Medical Author: Alan Rockoff, MD
Medical Editor: Frederick Hecht, MD, F.A.A.P.

• Introduction
• What should I look for?
• What if the changes are rapid or dramatic?
• What puts me at risk for melanoma?
• How do I know my level of risk for melanoma?
• What are the kinds of melanoma?
• How is melanoma diagnosed?
• How do doctors determine the prognosis (outlook) of a melanoma?
• What is the treatment for melanoma?
• What methods are available to help prevent melanoma?
• Conclusions
• Melanoma At A Glance
• Additional Resources

Introduction

Melanoma is a cancer that develops in the pigment cells, called melanocytes. It can be more serious than the other forms of skin cancer because it may spread to other parts of the body (metastasize) and cause serious illness and death. About 50,000 new cases of melanoma are diagnosed in the United States every year.

Because most melanomas occur on the skin where they can be seen, patients themselves are often the first to detect many melanomas. Early detection and diagnosis are crucial. Caught early, most melanomas can be cured with relatively minor surgery.

This article is written from the standpoint of the patient. In other words, instead of describing the disease in exhaustive detail, I will try to help answer the questions: "How do I know if I have melanoma?" and "Should I should be checked for it?"

Spots on the skin

Guideline # 1: Nobody can diagnose him or herself. If you see a spot that looks as though it is new or changing, show it to a doctor. When it comes to spots on the skin, it is always better to be safe than sorry.

Everybody gets spots on their skin. The older we are, the more spots we have. Some of these are freckles , others are moles, and still others are made up of collections of tissue, such as blood vessels or pigment cells. Most of these spots are benign. That means they are neither cancerous nor on the way to becoming cancerous.

Moles

Guideline # 2: The vast majority of moles stay as moles and do not turn into anything else.

Some people are born with moles (the medical name is "nevus," plural "nevi"). Almost everyone develops them, starting in childhood. On the average, people have about 25 moles, though some have fewer and others many more. Moles may be flat or raised, and they may range in color from tan to light brown to black.

What should I look for?

Guideline # 3: A changing spot may be a problem, but not every change is a problem. A mole may appear and then get bigger or become raised, but still be only a mole.

From childhood on, we are all told to be concerned about any spot on the skin that changes. The kinds of changes we are warned to worry about the most include pain, itching, bleeding, or swelling.

Most public health information about melanoma stresses the so-called ABCDs:

• Asymmetry -- one half of the mole is different from the other half
• Border irregularity -- the spot has borders which are not round or oval, but uneven or notched
• Color -- the spot has several colors in an irregular pattern
• Diameter -- the spot is larger than the size of a pencil eraser

These guidelines are somewhat helpful, but the problem is that many normal moles are not completely symmetrical in their shape or color. This means that many spots, which seem to have one or more of the ABCDs, are in fact just ordinary moles and not melanomas.

What if the changes are rapid or dramatic?

Guideline # 4: The more rapid and dramatic the change, the less serious the problem.

When changes such as pain, swelling, or even bleeding come on rapidly, within a day or two, they are likely to be caused by minor trauma, often a kind you don't remember (like scratching the spot in your sleep ). If a spot changes rapidly and then goes back to the way it was within a couple of weeks, or falls off altogether, it is not likely to represent anything serious. Keep in mind that what may seem like the sudden appearance of a spot or a rapid change in its appearance may just mean that something (or someone) has prompted you to look at an old spot for the first time.

Nevertheless, this would be a good time to say once again: Nobody can diagnose him or herself. If you see a spot that looks as though it is new or changing, show it to a doctor. When it comes to spots on the skin, it is always better to be safe than sorry.

What puts me at risk for melanoma?

Guideline # 5: The effect of sun exposure is cumulative and develops over many years. Just like one pizza won't make you fat, one bad sunburn may leave behind freckles , but does not itself substantially raise the risk of skin cancer.

Factors that raise your risk for melanoma include:

• Caucasian (white) ancestry
• Fair skin, light hair, and light-colored eyes
• A history of intense, intermittent sun exposure, especially in childhood
• Many (more than 100) moles
• Large, irregular, or "funny looking" moles
• Close blood relatives -- parents, siblings, children -- with melanoma

The presence of close (first-degree) family with melanoma is a high-risk factor although, looking at all of melanoma, only 10% of cases run in families.

How do I know my level of risk for melanoma?

The best way to know your risk level is to have a dermatologist perform a full body examination. That way you will find out whether the spots you have are moles and, if so, whether they are "funny looking" in the medical sense.

The medical term for such moles is "dysplastic." This is a somewhat confusing term, because among other things the criteria for defining it are not clear and it's not certain that a dysplastic mole is necessarily precancerous. If you have such moles, your doctor may do a biopsy in order to counsel you about the need for surveillance or further testing.

Sometimes, you learn at a routine skin evaluation that you do not necessarily need annual routine checkups. In other situations, your doctor may recommend regular checks at six-month or yearly intervals.

What are the kinds of melanoma?

The main kinds of melanoma are:

1. Superficial spreading melanoma: This type accounts for about 70% of all cases of melanoma. The most common locations are the legs of women and the backs of men and they occur most commonly between the ages of 30 and 50. (Note: Melanomas can occur in other locations and at other ages as well.) These melanomas are often barely raised and have a variety of colors. Such melanomas evolve over 1 to 5 years and can be readily caught in an early stage if they are detected and removed.

2. Nodular melanoma: About 20% of melanomas begin as deeper, blue-black to purplish lumps. They evolve faster and are more likely to spread.

3. Lentigo maligna: Unlike other forms of melanoma, lentigo maligna tends to occur on places like the face, which are exposed to the sun constantly rather than intermittently. Lentigo maligna looks like a large freckle and develops slowly. It takes to 5 to 15 years to evolve into an actual melanoma.

There are also other rarer forms of melanoma that may occur, for example, under the nails, on the palms and soles, in the eye, or sometimes even inside the body.

How is melanoma diagnosed?

Most doctors diagnose melanoma by examining the spot causing concern and doing a biopsy. A skin biopsy refers to removing all or part of the skin spot under local anesthesia and sending the specimen to a pathologist for analysis.

The biopsy report may show any of the following:

• A totally benign condition requiring no further treatment
• A dysplastic mole which, depending on the judgment of the doctor and the pathologist, may need a conservative removal (taking off a little bit of normal skin all around just to make sure that the spot is completely out)
• A melanoma requiring surgery

Some doctors are skilled in a clinical technique called epiluminescence microscopy (also called dermatoscopy). They cover a suspicious spot with olive oil and examine it with a brightly-lit magnifying instrument. The gold standard for a solid diagnosis, however, remains a skin biopsy.

How do doctors determine the prognosis (outlook) of a melanoma?

The most useful criterion for determining prognosis is tumor thickness. Thin melanomas, those measuring less than three-quarters of a millimeter, have excellent cure rates. The thicker the melanoma, the less optimistic the prognosis. Early diagnosis and treatment are essential.

What is the treatment for melanoma?

In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove one centimeter (less than 1/2 inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery.

Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph glands may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like chemotherapy and immunotherapy are sometimes recommended.

What methods are available to help prevent melanoma?

1. Reducing sun exposure: Avoidance of sun exposure is the best means of helping to prevent melanoma, followed by wearing hats and tightly-woven clothing, and then followed by broad-spectrum waterproof sunscreens applied liberally and often. There has been some controversy about the extent to which sunscreens protect against melanoma. The consensus among dermatologists is that sunblocks are at least partially helpful, and are certainly preferable to unprotected sun exposure. (Despite sensational articles in the popular press, there is no credible evidence that sunscreens can cause melanoma.)

2. Early detection: Get your skin checked at least once. Then, if it is recommended, have your skin checked on a regular basis. The American Academy of Dermatology sponsors free skin cancer screening clinics every May call over the country. Special "Pigmented Lesion Clinics" have also been established in many medical centers to permit close clinical and photographic follow-up of patients at high risk.

3. Screening of high-risk individuals: Anyone at high risk, such as anyone with a close relative who has melanoma, should be screened by a doctor for melanoma.

Conclusions

When it comes to spots on the skin, it is always better to be safe than sorry. Melanoma is a potentially serious form of skin cancer. Diagnosed early and treated properly, it can very often be cured. And, one more time:

Guideline # 1: Nobody can diagnose him or herself. If you see a spot that looks as though it is new or changing, show it to a doctor.

What is in the future for melanoma?

Research in melanoma is headed in three directions; prevention, more precise diagnosis, and better treatment for advanced disease.

• Prevention: Public education and more widely available screening clinics can increase public awareness of the need for sun avoidance and early detection of suspicious spots. "Pigmented Lesion Clinics" have been established in many medical centers for high risk-patients.
• More precise diagnosis: Newer techniques, such as the confocal scanning laser microscope, may help doctors make more certain calls on borderline spots.
• Better treatment for advanced disease: Because conventional chemotherapy has been disappointing with melanoma, researchers have turned their attention to biologic treatments of advanced melanoma to stimulate the body's own immune response against the tumor. These biologic treatments include interferon , interleukins, monoclonal antibodies, and tumor vaccines.

Melanoma At A Glance

• Melanoma is a cancer that develops in pigment cells, called melanocytes.
• Patients themselves are the first to detect many melanomas.
• Caught early, most melanomas can be cured with relatively minor surgery.
• Melanoma can be more serious than the other forms of skin cancer, because it may spread (metastasize) to other parts of the body and cause serious illness and death.
• Spots suspicious for melanoma show one or more of the following features (the ABCDs): Asymmetry, Border irregularity, Color changes, a Diameter more than the size of a pencil eraser
• Elevated risk factors for melanoma include Caucasian (white) ancestry; fair skin, light hair and light-colored eyes; a history of intense sun exposure; close blood relatives with melanoma; and moles that are unusually numerous, large, irregular, or "funny looking."
• Doctors diagnose melanoma by biopsy (removing a piece of skin for analysis).
• The most common forms of melanoma are superficial spreading melanoma, nodular melanoma, and lentigo maligna.
• Treatment of melanoma is primarily by surgical removal.
• Changing or suspicious spots should be brought to medical attention right away.

Additional Resources

• For additional information read the article on Melanoma .
• For further information about all aspects of melanoma, please visit MelanomaNet (http://www.skincarephysicians.com/melanomanet/) of the American Academy of Dermatology.
• You can obtain information about free skin cancer screening clinics held by the American Academy of Dermatology every May all over the country from the American Academy of Dermatology (www.aad.org).

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