Melanoma

skin anatomy

Melanoma is a disease in which malignant (cancer) cells form in the skin cells called melanocytes (cells that color the skin). Melanocytes are found throughout the lower part of the epidermis. They make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to tan, or darken.

The skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. The skin has 2 main layers: the epidermis (upper or outer layer) and the dermis (lower or inner layer).

There are 3 types of skin cancer:

  • Melanoma
  • Basal cell skin cancer
  • Squamous cell skin cancer

When melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma may also occur in mucous membranes (thin, moist layers of tissue that cover surfaces such as the lips). This information is about cutaneous (skin) melanoma and melanoma that affects the mucous membranes. When melanoma occurs in the eye, it is called intraocular melanoma. Melanoma is more aggressive than basal cell skin cancer or squamous cell skin cancer.

Melanoma can occur anywhere on the body. In men, melanoma is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma forms most often on the arms and legs. Melanoma is most common in adults, but it is sometimes found in children and adolescents

Risk Factors
Symptoms
Screening and Diagnosis
Staging
Treatment
Support

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Risk Factors

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for melanoma include the following:

  • Having a fair complexion, which includes the following:
    • Fair skin that freckles and burns easily, does not tan, or tans poorly.
    • Blue or green or other light-colored eyes.
    • Red or blond hair.
  • Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time.
  • Being exposed to certain factors in the environment (in the air, your home or workplace, and your food and water). Some of the environmental risk factors for melanoma are radiation, solvents, vinyl chloride, and PCBs.
  • Having a history of many blistering sunburns, especially as a child or teenager.
  • Having several large or many small moles.
  • Having a family history of unusual moles (atypical nevus syndrome).
  • Having a family or personal history of melanoma.
  • Being white.
  • Having a weakened immune system.
  • Having certain changes in the genes that are linked to melanoma.

Being white and having a fair complexion increases the risk of melanoma, but anyone can have melanoma, including people with dark skin.

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Symptoms

Huntsman Cancer Institute (HCI) recommends regular skin exams to get familiar with individual patterns of moles and freckles, and to look for symptoms of cancerous changes. These and other symptoms may be caused by melanoma. Other conditions may cause the same symptoms. Check with your doctor if you have any of the following problems:

  • A mole that
    • changes in size, shape, or color.
    • has irregular edges or borders.
    • is more than one color.
    • is asymmetrical (if the mole is divided in half, the 2 halves are different in size or shape).
    • itches.
    • oozes, bleeds, or is ulcerated (a hole forms in the skin when the top layer of cells breaks down and the tissue below shows through).
  • A change in pigmented (colored) skin.
  • Satellite moles (new moles that grow near an existing mole).

Learn about HCI's annual free skin cancer screening by calling the G. Mitchell Morris Cancer Learning Center at 1-888-424-2100.

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Screening and Diagnosis

Tests that examine the skin are used to detect (find) and diagnose melanoma. If a mole or pigmented area of the skin changes or looks abnormal, the following tests and procedures can help find and diagnose melanoma:

  • Skin exam: A doctor or nurse checks the skin for moles, birthmarks, or other pigmented areas that look abnormal in color, size, shape, or texture.
  • Biopsy: A procedure to remove the abnormal tissue and a small amount of normal tissue around it. A pathologist looks at the tissue under a microscope to check for cancer cells. It can be hard to tell the difference between a colored mole and an early melanoma lesion. Patients may want to have the sample of tissue checked by a second pathologist. If the abnormal mole or lesion is cancer, the sample of tissue may also be tested for certain gene changes.

A biopsy should be done on any abnormal areas of the skin. These areas should not be shaved off or cauterized (destroyed with a hot instrument, an electric current, or a caustic substance).

Mole mapping involves taking pictures of moles for magnification and for comparison of how they change over time. This is often used when a person has many moles or moles that apprea abnormal. People with a family history of melanoma may need to follow a different screening schedule based on recommendations from a health care provider.

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Staging

After melanoma has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body. The process used to find out whether cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Talk with your doctor about what the stage of your cancer is.

The following tests and procedures may be used in the staging process:

  • Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Lymph node mapping and sentinel lymph node biopsy: Procedures in which a radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to have spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist views a sample of tissue under a microscope to check for cancer cells. If no cancer cells are found, it may not be necessary to remove more nodes.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For melanoma, pictures may be taken of the chest, abdomen, and pelvis.
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
  • MRI (magnetic resonance imaging) with gadolinium: A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. A substance called gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. For melanoma, the blood is checked for an enzyme called lactate dehydrogenase (LDH). LDH levels that are higher than normal may be a sign of melanoma.

The results of these tests are viewed together with the results of the tumor biopsy to find out the stage of the melanoma.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if melanoma spreads to the lung, the cancer cells in the lung are actually melanoma cells. The disease is metastatic melanoma, not lung cancer.

The method used to stage melanoma is based mainly on the thickness of the tumor and whether cancer has spread to lymph nodes or other parts of the body.

The staging system is based on the following:

  • The thickness of the tumor. The thickness is described using the Breslow scale.
  • Whether the tumor is ulcerated (has broken the skin).
  • Whether the tumor has spread to the lymph nodes and if the lymph nodes are joined together (matted).
  • Whether the tumor has spread to other parts of the body.

The following stages are used for melanoma:

Stage 0 (Melanoma in Situ)

In stage 0, abnormal melanocytes are found in the epidermis. These abnormal melanocytes may become cancer and spread into nearby normal tissue. Stage 0 is also called melanoma in situ.

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

  • Stage IA: In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration.
  • Stage IB: In stage IB, the tumor is either:
    • not more than 1 millimeter thick and it has ulceration; or
    • more than 1 but not more than 2 millimeters thick, with no ulceration.

Stage II

Stage II is divided into stages IIA, IIB, and IIC.

  • Stage IIA: In stage IIA, the tumor is either:
    • more than 1 but not more than 2 millimeters thick, with ulceration; or
    • more than 2 but not more than 4 millimeters thick, with no ulceration.
  • Stage IIB: In stage IIB, the tumor is either:
    • more than 2 but not more than 4 millimeters thick, with ulceration; or
    • more than 4 millimeters thick, with no ulceration.
  • Stage IIC: In stage IIC, the tumor is more than 4 millimeters thick, with ulceration.

Stage III

In stage III, the tumor may be any thickness, with or without ulceration. One or more of the following is true:

  • Cancer has spread to one or more lymph nodes.
  • Lymph nodes may be joined together (matted).
  • Cancer may be in a lymph vessel between the primary tumor and nearby lymph nodes.
  • Very small tumors may be found on or under the skin, not more than 2 centimeters away from where the cancer first started.

Stage IV

In stage IV, the cancer has spread to other places in the body, such as the lung, liver, brain, bone, soft tissue, or gastrointestinal (GI) tract. Cancer may have spread to places in the skin far away from where it first started.

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Treatment

At Huntsman Cancer Institute, melanoma is treated by a team of specialists, including dermatologists (doctors who specialize in diseases of the skin), medical oncologists, nurses, social workers, dietitians, and other professionals.

Different types of treatment are available for patients with melanoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

New treatments are being tested in clinical trials.

The treatments used depend on the stage of the disease and the person's general health and medical history. Learn more in our factsheets by stage of melanoma.

Surgery

Surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:

  • Wide local excision: Surgery to remove the melanoma and some of the normal tissue around it. Some of the lymph nodes may also be removed.
  • Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer.
  • Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes.

Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.

Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Chemotherapy

Chemothrapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

One type of regional chemotherapy is hyperthermic isolated limb perfusion. With this method, anticancer drugs go directly to the arm or leg the cancer is in. The flow of blood to and from the limb is temporarily stopped with a tourniquet. A warm solution with the anticancer drugs is put directly into the blood of the limb. This gives a high dose of drugs to the area where the cancer is.

The way the chemotherapy is given depends on the type and stage of the cancer being treated. Learn more about this treatment in our introduction to chemotherapy video.

 

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Interferon and interleukin-2 (IL-2) are types of biologic therapy used to treat melanoma. Interferon affects the division of cancer cells and can slow tumor growth. IL-2 boosts the growth and activity of many immune cells, especially lymphocytes (a type of white blood cell). Lymphocytes can attack and kill cancer cells.

Tumor necrosis factor (TNF) therapy is a type of biologic therapy used with other treatments for melanoma. TNF is a protein made by white blood cells in response to an antigen or infection. Tumor necrosis factor can be made in the laboratory and used as a treatment to kill cancer cells.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. The following types of targeted therapy are being used in the treatment of melanoma:

  • Monoclonal antibody therapy: A cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used with chemotherapy as adjuvant therapy. Ipilimumab is a monoclonal antibody used to treat melanoma. Other monoclonal antibodies are being studied in the treatment of melanoma.
  • Signal transduction inhibitor therapy: A type of targeted therapy. Signal transduction inhibitors block signals that are passed from one molecule to another inside a cell. Blocking these signals may kill cancer cells. Vemurafenib is a signal transduction inhibitor used to treat some patients with advanced melanoma or tumors that cannot be removed by surgery.
  • Oncolytic virus therapy: A type of targeted therapy that is being studied in the treatment of melanoma. Oncolytic virus therapy uses a virus that infects and breaks down cancer cells but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells.
  • Angiogenesis inhibitors: A type of targeted therapy that is being studied in the treatment of melanoma. Angiogenesis inhibitors block the growth of new blood vessels. In cancer treatment, they may be given to prevent the growth of new blood vessels that tumors need to grow.

Clinical trials

These studies discover and evaluate new and improved cancer treatments. Patients are encouraged to talk with their doctors about participating in a clinical trial or any questions regarding research studies. For more information, visit HCI's clinical trials website.

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Support

When you or someone you love is diagnosed with cancer, concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, employment, or how to continue normal daily activities.

There are several places you can go for support:

  • Your health care team can answer your questions and talk to you about your concerns. They can help you with any side effects and keep you informed of all your treatments, test results, and future doctor visits.
  • The G. Mitchell Morris Cancer Learning Center has hundreds of free brochures and more than 3,000 books, DVDs, and CDs available for checkout. You can browse the library, perform Internet research, or talk with a cancer information specialist.
  • Our Patient and Family Support Services offer emotional support and resources for coping with cancer and its impact on daily life to HCI patients and their families.
  • The Linda B. and Robert B. Wiggins Wellness-Survivorship Center offers many programs to increase the quality of life and well-being of HCI patients and their families.

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Adapted from the National Cancer Institute's Physician Data Query (PDQ®) Cancer Information Summaries
This information last updated on HCI website April 2014

*If you are interested in a trial that is currently marked *Not Open, please contact the Patient Education team at 1-888-424-2100 or patient.education@hci.utah.edu for other trial options. Enrollment is updated daily.

Forte Research Systems in partnership with Huntsman Cancer Institute

Robert Hans Ingemar Andtbacka, M.D., C.M.

Locations
Huntsman Cancer Institute (801) 587-8808

Specialties: Gastrointestinal Stromal Tumors, Melanoma Surgery, Melanoma and Cutaneous Oncology, Oncology, Oncology Surgery, Sarcoma, Soft Tissue Sarcoma Surgery, Soft Tissue Sarcomas, Surgery, General

Glen M. Bowen, M.D.

Locations
Huntsman Cancer Institute (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology, Mohs Surgery

Keith Duffy, M.D.

Locations
Dermatology & Laser Center (801) 581-2955
Huntsman Cancer Institute (801) 581-2955
Redstone Health Center (435) 658-9262
South Jordan Health Center (801) 581-2955
University Hospital (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Dermatopathology, General Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology, Mohs Surgery

Mark J. Eliason, M.D.

Locations
Dermatology Murray Clinic (801) 581-2955
University Hospital (801) 581-2955

Specialties: Allergic Skin Diseases, Dermatology, General Dermatology, Melanoma and Cutaneous Oncology

Douglas Grossman, M.D., Ph.D.

Locations
Huntsman Cancer Hospital (801) 581-2955

Specialties: Dermatology, Melanoma Surgery, Melanoma and Cutaneous Oncology

Payam Tristani-Firouzi, M.D.

Locations
Dermatology & Laser Center (801) 581-2955
Dermatology Murray Clinic (801) 581-2955
University Hospital (801) 581-2955

Specialties: Dermatology, Laser and Cosmetic Dermatology, Melanoma and Cutaneous Oncology, Mohs Surgery

David A. Wada, M.D.

Locations
Huntsman Cancer Hospital (801) 581-2955
University Hospital (801) 581-2955

Specialties: Cutaneous Lymphoma, Dermatology, Dermatopathology, Melanoma and Cutaneous Oncology

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travis hakala skin cancer Melanoma and Cutaneous Oncology Program
Care coordinator: Travis Hakala
Phone: 801-585-0209
E-mail:travis.hakala@hci.utah.edu

Did You Know?

  • A person will sunburn 30% faster in Salt Lake City than in Los Angeles. This is because the UV intensity is much greater at Salt Lake City's high altitude.
  • For best skin protection, look for a broad-spectrum sunblock that contains zinc oxide or titanium dioxide with an SPF 30 or higher.
  • Huntsman Cancer Institute offers an annual free skin cancer screening. Call the Cancer Learning Center at 1-888-424-2100 for more information.
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