Read an Excerpt
Who is living with melanoma?
A forty-six-year-old man whose barber noticed a small black mole on his scalp during a regular haircut. An otherwise healthy eight-year-old girl, who came home from school one afternoon complaining of blurred vision. A thirty-two-year-old woman who had been suffering from garden-variety hemorrhoids for several months.
These three patients represent how cunning and varied a melanoma diagnosis can be. The locations it can emerge on the body and its lack of symptoms make it a challenging disease indeed to find and treat, as I know only too well. Iíve treated hundreds of patients for melanoma in the last fourteen years. In the years to come, I expect to see thousands more because the number of new melanoma patients worldwide is rising at a rate faster than that of any other cancer. Striking every age, gender, and socioeconomic group, melanoma is quickly becoming one of the most familiar cancers among the general population. Already melanoma has become the most common cancer among women aged twenty-five to twenty-nine. Among women aged thirty to thirty-four, it is second only to lung cancer (the leading cancer in both men and women).
Thatís why I decided to write this book. With such a dramatic rise in the incidence of melanoma, I felt it was more important than ever before to provide the many patients and families beyond the scope of my practice with a basic understanding of malignant melanoma, what it is, how it is diagnosed and treated, and where to go for appropriate care. As both a practicing physician and a clinical investigator, Iím in the unique position of being directly involved with cutting-edge treatment for this deadly disease. With early detection melanoma has a high rate of cure, but there is a great deal of controversy surrounding the treatment of the disease in its later stages. Despite a significant amount of research, the survival rate for patients with metastatic melanoma continues to be only 10ñ15 percent. And there is no consensus among experts as to the best course of action. Patients and their families faced with a melanoma diagnosis are understandably confused and afraid.
Given that melanoma often strikes previously healthy individuals in the prime of their lives, many find themselves ill prepared and poorly equipped for the medical and psychological journey on which they are forced to embark. Confronted with a melanoma diagnosis, a patient may be overwhelmed with questions:
- What is malignant melanoma?
- How is this disease different from other types of skin cancer?
- Why did I get this?
- What kind of doctor should I consult for this condition?
- How should I be treated?
- Can my disease be prevented or cured?
I hope to answer these questions and more in the following pages.
The proper care of malignant melanoma requires the cooperation of many different types of doctors with expertise in a wide variety of areas, including dermatology, surgery, oncology, radiation oncology, diagnostic radiology, and pathology. There are effective treatments for malignant melanoma when it is found at an early stage. It is essential to learn about malignant melanoma, because the more you know about it, the greater the chances of early detection. Then you can develop a logical treatment plan with experts in the management of this disease.
At the Melanoma Center of Columbia University Medical Center, we have established a multidisciplinary team approach to the diagnosis and treatment of malignant melanoma. This has been instrumental in providing the latest diagnostic techniques, surgical procedures, new treatments, and proper follow-up care for patients with malignant melanoma. Recent discoveries in molecular biology, genetics, and immunology are revolutionizing our approach to the malignant melanoma patient. By bringing together basic scientists, clinical practitioners, nursing specialists, and public-health experts, we are providing the most comprehensive care for our patients. Changes in biomedical research and clinical sciences are happening at a rapid pace, and it will be increasingly important for patients and physicians to obtain the most up-to-date information when making medical decisions.
I have based this book on the collective wisdom and work of the Columbia University Medical Center team. While I donít insist that our approach is applicable for all patients, my hope is that the information provided and the insight into our procedures and decision-making processes will help patients and their families understand what is happening and why. I offer you the same state-of-the-art research findings and treatment options from which my patients benefit at Columbia. No matter where you live, if melanoma strikes, you can use this book to understand the disease and begin the process of healing.
The book is divided into four main parts: prevention, diagnosis, treatment, and research. Part One explains melanoma and how it differs from other types of skin cancer. It also discusses the causes of melanoma and explains how melanoma may be prevented. In Part Two, I lead you step-by-step through the specific ways we diagnose and categorize, or stage, melanoma. Part Three is all about treating melanoma, from basic biopsy to experimental laser surgery, adjuvant therapy, and chemotherapy. No doubt many of you will want to turn directly to that section. I conclude with Part Four, which covers the most current research, including cytokine, vaccine, and genetic therapies as well as a thorough discussion of clinical trials.
My goal with this book is to help you organize key issues, understand the options, and make informed decisions about diagnostic and treatment procedures. Even when the disease is advanced, there are often dramatic responses, and occasionally even cures. By better understanding melanoma, you will learn how to live with the disease, and perhaps prevent it from occurring in your loved ones.
I hope that with the help of the information in this book, you and your loved ones never face a diagnosis of melanoma. But, if you do, here is all the information you need to cope with the diagnosis and increase the chances of survival.
What Is Melanoma?
The moment you or a loved one has been diagnosed with melanoma, questions begin to crowd out almost all other thoughts: What does melanoma mean? Whatís the difference between it and other skin cancers? What are the implications for me and my family? Before you can begin to grasp the diagnosis and start the recovery process, you need clear answers.
The good news is that most melanomas are found early, and the cure rate is approximately 85 percent in these cases. Even when melanoma is found in the advanced stages, treatments can often be remarkably successful.
Simply stated, melanoma is a type of skin cancer that arises from the melanocytes, one particular type of skin cell. Melanoma occurs when the melanocytes become severely abnormal, start dividing uncontrollably, and eventually spread to other parts of the body, sometimes resulting in death.
Most of our cells grow and divide continually. This process is essential for replacing old and worn-out cells, such as on the surface of the skin. The critical balance of cell growth, division, and death is tightly regulated by the genes, which are made up of a substance called DNA. When the DNA is altered, the normal life cycle of cells becomes impaired or out of control. Uncontrolled division of cells results in the growth of a tumor (ìtumorî comes from the Latin word for ìmassî).
Many things can cause alterations or mutations in DNA, including hereditary factors, exposure to radiation and ultraviolet light, certain toxic chemicals (such as tobacco), and certain viruses. Whatever the cause of the mutations, if the cells continue to divide without stopping, a growth or mass will form: cancer. When this process occurs in the skin, it is called skin cancer.
The severity of the disease is also determined by the ability of the cells to grow into a large size and then spread to other parts of the body, a process called metastasis. Cancers that are more aggressive in their growth and can spread to other parts of the body are called malignant. Cancers that remain small in size and do not spread are called benign, and generally behave in a less threatening manner. This is true not just for skin cancers, but for all cancers in the body.
The names of different forms of cancer are based on their classification as benign or malignant. Benign cancers usually end with the suffix ì-oma,î such as lipoma, which refers to a benign growth of fat cells that occurs just under the skin. In contrast, malignant cancers are often called ìcarcinomas,î such as breast carcinoma or colon carcinoma. Melanoma is one of the few exceptions to this rule, reflecting the early misconception that melanomas were benign cancers with little tendency to spread. When it became clear that melanomas could grow to large sizes and could spread to almost any other organ in the body, the medical term was changed to malignant melanoma in order to denote the more serious nature of this type of cancer.
Although this book focuses on malignant melanoma, many other kinds of skin cancer exist. These other skin cancers are much more common and usually are easier to cure than melanoma. The type of skin cancer and its severity depends on which cell is the source of the cancer. So in order to understand melanoma and other skin cancers, itís helpful to put them in the context of the normal structures and cells of the skin.
The Structure of the Skin
While its primary function is to protect the body from invading germs, chemicals, water, temperature, and other conditions or irritating substances, the skin also performs other vital functions including:
- regulating body temperature
- fighting infections in conjunction with the bodyís immune system
- protecting us from ultraviolet damage by the sun
- regulating Vitamin D metabolism
The skin is a complex body organ comprised of two major layers: the epidermis and the dermis. Each of these two main layers contains highly specialized skin cells arranged in sub-layers.
The epidermis, the layer closest to the skinís surface, contains five sub-layers, or strata. The outermost sub- layers provide a critical protective barrier for the body (see Table 1-1). Generally considered ìdeadî because their cells do not divide, these outermost layers continually slough off. Cells in the deepest sub- layer (the stratum basale) divide and replace the cells in the outer layers, completely renewing the skin every twenty-five to fifty days.
Melanocytes are specialized cells that produce melanin, the dark brown pigment responsible for darkening the skin. Melanocytes are located in the deepest epidermal sub-layer (the stratum basale). In response to direct sunlight, these cells produce melanin, which causes the skin to become darker and is visible to the human eye as tanning. Melanin also helps protect against ultraviolet radiation and sun damage.
The activity of the melanocytes determines the natural color of the skin. In other words, your skin color depends not on the number of melanocytes present, but on how much melanin they make.
Table 1-1. The five layers of the epidermis and their function
Layer of the Epidermis
Outermost layer; protects the body from external forces
Provides cells and keratin for the outer layers of skin
Produces proteins that cement the skin and helps protect the body from water and other outside forces
Provides a layer of strong attachments that prevents abrasions of the skin
Innermost layer of epidermis, where melanocytes are located; provides a source for cells in the outer layers of epidermis
The dermis is the larger, inner layer of the skin and, like the epidermis, contains sub-layers (see Table 1-2). To better understand melanoma, it is important to know that the deeper (reticular) layer contains blood vessels, lymphatic vessels, and larger nerves of the skin. The vessels in this layer can pick up specialized cellsóincluding melanoma cellsóand carry them to the lymph nodes. From there, melanomas may travel through the lymphatic and vascular systems and cause cancers in almost any other part of the body.
Table 1-2. The two layers of the dermis and their function
Layer of the Dermis
Papillary dermis: thin layer
Contains papilla that hold the epidermis and dermis together
Layer of the Dermis
Reticular dermis: thick layer
Contains blood vessels involved in regulation of temperature
Contains sweat glands for temperature control and pheromone release
Contains nerve endings and specialized cells that regulate the sense of touch
Contains hair follicles and sebaceous glands
Cancers of the Skin
When I examine a new patient with a skin growth, also known as a lesion, the first question I always ask is whether it has changed from its usual size or shape. This is a crucial question, because nearly all cancerous lesions will exhibit a change. In fact, such changes are the most common reason why people seek medical attention for a skin growth. If a lesion has been present since childhood and has not changed in any way, the likelihood of a serious cancer is much lower.
The second question I ask is whether the skin lesion is pigmented. Whether or not I see pigment is key because melanin is a clue that the melanocyte is the source of the growth, which raises concern about melanoma. Please note that not all melanoma lesions will have pigment. About five percent of melanomas have no pigment at all and are called amelanotic melanomas. Nonetheless, the first distinction that your dermatologist or pathologist will make is whether the skin growth is pigmented or non-pigmented.
Cancer can develop from almost any cell in the skin (or elsewhere in the body), but certain cells are far more frequent culprits than others. Non-pigmented cellsóas opposed to pigmented melanocytesóare the predominant source of skin cancers.
Non-Pigmented Skin Cancer
The two most common non-pigmented skin cancers are basal cell carcinoma and squamous cell carcinoma, named after the respective cells that cause them. Fortunately, the most common variety of non-pigmented skin cancer is relatively easy to cure (see Table 1-3).
Basal cell carcinoma, the most common human cancer, likely accounts for about one quarter of all cancers in the United States. Parts of the body that are exposed to the sun, such as the faceóespecially the nose and scalpóare the most frequent sites of basal cell carcinoma. Most experienced dermatologists will be able to recognize a basal cell carcinoma, although some are trickier to identify. One type that happens to produce pigment, for example, can be confused with a melanoma.
Although fairly common, basal cell carcinoma only spreads (metastasizes) to other parts of the body in fewer than 0.1 percent of cases. But treatment is still required since it can disrupt the surrounding normal tissues. Basal cell carcinomas on the nose, ear, and eyelid are often more prone to recurrence, so it is important to make sure that they are completely removed or treated.
Patients with basal cell carcinoma should be examined at least once a year by a dermatologist. If basal cell carcinomas recur, they usually do so within one to five years but may develop at any time. In addition, patients with one basal cell carcinoma may develop other basal cell carcinomas.
Squamous cell carcinoma occurs when the keratin-producing cells in the skin divide without control. Squamous cell carcinoma is the second most common skin cancer, occurring in about 100,000 people each year in the United States. Those who have difficulty tanning and tend to burn when exposed to the sun for a prolonged period of time appear to be at higher risk for developing squamous cell carcinomas. People with fair complexions and those of Celtic descent also have a higher frequency.
Like basal cell carcinomas, this cancer also occurs most commonly on sun-exposed parts of the body and is slightly more common in men than women. But squamous cell carcinoma is much more serious because it is more aggressive and grows more rapidly, causing local destruction of normal tissues, and it has the potential for metastasizing to other parts of the body.
Squamous cell carcinomas appear on the skin as slightly raised and reddish areas and may grow over a period of several weeks to months. Squamous cell carcinomas that occur on the lips and ear are usually more difficult to control than those occurring elsewhere. The severity of squamous cell carcinomas depends on their size, how deep they are located within the layers of the skin, and on the characteristics of the cells involved. This information can only be obtained by a biopsy and examination under a microscope. Some forms of squamous cell carcinoma are very thin and located only in the epidermis and are usually easier to control.
When squamous cell carcinomas spread, they may send cells to the lymph nodes nearby or to internal organs. Always have the lymph node areas of the body examined if you have a squamous cell carcinoma. In cases where the cancer is very large or the cells are very aggressive, further evaluation of the internal organs may be necessary by obtaining a special X-ray known as a CT or CAT scan.
Since squamous cell carcinoma can recur and because a second squamous cell carcinoma can develop, it is important to see a dermatologist on a regular basis after having a squamous cell carcinoma. A good rule of thumb is to have a full skin and lymph node evaluation every three months for the first year after treatment, then every six months during the second year, and once a year after that.
RARE FORMS OF NON-PIGMENTED SKIN CANCERS
Cancer can occur from any of a number of other specialized cells and structures within the skin. Although these cancers are extremely rare, they can be quite serious, even life threatening. The diagnosis of a rare non-pigmented skin cancer usually requires referral to specialists.
Cancer of the sweat glands is called microcystic adnexal carcinoma. More common in women, it usually occurs in middle age. People who received radiation treatment for acne and thyroid cancer may be prone to this type of cancer. Patients require close monitoring, since there is a high likelihood that the cancer may come back in the same location.
Cancer in the sebaceous glands is sebaceous carcinoma. These cancers occur more frequently in women, are most commonly located on the upper eyelid, and may be associated with exposure to previous radiation. In about 20 percent of the cases the cancer may spread to other sites. Occasionally sebaceous carcinomas have been linked to cancer in other organs, especially the colon and urinary tracts. Because of this relationship, patients with sebaceous carcinoma are evaluated for colon cancer and urinary tract cancers. Atypical fibroxanthoma appears as a nodule on the head and neck region in elderly adults or on the torso, arms, and legs in younger adults. The cells involved have a spindlelike appearance. This cancer has been known to metastasize and should therefore be treated by simple excision.
A specialized cell whose function may relate to the sense of touch or to the endocrine system, the Merkel cell can develop into aggressive cancers known as Merkel cell carcinomas. Found most often on the head in older people, these cancers have a tendency to spread to the lymph nodes and later to internal organs.
In addition to these skin cell cancers, cancers of other parts of the body such as the breast, lung, and colon, may spread to the skin. Sometimes the cancer in the skin is the first sign of the primary cancer.
Table 1-3. Types of non-pigmented skin cancer
Type of Cancer
Basal cell carcinoma
Most common skin cancer; rarely spreads; several methods of effective therapy
Squamous cell carcinoma
Less common but more likely to spread; usually treated by surgery or Mohs procedure
Microcystic adnexal carcinoma
Cancer of the sweat glands; aggressive cancer but unlikely to spread
Sebaceous gland carcinoma
Most often occur on the eyelid and can spread; treatment is surgical excision
Spindle-shaped cancer cells that appear as nodules; can spread; treated by Mohs procedure
Merkel cell carcinoma
Rare but aggressive cancer arising from Merkel cells; may spread to lymph nodes
Cancers from internal organs that spread to the skin; prognosis depends on the type of cancer
Pigmented Skin Lesions
In addition to the non-pigmented skin lesions Iíve mentioned above, there is another broad category: pigmented skin lesions. They include both benign and malignant forms. Benign pigmented skin lesions, which comprise the majority, are called moles. Malignant pigmented skin lesions are called melanoma. Melanocytes, the cells that produce the pigment melanin, are the most common source of both kinds of pigmented skin growths. Melanoma occurs only when the melanocytes become severely abnormal and start dividing uncontrollably.
Moles are a normal part of the skin. When melanocytes, which are distributed in the lower layers of the epidermis throughout the body, grow in clusters with surrounding normal cells, a mole occurs. The difference between a mole and melanoma is that the melanocytes stop dividing in the mole but continue to grow without stopping in a melanoma. Moles can develop anywhere on the body that is covered by skin. The typical mole appears as a small flat or slightly raised growth of pink, tan, or brown coloration. Moles are usually symmetrical, which means the border is very smooth. Some moles may be unusual and can lead to cancer.
Everybody has molesóbetween ten and forty is considered normal. Both children and adults may develop new moles (although the growth of new moles is less common after about forty years of age). Sometimes moles may grow and lift off the skin, but they are usually smaller than a pencil eraser. Moles may also fade or disappear completely over time.
The number and size of moles may be important factors in predicting the risk of melanoma. Interestingly, the number of moles is genetically determined, as demonstrated by the fact that identical twins have exactly the same number of moles, but non-identical twins do not. The risk of melanoma increases in people with more than fifty moles that are larger than two millimeters in diameter and in people with five or more moles larger than five millimeters in diameter.
TYPES OF MOLES
Doctors refer to a mole as a nevus, and multiple moles are called nevi. The common nevus is a typical mole and is sub-categorized by the pathologist depending on where the growth is located in the layers of the skin:
- a junctional nevus occurs only in cells in the epidermis
- a compound nevus contains cells in both the epidermis and dermis
- a dermal nevus is a mole in which cells are confined to the dermis. Dermal nevi may not appear pigmented since they are below the epidermis.
The blue nevus, a variant of the common nevus, is named for the blue color caused by the melanin- containing cells deep within the epidermis. Most common in women, it can occur in children and young adults. These nevi develop on the scalp, hands, and feet and are considered benign lesions. But treatment by simple surgical excision is usually recommended because, on rare occasions, melanoma can develop in a blue nevus.
A common nevus occasionally develops unusual features that distinguish it from all the others. These unusual moles are called atypical or dysplastic nevi, and differ from common nevi in several ways. First, atypical nevi are larger than five millimeters in diameter. In addition, these lesions may have inconsistent coloration, irregular or notched edges, and blurry borders. These lesions are sometimes smooth, but have also been described as scaly or ìpebbly.î
Atypical nevi are more likely than common nevi to develop into melanoma, although the exact relationship between atypical nevi and melanoma remains the subject of some speculation among experts. Any signs of a change in a mole, including an increase in the size of the mole, change in the edges, color, or new bleeding from the mole, all warrant evaluation by a medical professional. Atypical nevi are found in about 5 percent of the general population but in 30ñ40 percent of patients with melanoma, suggesting a strong correlation. There are many more patients with atypical nevi that do not develop melanoma, however, so other factors are likely involved as well.
A congenital nevus is an elevated, pigmented lesion present at birth in some babies. These lesions, which can vary in size and be quite large, have been suspected of increasing the risk of melanoma, a rare but possible occurrence in children. The risk seems to be related to the size of the congenital nevus, with those that cover more than 5 percent of the childís body, roughly equivalent to the right leg of an average two- year-old, having a significant risk. Since almost half the melanomas arising from congenital nevi occur in the first ten years of life, large congenital nevi should be removed as early as possible.
Another lesion that can be difficult to distinguish from melanoma in children is called a Spitz nevus (named after the pathologist who first reported it). These are usually small pinkish nodules, although they may also be pigmented. Spitz nevi are considered benign, but must be reviewed by an experienced pathologist to make certain.
COMMON BENIGN PIGMENTED SKIN LESIONS
- Common nevus
- Blue nevus
- Atypical or dysplastic nevus
- Congenital nevus
- Spitz nevus
Now that Iíve described the non-pigmented skin cancers and the benign pigmented skin lesions, only one category is left: malignant pigmented skin lesions, more commonly known as melanoma.
What Is Melanoma?
The appearance of melanoma is often obvious to professionals who treat the disease on a regular basis, but there are no absolute criteria that determine if a particular lesion is a melanoma. Melanomas are as diverse in appearance as people are, and therefore a challenge to identify through visual inspection alone. Any suspicious skin lesion should be considered for a biopsy, as this is the only way to know for certain if it is a melanoma. Some melanomas may start from a mole that has been present for many years, but increases in size, changes in its borders, or begins to bleed. Other melanomas may start as a new pigmented lesion that starts to grow in a normal area of the skin. Most melanomas are irregular in shape with uneven areas raised above the skin, although some may grow just below the skin and be felt as a hard nodule. Many melanomas are dark brown or even black in color, but some may be reddish or blue in color, and others may even be flesh colored. Some melanomas may develop areas of bleeding, a process referred to as ulceration.
I am suspicious, then, that it may be melanoma when I see a mole change in appearance or begin to bleed, or the development of a new pigmented skin lesion in a previously normal area of skin.
Please remember that most skin growths, or lesions, are not melanoma, and are not even cancerous. Furthermore, of all skin cancers, only about 5 percent are melanoma. That is precisely why determin- ing the source of skin cancers is so essential, since the non-melanoma cancers are more easily treated and the diagnosis of melanoma warrants more attention. Even though the odds favor a benign skin lesion, al- ways try to find out as soon as possible that a new growth or a change in a known mole definitely is not melanoma: Early recognition saves lives.
Where is Melanoma Found on the Body?
Melanoma can occur anywhere that melanocytes, the pigment-producing cells of the body, are found. The most common location is the skin, and melanomas arising in the skin are referred to as cutaneous melanomas. As I mentioned, they may occur within an existing mole or may start in a previously normal- appearing part of the skin.
Table 1-4. Distribution of cutaneous melanoma
Skin site Frequency Head and neck 22ñ43%
Chest, abdomen, and back 13ñ32%
Melanomas may also occur in the mucous membranes around the mouth and nasal cavities (called mucosal melanomas) or around the anus (called anal melanomas). Another form of melanoma, called ocular melanoma, can even develop in the eye and is, in fact, the most common tumor of the eye. (Because they do not behave exactly like cutaneous or skin melanomas, mucosal, anal, and ocular melanomas are discussed separately in Chapter 9.)
After a melanoma has spread to other internal organs or lymph nodes, the original site cannot always be identified. Experts believe that, in such cases, the immune system may have destroyed the original (or primary) melanoma.
Table 1-5. Sites of melanoma on the body
Body site Frequency of melanoma
Mucous membranes 2%
Who Gets Melanoma?
Melanoma is not a disease of the elderly. Most patients are diagnosed during their forties or fifties. Very rarely, melanoma has been reported in young infants (see the age distribution of melanoma in Figure 1-1). Race is an important filter, as melanoma most commonly strikes Caucasians of European descent. The disease is less prevalent among African Americans and is very rare in the Japanese population. Nonetheless, melanoma can and does occur in nearly all races and can be found all over the world. Melanoma is strongly associated with exposure to the sun, especially for Caucasians. Proximity to the equator also increases your risk of melanoma. The highest risk of melanoma in the world occurs in Australia, where the disease affects 1 in every 60 Australians. Although nothing has been proven yet, this striking increase in melanoma may be related to the degradation of the protective ozone layer (which shields out harmful ultraviolet light), combined with the popularity of sunbathing and outdoor activities. A familial or genetic form of melanoma is responsible for approximately 10 percent of all melanoma cases. The next chapter explains the causes and additional risk factors for developing melanoma.
Why Is Melanoma So Dangerous?
When a melanoma is confined to the skin, it is usually treated easily by surgical removal. If melanoma grows to a certain depth within the dermis, however, some cells may break off and spread. These renegade cells usually enter the lymphatic system in the dermis and spread to nearby lymph nodes. From there they may spread almost anywhere else in the body, where they can cause serious damage to other organs and threaten life.
Although malignant melanoma accounts for only about 5 percent of all skin cancers, it is responsible for about 80 percent of all deaths related to skin cancer. In the United States, an estimated 52,000 people develop melanoma annually; almost 8,000 people die of melanoma each year, or twenty people every day. Melanoma is the sixth leading cause of cancer-related deaths in men and the seventh leading cause of cancer-related deaths in women. Melanoma has become the leading cause of cancer deaths in women between the ages of twenty-five and thirty.
Melanoma is also increasing at a faster rate than almost any other cancer. In 1935 melanoma afflicted 1 of every 1,500 persons living in the United States. This rate has steadily increased by 5ñ7 percent per year, so that by the year 2000 melanoma struck one in every seventy-five persons. The true incidence of melanoma may be much higher, since many skin lesions are destroyed by freezing, laser ablation, and other methods where biopsy confirmation of melanoma is not obtained or reported.
Although this data may sound disturbing, there is some good news: Despite the soaring number of melanoma cases, the mortality rate has not increased proportionately during the last twenty years. This may be due to the fact that melanoma is being detected earlier, when it is more likely to be cured, or it may be that better surgical techniques are achieving better cure rates.
In the next few chapters you will learn more about the causes of melanoma and how to prevent the disease, how to identify melanoma, and current treatment options and experimental therapies being developed for patients with melanoma.
Columbia Melanoma Center Case Studies
A thirty-two-year-old medical resident named Juan was working at the hospital when he noticed a dark, pigmented skin lesion on his left great toe, which had increased in size for about three months. Originally from Puerto Rico, he had spent a lot of time in the sun but there was no melanoma in his family. When I examined Juan, I found a one-centimeter smooth, flat blue-black pigmented lesion over the upper part of his toe. There was no evidence of abnormal lymph nodes in the leg or groin. We performed an excision of the skin lesion using a local anesthetic. After the pathologist reported that the lesion was a blue nevus and the margins of the lesion were all normal skin, I was able to reassure Juan that this was not melanoma. I advised him to have his dermatologist do at least an annual checkup, sooner if he notices any other unusual skin lesions.
This case is typical of pigmented skin lesions. The change in the size of the lesion over a three-month period was the most worrisome sign and the reason Juan was referred for evaluation. Like most peopleís pigmented skin lesions, his turned out to be of no serious consequence. The pathology report confirmed that the lesion was benign and the excision provided adequate treatment for Juan. Although I might have chosen to simply observe the skin lesion and remove it later, the recent change in size and Juanís peace of mind made me opt for excision.
Ask Your Doctor
IF YOU DEVELOP A NEW SKIN LESION OR NOTICE A CHANGE IN AN OLD SKIN MOLE, ASK THE FOLLOWING QUESTIONS:
1. Is the lesion pigmented or non-pigmented? Pigmented lesions are usually brown or black and are more worrisome for melanoma than non-pigmented lesions.
2. Is the lesion suspicious for malignancy or cancer? Many doctors will have experience looking at skin lesions and may be able to tell you what the problem is by simple inspection.
3. Should I see a dermatologist? A dermatologist is a doctor who has additional training in diseases of the skin and may be better equipped to identify difficult lesions. Many dermatologists are also trained in the treatment of skin cancers.
4. Do I need a biopsy? A biopsy is the only way to be certain of what the lesion is. It must be examined by a trained pathologist with experience in skin diseases. Always ask that your doctor review the pathology report with you after any biopsy procedure.
5. Is my family at risk for developing a skin lesion or cancer? Some types of skin cancer, especially melanoma, may be more common in close relatives. If your doctor believes that you have this type of cancer, it may be helpful to have close family members (parents, children, and siblings) see a dermatologist for a routine examination or screening so that lesions can be detected as early as possible.