Melanoma Symptoms and Diagnosis

Melanoma
Understanding and Combatting Skin Cancer

What is Melanoma?

Melanoma is a serious form of skin cancer that originates in the melanocytes, the pigment-producing cells found in the outer layer of the skin, known as the epidermis. These cells are responsible for the production of melanin, the pigment that gives skin its color.

Development of Melanoma

In melanoma, the melanocytes begin to grow uncontrollably, leading to the formation of a tumor. This uncontrolled growth can occur due to various factors, including genetic mutations, excessive sun exposure, and environmental influences. While melanomas are most commonly associated with dark brown or black pigmentation, they can also present in a variety of other colors, such as red, blue, or white, making early detection challenging.

Key Characteristics

Appearance: Melanomas often appear as unusual moles or spots on the skin, exhibiting asymmetry, irregular borders, and varying colors. They can change in size and may have a diameter larger than 6mm.

Location: Melanoma can develop anywhere on the body, but it is most frequently found in areas that have been exposed to the sun, such as the back, legs, arms, and face. However, it can also occur in areas not typically exposed to sunlight.

Types: There are several subtypes of melanoma, including:

Superficial spreading melanoma: The most common form, characterized by a flat or slightly raised, irregularly shaped lesion.

Nodular melanoma: This type appears as a raised, darkly pigmented bump and tends to grow quickly.

Lentigo maligna melanoma: Typically found in older adults, it often appears as a flat, tan or brown spot on sun-damaged skin.

Acral lentiginous melanoma: A rare form that occurs on the palms, soles of the feet, or under the nails, often seen in individuals with darker skin tones.

Importance of Early Detection

Early detection is crucial in improving the prognosis for individuals diagnosed with melanoma. Regular self-examinations and awareness of the ABCDE rule can aid in identifying suspicious moles or changes in existing skin lesions. The earlier melanoma is detected, the easier it is to treat, often resulting in a higher cure rate.

Understanding what melanoma is and recognizing its characteristics can significantly impact outcomes for those affected. With awareness and vigilance, individuals can take proactive steps toward monitoring their skin health and seeking medical evaluation for any concerning changes.

Who Gets It?

In 2019, melanoma was the 7th most common type of newly diagnosed cancer for both males and females in the United States. Among youth and young adults (ages 15 to 29), melanoma ranked as the 4th most common newly diagnosed cancer, accounting for approximately 7% of the total new cases diagnosed, following thyroid, testicular, and Hodgkin lymphoma.

Approximately 100,000 people in the United States are expected to be diagnosed with melanoma in 2020, with an estimated 6,850 deaths resulting from the disease. While the incidence rates of some cancer types have been decreasing annually (e.g., laryngeal cancer for both sexes, lung cancer in males, and cervical cancer in females), melanoma remains one of the few cancers with increasing rates each year.

In males, the incidence rate for melanoma has increased steadily at approximately 2.2% per year since 1984, marking it as the 3rd-largest overall increase in incidence rates for males, following thyroid cancer (6.4%) and multiple myeloma (2.6%).

In females, the incidence rate for melanoma remained stable from the mid-1980s to the mid-1990s; however, since 1994, the rate has increased by 2.0% per year, representing the 2nd-largest overall increase in incidence for females, after liver cancer (2.7%).

Studies indicate that older, fair-skinned men are more likely to die from melanoma than any other demographic group. A lack of awareness about the disease and its frequent occurrence in hard-to-see areas—such as the back—are likely contributing factors to this increased mortality.

In the United States, the lifetime risk of developing melanoma for men is currently about 1 in 29, while for women, it is approximately 1 in 40. In comparison, the lifetime risk of melanoma for North Americans in the 1930s was around 1 in 1,500.

What Causes It?

Excessive exposure to ultraviolet (UV) radiation from the sun and tanning beds is a primary factor in the development of melanoma and is the most preventable cause. Experts estimate that about 90% of melanomas are associated with severe UV exposure and sunburns experienced over a lifetime.

Factors contributing to increased risk include:

Geographic Location: Individuals living in areas with high UV radiation, such as closer to the equator or at higher altitudes, are at greater risk.

Skin Type: Fair-skinned individuals, particularly those with red or blond hair, blue or green eyes, and a tendency to freckle, have a higher susceptibility to UV damage.

Family History: A family history of melanoma or other skin cancers increases one's risk of developing the disease.

Number of Moles: People with a higher number of moles, particularly atypical or dysplastic moles, are at increased risk.

Previous Skin Cancer: Having a history of nonmelanoma skin cancer increases the likelihood of developing melanoma.

Taking preventive measures, such as wearing sunscreen, avoiding tanning beds, and seeking shade, can significantly reduce the risk of developing melanoma.

How Can I Protect Myself?

The best ways to protect yourself from melanoma include:

Understand Your Risk: Familiarize yourself with the well-known risk factors for melanoma, such as fair skin, a history of sunburns, and family history.

Learn the Early Signs of Melanoma: Educate yourself on the early signs of melanoma by referring to resources like the Skin Cancer Self-Examination guide. Knowing how to check your skin and what to look for is crucial.

Protect Yourself from the Sun: From spring to fall, take precautions to shield yourself from the sun’s harmful rays. This includes:

Wearing broad-spectrum sunscreen with an SPF of 30 or higher.

Seeking shade, especially during peak sun hours (10 a.m. to 4 p.m.).

Wearing protective clothing, wide-brimmed hats, and sunglasses.

Avoid Tanning Beds: Stay away from tanning beds, which can significantly increase your risk of developing melanoma.

Conduct Monthly Skin Checks: Perform monthly self-examinations of your skin to monitor for any changes, new moles, or unusual spots.

Consult a Doctor for Suspicious Spots: If you notice any suspicious changes on your skin, such as asymmetrical moles, irregular borders, multiple colors, or growths that itch or bleed, consult a healthcare professional promptly.

By taking these proactive measures, you can significantly reduce your risk of melanoma and ensure early detection if it does occur.

Early Detection Linked to Survival

Unlike many other cancers, melanoma is distinctly visible on the outer surface of the skin. When detected in its early stages, the tumor is usually thin and has not yet spread to the lymph nodes. This early-stage melanoma is highly treatable and often curable through surgical removal.

Regular skin examinations, both by yourself and by a healthcare professional, are crucial for early detection. The sooner melanoma is identified, the better the chances of successful treatment and long-term survival. Being proactive about monitoring your skin can make a significant difference in outcomes.

Risk Factors

Individuals who are more likely to develop melanoma often have the following characteristics:

Fair, Sun-Sensitive Skin: Skin that burns easily rather than tans, with freckles, red, or blond hair.

Numerous Moles: More than 50 moles on the body.

Unusual Moles: Moles that are large, asymmetrical, or exhibit irregular color or shape.

Family History: A close family history of melanoma, or a personal history of the disease.

Excessive UV Exposure: High levels of exposure to ultraviolet (UV) radiation from the sun or tanning beds.

History of Severe Sunburns: Previous severe sunburns can significantly increase risk.

The risk of developing melanoma multiplies when several of these factors are present, such as having both unusual moles and a family history of melanoma.

It's important to note that melanoma can also occur in individuals without any known risk factors, including those with darker skin tones.

Why Should I Check My Skin?

Many people are effective at detecting melanoma on their own skin or that of a family member. Research indicates that 53% of melanomas are discovered by patients themselves, while an additional 17% are identified by family members. Regular skin checks can lead to early detection, significantly improving survival rates; early-stage melanomas have a cure rate of over 90%, meaning that lives can be saved.

Conducting a skin self-exam is simple and only requires about 10-15 minutes once a month. Recent studies have shown that individuals at risk who have a friend or family member assist with skin checks tend to find melanoma at much earlier stages, resulting in a 63% lower death rate compared to those who do not regularly check their skin.

It’s also important to note that having a history of melanoma increases the risk of developing not only melanoma again but also non-melanoma skin cancers. The risk of melanoma recurrence is particularly high if the disease is diagnosed at advanced stages.

What Does Melanoma Look Like?

Melanoma can develop in weeks, months, or even years. It may appear as a new mole or freckle-like spot on the skin, or it can develop within an existing mole. While melanomas are typically dark brown or black, they can also present a mixture of colors, including blue, gray, and red.

The most common locations for melanoma are:

In men: the back

In women: the legs

However, melanoma can also appear on the arms, scalp, or face. Although it is less common in individuals with darker skin, melanoma can still manifest on the soles of the feet, toenails, and palms of the hands.

To help detect melanoma early, remember the ABCDEs:

Asymmetry: One half of the mole or spot is different from the other.

Border: The edges are irregular, ragged, notched, or blurred.

Color: The color is not uniform and may include shades of brown, black, or patches of pink, red, white, or blue.

Diameter: The mole is larger than 6mm (about the size of a pencil eraser), though melanomas can sometimes be smaller when first detected.

Evolving: The mole or spot is changing in size, shape, or color.

Being vigilant about these characteristics can help you catch melanoma early when it is most treatable.

The Ugly Duckling Sign

One useful tip for detecting melanoma is the Ugly Duckling Sign. Most moles on your body tend to look similar, but melanomas typically stand out. The Ugly Duckling Sign suggests that if you notice a spot that looks or feels different from all your other moles—whether in color, shape, or size—it may warrant further investigation.

Generally, only one melanoma appears at a time, making it important to pay attention to any moles that change differently compared to others. If you find a mole that seems unusual or has recently changed, it’s crucial to consult your dermatologist or family doctor as soon as possible.

What If a Suspicious Spot or Mole Is Found?

If you discover a suspicious spot or mole, it’s important to see your dermatologist or family doctor as soon as possible for a thorough examination. They may recommend a skin biopsy, which can typically be performed under local anesthesia. During this procedure, a small sample of the lesion will be removed for analysis. A pathologist will then examine the sample to determine whether it is benign or malignant.

What If Melanoma Is Found?

If a biopsy confirms a diagnosis of melanoma, further surgery will typically be necessary to remove a margin of healthy tissue around the tumor. This procedure aims to eliminate any remaining cancer cells that may be present at the melanoma site.

Receiving a cancer diagnosis can be an emotional shock for many patients. It’s essential to express any concerns regarding the diagnosis, and some individuals may benefit from speaking with professional counselors or mental health professionals to help navigate this challenging time.

Factors Affecting Treatment

The primary factor in determining the treatment plan for melanoma is the depth of the tumor in the skin, measured by the pathologist using the Breslow index. Generally, the deeper the melanoma, the greater the risk of spread and recurrence.

Melanomas that are less than 1 mm thick rarely metastasize. In such cases, treatment typically involves the surgical removal of the melanoma along with a surrounding margin of healthy skin. Other factors that can influence treatment decisions include the location of the melanoma on the body and whether the tumor exhibits ulceration.

Further Tests

If the melanoma is thicker, typically more than 1 mm, a lymph node biopsy is often recommended to check for cancer cells in the lymph node nearest to the melanoma. The results from this biopsy are crucial in determining the stage of the melanoma and informing the appropriate treatment plan. This biopsy is often performed during the surgical procedure to remove the melanoma.

In addition to lymph node biopsy, other diagnostic tests may include blood tests, a CT scan, or a PET scan, which uses nuclear medicine to provide detailed images of the body's tissues and organs. These tests help assess whether the cancer has spread and guide treatment decisions. (See Stages of Melanoma.)

Types of Melanoma

Melanoma can be classified into four main types, each with distinct characteristics:

Superficial Spreading Melanoma: This is the most common type, accounting for approximately 70% of all melanoma cases. Superficial spreading melanoma typically grows horizontally across the skin before penetrating deeper layers. It's essential to monitor for spots or moles that appear to be growing or spreading, as this is a key indicator of this type.

Nodular Melanoma: This form of melanoma is considered more dangerous due to its rapid downward growth into the skin. Nodular melanoma often appears in areas that are not typically exposed to sunlight, such as the trunk or limbs. It generally presents as a raised lesion that is usually very dark but can sometimes appear reddish. Because of its aggressive nature, early detection is crucial.

Lentigo Maligna Melanoma: Commonly found on body parts that are consistently exposed to direct sunlight, this type of melanoma is frequently seen in older individuals. It often manifests as a large, flat brown patch with varying shades of brown and black. Lentigo maligna melanoma can take years to develop, making regular skin checks especially important for older adults.

Acral Lentiginous Melanoma: This is the most common type of melanoma among individuals with darker skin tones and those of Asian descent. Acral lentiginous melanoma typically appears on the soles of the feet, palms of the hands, and under toenails and fingernails. Its occurrence in areas that are not usually sun-exposed can lead to delays in diagnosis, underscoring the importance of self-examinations in these areas.

Understanding these types of melanoma is vital for early detection and effective treatment. Regular skin checks and awareness of changes in your skin can help catch melanoma in its early stages.

Stages of Melanoma

Melanoma is categorized into five stages, determined by the tumor's thickness and other characteristics. These stages are crucial for guiding treatment decisions, assessing the risk of recurrence, and determining the need for further tests.

Stage 0

Melanoma in Situ: At this earliest stage, the melanoma is confined to the outer layer of the skin (the epidermis) and has not invaded deeper tissues. Treatment involves surgical removal of the melanoma and a margin of surrounding skin, which generally results in an excellent prognosis.

Stage 1

Early Melanoma: This stage includes very early melanomas, which are still relatively thin. Depending on specific characteristics, a sentinel lymph node biopsy may be recommended, along with local re-excision to remove any remaining cancerous tissue.

Stage 2

Moderate Melanoma: In this stage, the tumor is thicker and has invaded deeper layers of the skin. A sentinel lymph node biopsy is typically recommended to assess whether cancer has spread to the lymph nodes. There is a moderate risk of recurrence or metastasis due to the tumor's depth.

Stage 3

Advanced Local Melanoma: At this stage, the melanoma has spread to nearby lymph nodes. Surgical removal of the affected lymph nodes is part of the treatment plan, and further treatment may be required to manage the risk of recurrence.

Stage 4

Metastatic Melanoma: This is the most advanced stage, where the cancer has spread to distant organs, such as the lungs, liver, brain, or abdomen. Although less common, this stage poses significant challenges for treatment.

Treatment Options for Stages 3 and 4

For individuals diagnosed with Stage 3 or Stage 4 melanoma, post-surgical treatment focuses on preventing recurrence and targeting remaining cancer cells in the body. The following therapies may be used alone or in combination:

Chemotherapy: Chemotherapy drugs are often utilized to treat local recurrences or advanced melanoma. Side effects can include nausea, vomiting, fatigue, and hair loss, as well as an increased risk of infection during treatment.

Biological Therapy (Immunotherapy): This approach enhances the immune system's ability to fight cancer cells. Biological therapies target specific cell types and can cause side effects such as fatigue, fever, chills, rashes, or reactions at the injection site. Common agents include interferon, interleukin-2, ipilimumab, nivolumab, and pembrolizumab.

Targeted Therapy: This treatment is suitable for patients with specific genetic mutations, such as the BRAFV600 mutation. These mutations are identified through tumor testing. Targeted therapies, such as vemurafenib, dabrafenib, and trametinib, work by inhibiting the growth of cancer cells. Side effects may include skin issues, fevers, eye problems, diarrhea, and cardiac complications. New targeted therapies are continuously being evaluated in clinical trials.

Radiation Therapy: This therapy employs high-energy x-rays or other radiation types to kill cancer cells or inhibit their growth. It may be used post-surgery to relieve symptoms or to treat melanoma that has metastasized to the brain. Side effects vary based on the treatment area and may include skin irritation and fatigue. In Stage III melanoma, radiation therapy may be employed after surgery to prevent recurrence.

5-Step Skin Cancer Self-Examination

Regular skin self-exams can be an effective way to spot potential signs of melanoma. Follow these five steps, along with the “ABCDEs” of melanoma, to check your skin thoroughly.

Step 1: Gather Your Supplies

Find a well-lit area and use a full-length mirror and a hand-held mirror for a complete view of your body. You may also want to have a comb or a blow dryer handy to part your hair.

Step 2: Check Your Body

Face and Neck: Begin by examining your face, neck, and ears, looking for any unusual moles or spots.

Torso and Arms: Move to your torso, checking the front and back. Don’t forget to look at your underarms and arms, including the backs and palms.

Legs and Feet: Sit down and examine your legs, including your shins, thighs, and between your toes. Check the soles of your feet and your toenails.

Step 3: Use the “ABCDEs” Method

Asymmetry: Look for moles that are not symmetrical. If you were to fold it in half, both sides should match.

Border: Check for irregular, scalloped, or poorly defined borders.

Color: Look for a variety of colors (brown, black, tan, red, white, or blue) in a single mole.

Diameter: Be cautious of moles larger than 6mm (about the size of a pencil eraser), although melanomas can be smaller.

Evolving: Pay attention to any changes in size, shape, or color over time.

Step 4: Document Your Findings

Keep a record of your moles and any changes you notice. Taking photos can help you track changes over time.

Step 5: Consult a Doctor

If you find any spots or moles that fit the ABCDE criteria or that look suspicious, schedule an appointment with your dermatologist or primary care doctor for a professional evaluation.

Contact a Dermatologist