A single copy of this article may be reprinted for personal, noncommercial use only.
MelanomaBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/melanoma/DS00439
CLICK TO ENLARGE
Melanoma, the most serious type of skin cancer, develops in the cells (melanocytes) that produce melanin — the pigment that gives your skin its color. Melanoma can also form in your eyes and, rarely, in internal organs, such as your intestines.
The exact cause of all melanomas isn't clear, but exposure to ultraviolet (UV) radiation from sunlight or tanning lamps and beds increases your risk of developing melanoma. Limiting your exposure to UV radiation can help reduce your risk of melanoma.
The risk of melanoma seems to be increasing in people under 40, especially women. Knowing the warning signs of skin cancer can help ensure that cancerous changes are detected and treated before the cancer has spread. Melanoma can be treated successfully if it is detected early.
Melanomas can develop anywhere on your body. They most often develop in areas that have had exposure to the sun, such as your back, legs, arms and face. Melanomas can also occur in areas that don't receive much sun exposure, such as the soles of your feet, palms of your hands and fingernail beds. These hidden melanomas are more common in people with darker skin.
The first melanoma signs and symptoms often are:
- A change in an existing mole
- The development of a new pigmented or unusual-looking growth on your skin
Melanoma doesn't always begin as a mole. It can also occur on otherwise normal-appearing skin.
Normal moles are generally a uniform color, such as tan, brown or black, with a distinct border separating the mole from your surrounding skin. They're oval or round and usually smaller than 1/4 inch (about 6 millimeters) in diameter — the size of a pencil eraser.
Most people have between 10 and 45 moles. Many of these develop by age 40, although moles may change in appearance over time — some may even disappear with age.
Unusual moles that may indicate melanoma
To help you identify characteristics of unusual moles that may indicate melanomas or other skin cancers, think of the letters A-B-C-D-E:
- A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves.
- B is for irregular border. Look for moles with irregular, notched or scalloped borders — characteristics of melanomas.
- C is for changes in color. Look for growths that have many colors or an uneven distribution of color.
- D is for diameter. Look for new growth in a mole larger than 1/4 inch (about 6 millimeters).
- E is for evolving. Look for changes over time, such as a mole that grows in size or that changes color or shape. Moles may also evolve to develop new signs and symptoms, such as new itchiness or bleeding.
Other suspicious changes in a mole may include:
- Spreading of pigment from the mole into the surrounding skin
- Oozing or bleeding
Cancerous (malignant) moles vary greatly in appearance. Some may show all of the changes listed above, while others may have only one or two unusual characteristics.
Melanomas can also develop in areas of your body that have little or no exposure to the sun, such as the spaces between your toes and on your palms, soles, scalp or genitals. These are sometimes referred to as hidden melanomas, because they occur in places most people wouldn't think to check. When melanoma occurs in people with darker skin, it's more likely to occur in a hidden area.
Hidden melanomas include:
- Melanoma under a nail. Subungual melanoma is a rare form that occurs under a nail and can affect the hands or the feet. It's more common in blacks and in other people with darker skin pigment. The first indication of a subungual melanoma is usually a brown or black discoloration that's often mistaken for a bruise.
- Melanoma in the mouth, digestive tract, urinary tract or vagina. Mucosal melanoma develops in the mucous membrane that lines the nose, mouth, esophagus, anus, urinary tract and vagina. Mucosal melanomas are especially difficult to detect because they can easily be mistaken for other, far more common conditions.
- Melanoma in the eye. Eye melanoma, also called ocular melanoma, occurs in the uvea — the layer beneath the white of the eye (sclera). An eye melanoma may cause vision changes and may be diagnosed during an eye exam.
When to see a doctor
Make an appointment with your doctor if you notice any skin changes that seem unusual.
CLICK TO ENLARGE
|Where skin cancer develops|
Melanoma occurs when something goes awry in the melanin-producing cells (melanocytes) that give color to your skin. Normally, skin cells develop in a controlled and orderly way — healthy new cells push older cells toward your skin's surface, where they die and eventually fall off. But when some cells develop DNA damage, new cells may begin to grow out of control and can eventually form a mass of cancerous cells.
Just what damages DNA in skin cells and how this leads to melanoma isn't clear. It's likely that a combination of factors, including environmental and genetic factors, causes melanoma. Still, doctors believe exposure to ultraviolet (UV) radiation from the sun and from tanning lamps and beds is the leading cause of melanoma.
UV light doesn't cause all melanomas, especially those that occur in places on your body that don't receive exposure to sunlight. This indicates that other factors may contribute to your risk of melanoma.
Factors that may increase your risk of melanoma include:
- Fair skin. Having less pigment (melanin) in your skin means you have less protection from damaging UV radiation. If you have blond or red hair, light-colored eyes, and freckle or sunburn easily, you're more likely to develop melanoma than is someone with a darker complexion. But melanoma can develop in people with darker complexions, including Hispanics and blacks.
- A history of sunburn. One or more severe, blistering sunburns can increase your risk of melanoma as an adult.
- Excessive ultraviolet (UV) light exposure. Exposure to UV radiation, which comes from the sun and from tanning beds, can increase the risk of skin cancer, including melanoma.
- Living closer to the equator or at a higher elevation. People living closer to the earth's equator, where the sun's rays are more direct, experience higher amounts of UV radiation than do those living in higher latitudes. In addition, if you live at a high elevation, you're exposed to more UV radiation.
- Having many moles or unusual moles. Having more than 50 ordinary moles on your body indicates an increased risk of melanoma. Also, having an unusual type of mole increases the risk of melanoma. Known medically as dysplastic nevi, these tend to be larger than normal moles and have irregular borders and a mixture of colors.
- A family history of melanoma. If a close relative, such as a parent, child or sibling, has had melanoma, you have a greater chance of developing it, too.
- Weakened immune system. People with weakened immune systems have an increased risk of skin cancer. This includes people who have HIV/AIDS and those who have undergone organ transplants.
Preparing for your appointment
Start by seeing your family doctor or a general practitioner if you notice any skin changes that concern you. Depending on your situation and the outcome of any tests, you may be referred to a doctor who specializes in skin diseases (dermatologist) or to a doctor who specializes in cancer treatment (oncologist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready and know what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Make a list of all medications, as well as any vitamins or supplements, that you're taking.
- Take a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important, in case time runs out. For melanoma, some basic questions to ask your doctor include:
- Do I have melanoma?
- How large is my melanoma?
- How deep is my melanoma?
- Has my melanoma spread beyond the area of skin where it was first discovered?
- What additional tests do I need?
- What are my treatment options?
- Can any treatment cure my melanoma?
- What are the potential side effects of each treatment option?
- Is there one treatment you feel is best for me?
- How long can I take to decide on a treatment option?
- Should I see a specialist? What will that cost, and will my insurance cover it?
- Are there any brochures or other printed material that I can take with me? What websites do you recommend?
- What will determine whether I should plan for a follow-up visit?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask any other questions during your appointment.
Tests and diagnosis
Skin cancer screening
Ask your doctor whether you should consider periodic screening for skin cancer. You and your doctor may consider screening options such as:
- Skin exams by a trained professional. During a skin exam, your doctor conducts a head-to-toe inspection of your skin.
- Skin exams you do at home. A self-exam may help you learn the moles, freckles and other skin marks that are normal for you so that you can notice any changes. It's best to do this standing in front of a full-length mirror while using a hand-held mirror to inspect hard-to-see areas. Be sure to check the fronts, backs and sides of your arms and legs. In addition, check your groin, scalp, fingernails, soles of your feet and spaces between your toes.
Some groups recommend periodic skin exams by your doctor and on your own. Other groups don't recommend skin cancer screening exams because it's not clear whether screening saves lives. Instead, finding an unusual mole could lead to a biopsy, which, if the mole is found to not be cancerous, could lead to unnecessary pain, anxiety and cost. Talk to your doctor about what screening is right for you based on your risk of skin cancer.
Sometimes cancer can be detected simply by looking at your skin, but the only way to accurately diagnose melanoma is with a biopsy. In this procedure, all or part of the suspicious mole or growth is removed, and a pathologist analyzes the sample. Biopsy procedures used to diagnose melanoma include:
- Punch biopsy. During a punch biopsy, your doctor uses a tool with a circular blade. The blade is pressed into the skin around a suspicious mole and a round piece of skin is removed.
- Excisional biopsy. In this procedure, the entire mole or growth is removed along with a small border of normal-appearing skin.
- Incisional biopsy. With an incisional biopsy, only the most irregular part of a mole or growth is taken for laboratory analysis.
The type of skin biopsy procedure you undergo will depend on your situation.
If you receive a diagnosis of melanoma, the next step is to determine the extent (stage) of the cancer. To assign a stage to your melanoma, your doctor will:
- Determine the thickness. The thickness of a melanoma is determined by carefully examining the melanoma under a microscope and measuring it with a special tool (micrometer). The thickness of a melanoma helps doctors decide on a treatment plan. In general, the thicker the tumor, the more serious the disease.
- See if the melanoma has spread. To determine whether your melanoma has spread to nearby lymph nodes, your surgeon may use a procedure known as a sentinel node biopsy. During a sentinel node biopsy, a dye is injected in the area where your melanoma was removed. The dye flows to the nearby lymph nodes. The first lymph nodes to take up the dye are removed and tested for cancer cells. If these first lymph nodes (sentinel lymph nodes) are cancer-free, there's a good chance that the melanoma has not spread beyond the area where it was first discovered. Cancer can still recur or spread, even if the sentinel lymph nodes are free of cancer.
Other factors may go into determining the aggressiveness of a melanoma, including whether the skin over the area has formed an open sore and how many dividing cancer cells are found when looking under a microscope.
Melanoma is staged using the Roman numerals I through IV. A stage I melanoma is small and has a very successful treatment rate. But the higher the numeral, the lower the chances of a full recovery. By stage IV, the cancer has spread beyond your skin to other organs, such as your lungs or liver.
Treatments and drugs
The best treatment for you depends on your stage of cancer and your age, overall health and personal preferences.
Treating early-stage melanomas
Treatment for early-stage melanomas usually includes surgery to remove the melanoma. A very thin melanoma may be removed entirely during the biopsy and require no further treatment. Otherwise, your surgeon will remove the cancer as well as a small border of normal skin and a layer of tissue beneath the skin. For people with early-stage melanomas, this may be the only treatment needed.
Treating melanomas that have spread beyond the skin
If melanoma has spread beyond the skin, treatment options may include:
- Surgery to remove affected lymph nodes. If melanoma has spread to nearby lymph nodes, your surgeon may remove the affected nodes. Additional treatments before or after surgery may also be recommended.
- Chemotherapy. Chemotherapy uses drugs to destroy cancer cells. Chemotherapy can be given intravenously, in pill form or both so that it travels throughout your body. Or chemotherapy can be given in a vein in your arm or leg in a procedure called isolated limb perfusion. During this procedure, blood in your arm or leg isn't allowed to travel to other areas of your body for a short time so that the chemotherapy drugs travel directly to the area around the melanoma and don't affect other parts of your body.
- Radiation therapy. This treatment uses high-powered energy beams, such as X-rays, to kill cancer cells. It's sometimes used to help relieve symptoms of melanoma that has spread to another organ. Fatigue is a common side effect of radiation therapy, but your energy usually returns once the treatment is complete.
- Biological therapy. Biological therapy boosts your immune system to help your body fight cancer. These treatments are made of substances produced by the body or similar substances produced in a laboratory. Biological therapies used to treat melanoma include interferon and interleukin-2. Side effects of these treatments are similar to those of the flu, including chills, fatigue, fever, headache and muscle aches. Ipilimumab (Yervoy) is another drug that uses your immune system to fight melanoma. Ipilimumab is used to treat advanced melanoma that has spread beyond its original location.
- Targeted therapy. Targeted therapy uses medications designed to target specific vulnerabilities in cancer cells. Vemurafenib (Zelboraf) is a targeted therapy approved to treat advanced melanoma that can't be treated with surgery or melanoma that has spread through the body. Vemurafenib only treats melanoma that has a certain genetic mutation. Cells from your melanoma can be tested to see whether this treatment may be an option for you.
Experimental melanoma treatments
Clinical trials are studies of new treatments for melanoma. Doctors use clinical trials to determine whether a treatment is safe and effective. People who enroll in clinical trials have a chance to try evolving therapies, but a cure isn't guaranteed. And sometimes the potential side effects aren't known.
Some melanoma treatments being studied in clinical trials include:
- New combinations of treatments. Researchers are testing whether combining treatments may increase the effectiveness of melanoma treatment. For instance, different combinations of chemotherapy, biological therapy, targeted therapy and radiation have been proposed. However, combining treatments can make severe side effects more likely.
- New targeted therapies. Researchers are testing new targeted medications in people with advanced melanoma. For instance, targeted drugs designed to stop melanoma from attracting blood vessels have shown some success. Blood vessels carry nutrients to the melanoma, and blood vessels help spread cancer cells throughout the body. A drug that stops this process could cause a melanoma to remain small and localized.
- Vaccine treatment. Vaccines for treating cancer are different from vaccines used to prevent diseases. Vaccine treatment for melanoma might involve injecting altered cancer cells into the body to draw the attention of the immune system.
The best news about melanoma is that many cases of skin cancer can be prevented by following these precautions:
- Avoid midday sun. Avoid the sun when its rays are the strongest. For most places, this is between about 10 a.m. and 4 p.m. Because the sun's rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter or when the sky is cloudy. You absorb UV radiation year-round, and clouds offer little protection from damaging rays.
- Wear sunscreen year-round. Use a broad-spectrum sunscreen with an SPF of at least 15. Apply sunscreen generously, and reapply every two hours — or more often if you're swimming or perspiring. Use a generous amount of sunscreen on all exposed skin, including your lips, the tips of your ears, and the backs of your hands and neck.
- Wear protective clothing. Sunscreens don't provide complete protection from UV rays, so wear tightly woven clothing that covers your arms and legs and a broad-brimmed hat, which provides more protection than a baseball cap or visor does. Some companies also sell photoprotective clothing. Your dermatologist can recommend an appropriate brand. Don't forget sunglasses. Look for those that block both types of UV radiation — UVA and UVB rays.
- Avoid tanning beds. Tanning beds emit UV radiation, which can increase the risk of skin cancer.
- Become familiar with your skin so you'll notice changes. Examine your skin so that you become familiar with what your skin normally looks like. This way, you may be more likely to notice any skin changes. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk and the tops and undersides of your arms and hands. Examine both the front and back of your legs and your feet, including the soles and the spaces between your toes. Also check your genital area and between your buttocks. If you notice anything unusual, point it out to your doctor at your next appointment.
- What you need to know about melanoma and other skin cancers. National Cancer Institute. http://www.cancer.gov/cancertopics/wyntk/skin. Accessed May 10, 2012.
- Abeloff MD, et al. Abeloff's Clinical Oncology. 4th ed. Philadelphia, Pa.: Churchill Livingstone Elsevier; 2008. http://www.mdconsult.com/das/book/body/208746819-4/0/1709/0.html. Accessed May 10, 2012.
- Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. Edinburgh, U.K.; New York, N.Y.: Mosby Elsevier; 2010. http://www.mdconsult.com/books/about.do?about=true&eid=4-u1.0-B978-0-7234-3541-9..X0001-6--TOP&isbn=978-0-7234-3541-9&uniqId=230100505-57. Accessed May 7, 2012.
- Sureda N, et al. Conservative surgical management of subungual (matrix derived) melanoma: Report of seven cases and literature review. British Journal of Dermatology. 2011;165:852.
- Seetharamu N, et al. Mucosal melanomas: A case-based review of the literature. The Oncologist. 2010;15:772.
- Intraocular (eye) melanoma treatment (PDQ). National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/intraocularmelanoma/patient/. Accessed May 15, 2012.
- Smith RA, et al. Cancer screening in the United States, 2012: A review of current American Cancer Society guidelines and current issues in cancer screening. CA A Cancer Journal for Clinicians. 2012;62:129.
- Skin examinations. SkinCancerNet. http://www.skincarephysicians.com/skincancernet/skin_examinations.html. Accessed May 10, 2012.
- Preventive services for adults. Bloomington, Minn.: Institute for Clinical Systems Improvement. http://www.icsi.org/guidelines_and_more/gl_os_prot/preventive_health_maintenance/preventive_services_for_adults/preventive_services_for_adults__11.html. Accessed May 15, 2012.
- Zelboraf (prescribing information). South San Francisco, Calif.: Genentech Inc.; 2011. http://www.zelboraf.com/dermatology/index.html. Accessed May 11, 2012.
- U.S. Preventive Services Task Force. Screening for skin cancer: U.S. Preventive Services Task Force Recommendation statement. Annals of Internal Medicine. 2009;150:188.
- Melanoma. Fort Washington, Pa.: National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed May 10, 2012.
- Melanoma treatment. National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/melanoma/healthprofessional/. Accessed May 10, 2012.
- Finn L, et al. Therapy for metastatic melanoma: The past, present and future. BMC Medicine. 2012;10:23.
- Reed KB, et al. Increasing incidence of melanoma among young adults: An epidemiological study in Olmsted County, Minnesota. Mayo Clinic Proceedings. 2012;87:328.
- Gibson LE (expert opinion). Mayo Clinic, Rochester, Minn. May 17, 2012.