mole-- such as its size, shape, or color-- that suggest a melanoma may be developing.

• Abnormal Moles

You should see your doctor if you have a mole or growth that worries you. Your doctor may have you see a dermatologist, a doctor who specializes in skin problems. There are methods (called dermatoscopy or epiluminescence) that help doctors tell the difference between a harmless growth and one that might be cancer. Using these methods could mean that a biopsy is not needed.

The ABCD rule can also help tell a normal mole from a melanoma:

• A: asymmetry – one half of the mole does not match the other half.
• B: border irregularity – the edges of the mole are ragged or notched.
• C: color – the color of the mole is not the same all over. There may be shades of tan, brown, or black, and sometimes patches of red, blue, or white.
• D: diameter – the mole is wider than about 1/4 inch (although doctors are now finding more melanomas that are smaller).

Other important signs of melanoma include changes in size, shape, or color of a mole. Some melanomas do not fit the descriptions above, and it may be hard to tell if the mole is normal or not, so you should show your doctor anything that you are unsure of.

If Cancer Is Suspected

If there is any reason to suggest that you have a melanoma, your doctor will order further exams and tests to find out if that is the case.

The doctor probably will ask about your symptoms and risk factors, including your age, when the mark on the skin first appeared, and whether it has changed in size or the way it looks. You may also be asked about whether anyone in your family has had skin cancer and about past exposure to known causes of skin cancer.

During the exam, the doctor will note the size, shape, color, and texture of the area in question, and whether there is bleeding or scaling. The rest of the body will be checked for other spots and moles. The doctor may also examine lymph nodes in the groin, underarm, or neck areas near the area in question. Enlarged lymph nodes might suggest the spread of a melanoma. You might be referred to a dermatologist.

• Types of Skin Biopsies

If the doctor thinks you might have a melanoma, he or she will take a sample of the skin to look at under a microscope. This is called a biopsy. Different methods can be used for a biopsy of a skin tumor. The choice depends on the size of the area in question and where it is found on the body. All methods are likely to leave a scar. Since different methods leave different types of scars, you should ask the doctor about this before the biopsy is done.

After a biopsy, the skin sample is sent to a lab to be looked at under a microscope. The sample may also be sent to a doctor with special training in diagnosing from skin samples.

The skin around the area of the biopsy will be numbed before the biopsy. You will feel a small needle stick and a little burning with some pressure for less than a minute, but no pain.

• Incisional and excisional biopsies: If the doctor has to look at a tumor in the deeper layers of the skin, an incisional or excisional biopsy will be done. A surgical knife is used to cut through the full thickness of skin. A wedge of skin is removed, and the edges of the wound are sewn together.
  • An incisional biopsy removes only a portion of the tumor.
  • If the entire tumor is removed, it is called an excisional biopsy. The skin in that area will be numbed before the biopsy. Excisional biopsy is the method most often used when melanoma is suspected.
• Shave biopsy: After numbing the area, the doctor "shaves" off the top layers of the skin. A shave biopsy is useful for many types of skin diseases and in treating benign moles. But it is not recommended if a melanoma is suspected because the sample may not be thick enough to find out how deeply the cancer goes into the tissues.
• Punch biopsy: In a punch biopsy a deeper sample of skin is removed. The doctor uses a tool that looks like a tiny round cookie cutter. Once the skin is numbed, the doctor rotates the tool on the surface of the skin until it cuts through all the layers of the skin and brings up a sample of tissue. Again, this method is not often used for melanoma.

Rarely, some melanomas spread so quickly that a person could have a lot of cancer in the lymph nodes, lungs, brain, or other places, while the original skin melanoma is still small. Melanoma that has spread to other parts of the body may not be found until long after the first melanoma was removed from the skin.

When this happens, melanoma in those organs might be confused with a cancer starting in that organ. For example, melanoma that has spread to the lung might be confused with a cancer that starts in the lung. There are special tests that can be done on biopsy samples to tell whether it is a melanoma or some other kind of cancer. This is important because different treatments are used for different cancers.

How are Metastases Found?

• Fine needle aspiration biopsy (FNA) can sometimes be used if the doctor suspects the melanoma has spread to organs such as the lung or liver. A thin needle is used to remove very small tissue samples from a tumor. The test rarely causes much discomfort and does not leave a scar. The FNA is not used to diagnose a suspicious mole, but it may be used to biopsy large lymph nodes near a melanoma to find out if it has spread.
• Surgical (excisional) lymph node biopsy: This method involves removing an abnormally large lymph node through a small incision. It is often done if a lymph node’s size suggests spread of melanoma but FNA did not find any cancer cells.
• Sentinel lymph node biopsy has become the standard method for finding out if the cancer has spread to lymph nodes in patients with more advanced melanoma. A surgeon injects a radioactive substance into the area of the melanoma. Within an hour, lymph nodes are checked for radioactivity to find which one is the first to drain fluid from the skin near the melanoma. Then the lesion is injected with a blue dye that will travel to the node t hat the cancer would first drain into. When this first lymph node- called the sentinel node- has been found, it will be removed and looked at under a microscope. If cancer cells are found in this lymph node, the rest of the lymph nodes in this area are removed. If the sentinel node does not contain cancer cells, further lymph node surgery might not be needed.
• X-rays: Sometimes the doctor will order x-rays of the chest to see if the cancer has spread to the lungs.
• CT (computed tomography) scans: If there is any reason to suspect that the melanoma has spread to the liver or other organs, the doctor might order CT scans. These scans use many x-ray images that are combined by a computer to give a detailed, cross-sectional view of the body. CT scans take longer than regular x-rays and you usually need to lie still on a table for 15 to 30 minutes while they are being done.
• MRI (magnetic resonance imaging) is like a CT scan except that it uses radio waves and strong magnets to produce an image. MRI scans are very helpful in looking at the brain and spinal cord.
• PET (positron emission tomography) scans: In this test, a special kind of radioactive sugar is injected into the patient’s vein. The sugar collects in areas that have cancer and a scanner can spot these areas. This test is useful when the doctor thinks the cancer has spread but doesn’t know where. Doctors find it most useful in people with advanced stages (see below) of melanoma. It is not very helpful in people with early stage melanoma.
• Nuclear bone scans: In this test a radioactive chemical is injected into a vein. The substance collects in the bones where the cancer has spread.

Staging
 
Staging is the process of finding out how widespread the cancer is. This is very important because the treatment and the outlook for your recovery depend on the stage of the cancer.

Stages are labeled using 0 and the Roman numerals I through IV (1-4). In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

There are really 2 types of staging for melanoma

• The clinical stage is based on what is found in the physical exam, biopsy, and x-rays, CT scans, etc.
• The pathological stage uses all of this information plus what is found during biopsies of lymph nodes or other organs

After looking at your test results, the doctor will tell you the stage of your cancer. The skin sample will be measured. The thinner the melanoma, the better the outlook. For the most part, melanomas less than about 1/25 of an inch in depth (about the size of a period or a comma) have a very small chance of spreading. Thicker melanomas have a greater chance of spreading. The thickness of the melanoma also guides the choice of treatment. In one method of measuring the thickness of the melanoma, the doctor uses a device something like a small ruler. This is called the Breslow measurement.

Another system describes the thickness of a melanoma in relation to layers of the skin instead of actually measuring it. The Clark level of a melanoma uses a scale of I to V (1-5) to describe which layers of the skin are involved. Higher numbers mean a deeper melanoma.

Most often, the Breslow measurement of thickness is used in staging the cancer. Sometimes, though, the Clark level shows that a melanoma is more advanced than it appears from the Breslow measurement. Because of this, both systems may be used to describe a melanoma.

In either system, the melanoma is said to have a worse prognosis if it is ulcerated; that is, the covering layer of skin is absent
 
How Is Melanoma Skin Cancer Treated? 

• Types of Surgery for Melanoma

Simple excision: Thin melanomas can be completely cured by a minor operation called simple excision. The tumor is cut out, along with an amount of normal skin at the edges. The wound is carefully stitched back together. This surgery will leave a scar.

Re-excision: If the melanoma were confirmed by biopsy, the area will need to be excised again. More skin will be cut away from the area around the melanoma and the tissue will be examined to make sure that no cancer cells remain in the skin. If the cancer is on the face, a smaller amount of tissue may be removed. A technique called Mohs surgery may be used. In this approach, the cancer is removed layer by layer until the tissue shows no signs of cancer.

Amputation: If the melanoma is on a finger or toe, the treatment may mean amputation. At one time, some melanomas of the arms and legs were also treated by amputation, but that is no longer done. Studies have shown that wide excision works as well in these cases as amputation.

Lymph node dissection: Once a diagnosis of melanoma has been made, the doctor will check the lymph nodes nearest the cancer. If the nodes are not enlarged, then a sentinel node biopsy may be done. If the sentinel node does not show cancer, then the disease has most likely not spread to other nodes. There would be no need to remove lymph nodes.

If the sentinel lymph node does show cancer, then the remaining nodes might be removed. But right now there is no proof that removing lymph nodes saves lives. Clinical trials are going on to find this out. If the nodes feel very hard or large, and the FNA biopsy shows that the cancer has spread, then the nodes are usually removed.

Removing lymph nodes can cause some upsetting side effects. Some of these can be permanent. The most troublesome is called lymphedema . Lymph nodes help drain fluid from the arms and legs. Without them, fluid can build up. This side effect, along with the discomfort of the surgery itself, is the reason lymph nodes are not removed unless the doctor thinks it’s necessary.

Surgery for melanoma that has spread: Once it looks like the melanoma has spread from the skin to distant organs (such as the lungs or brain), doctors generally assume it can no longer be cured by surgery. Even so, surgery is sometimes done because removing even a few areas of spread could help some people to live longer or to have a better quality of life.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. Chemotherapy is useful in treating cancer that has spread.

While chemotherapy drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. These side effects will depend on the type of drugs used, the amount taken, and the length of treatment.

Temporary side effects might include:

• Nausea and vomiting
• Loss of appetite
• Hair loss
• Mouth sores
• Increased chance of infection (from a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (from low platelet counts)
• Tiredness (from a shortage of red blood cells)

Most side effects go away once treatment is over. There are ways to help many of the side effects, so be sure to tell your doctor or nurse if you are having any of these problems.

Several types of chemotherapy can be used for stage IV melanoma. Although chemotherapy does not usually work as well for melanoma as it does for some other types of cancer, it may relieve symptoms or extend the life of some patients with stage IV melanoma. Recent studies have found that combining several drugs with one or more immunotherapy drugs works much better than using a single drug.

Isolated limb perfusion is a new type of chemotherapy sometimes used for treating melanomas on the arms or legs. The method temporarily separates the blood flow of the limb with cancer from the rest of the body. High doses of chemotherapy are injected into the artery feeding the limb.

Immunotherapy

Immunotherapy helps a person’s immune system to better attack the cancer. There are several types of immunotherapy used for people with advanced melanoma.

Cytokines (sight-o-kines) are proteins that "turn on" the immune system. They can help shrink stage III and IV melanomas in about 10% to 20% of patients. Side effects, though, may include fever, chills, aches and severe tiredness. One kind of approach can cause fluid to build up in the body so that the person swells up and can feel quite sick.

Interferon-alpha: Interferons are immune substances that the body makes in response to infection. Interferon-alpha2b can be used along with other treatments. In order to work, though, high doses must be used. Many patients can’t take the side effects of these high doses. These side effects could include fever, chills, aches, severe tiredness, and effects on the heart and liver. Patients having this treatment should be followed by a cancer doctor (oncologist) who has experience with this treatment.

Vaccine therapy: Weakened melanoma cells (or certain substances found in these cells) can be injected into a patient in an attempt to stimulate the body’s immune system to destroy cancer cells. This is something like the way we use vaccines to destroy viruses that cause polio, measles, and mumps. But making a vaccine against a tumor like melanoma is harder than making a vaccine to fight a virus. Clinical trials are going on to test the value of treating people with stage III or stage IV melanoma with vaccines, sometimes combined with cytokine therapy as well. This approach is still being studied. Its value has not yet been proven.

Radiation Therapy

Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. External beam radiation focuses radiation from outside the body on the skin tumor. This method may be used for treating some patients with melanoma.

Radiation therapy is not commonly used to treat the original tumor that started on the skin. But it may be used to treat cancer that has come back, either in the skin or lymph nodes, if it cannot all be removed by surgery. It may also be used to treat distant spread or to relieve symptoms of cancer that has spread to the brain or the bone. Radiation therapy used this way is not meant to cure the cancer.

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