People may think the lives of stars, prominent politicians, and celebrities are charmed, but one doesn't have to be an ordinary person to develop malignant melanoma. Troy Aikman, the famous quarterback of the Dallas Cowboys, was diagnosed with malignant melanoma by his dermatologist. It is important for public awareness that prominent celebrities and sports figures come forward with their diseases. Mr. Aikman is to be commended for choosing the public good over his privacy. His move may save hundreds, possibly even thousands, of lives. As with all skin cancers, self-examination, awareness and knowledge will usually improve a patient's chances of survival. Senator John McCain of Arizona was treated for melanoma at the Mayo Clinic.

The chances that an American will develop melanoma are rapidly rising. If current trends continue, one in every one hundred Americans born today will eventually develop melanoma. One in every five patients who develop melanoma will die from it. Melanoma tends to occur in adults in the prime of their family and professional lives. Traits and factors associated with melanoma include multiple typical moles, atypical moles, familial atypical mole syndrome, familial melanoma syndrome, disorders of DNA repair, excessive sun exposure, freckling, history of painful or blistering sunburn, ease of burning, inability to tan, blue eyes and light hair. Increasing public awareness of melanoma and its treatment without causing unnecessary fear is always a challenge for truly concerned government policy makers and dermatologists.

In this section, we will mainly discuss melanoma confined to the skin (Stage I). The author is in the process of publishing an addendum on more advanced stages of melanoma that will eventually be included in this Web site. Presently, we refer you to the Dermatology Department at New York University, a reputable institution, for more information on the more advanced stages of melanoma. Reviewing material on the Web as of 2003, the author saw some accurate and much inaccurate information regarding more advanced melanoma. The most-accurate information now appears to come from medical schools and university-based authors of Web sites. Keep posted for the previously mentioned addendums, updates and modifications to this Website.

......Melanoma is a disease of the pigment (tanning) cell called the melanocyte. Melanocytes live in the lowermost epidermis, the bottom of the paper-thin upper sheet of outer skin, and make the pigment granules that give us a good portion of our skin color. The only physical skin difference among people of various colors is the size and type of pigment granules present in their melanocytes. Everyone has melanocytes, even albinos. In albinos, the melanocytes just do not make the pigment properly. Normal melanocytes don't hold onto the pigment granules; they pass them off in little tentacles to the keratinocytes, the cells that make up the majority of the epidermis.

Melanocytes can influence hair color, among other things. The melanocytes' granules are responsible for the non-red portion of tanning. Melanocytes are an adaptive protective mechanism for the skin. Note that people native to equatorial countries and southern Europe are darker skinned and sunburn less often than Celts, a fair-skinned people from northern Europe. Melanocytes are also present in the eye, brain, anus, groin and mouth.

Anywhere normal melanocytes can be found, abnormal melanocytes may develop and can become even more abnormal, developing into cancer and causing death. The most abnormal melanocytes result in melanoma, which is malignant and deadly, in many cases, if not treated properly or early enough. All cutaneous (skin) melanomas start high up in the skin at the junction of the epidermis and dermis, where the melanocytes reside. Late detection is the major problem that both patients and doctors face with melanoma. For example, melanoma of the mouth, the most common form of melanoma in Japanese people, is usually found when it is too thick. The later the melanoma is found, in this case because it is hidden in the mouth, the worse the situation will be and the thicker the tumor will be.

 

There are several types of melanoma, some extremely bad and some not even as bad as some basal-cell carcinomas. Skin cancers lie on a spectrum; knowledge is necessary to determine exactly where a particular cancer may lie and how to treat a specific case. See "Gray Zones." Fortunately, if caught early enough, melanoma is one of the most treatable cancers known.

DETECTION

Early detection requires some knowledge and some luck. Some melanomas may not have pigment granules and may be the color of normal skin. These may be hard to find or diagnose even for some good dermatologists. Some melanomas can look like normal moles to both patients and well-trained dematologists. That is why it is better to insist that anything taken from your skin be sent to a reputable dermatopathology laboratory for analysis. The lab should be staffed by well-trained Board-Certified Dermatopathologists.

In October 1998, John Wayne Cancer Institute researchers reported a melanoma blood test that caused much excitement and hope for future improvements. The TA-90 glycoprotein blood test has been found to be a "pretty good" indicator of whether an EARLY STAGE melanoma had metastasized. Having a positive result for TA-90 showed a reduced chance of surviving 5-years by about 20%. Unfortunately, the test is not foolproof. False positive and false negative results run over 25%. This means that if the test says you are "positive" it is wrong about 1 in 4 times. It also means that if the test is "negative" that result is wrong about 1 in 4 times. The Web site author hopes that protein tests like this and others coming in the future will improve detection. If the Web site author had early stage melanoma he would not have the TA-90 test done due to the number of false positives and negatives. The Web site author believes that it may be possible in the future to detect melanoma with nuclear matrix proteins (NMP's). However, NMP technology is in its infancy. One biotechnology company with good quality NMP patents and molecules which showed impressive results in cervical cancer, bladder cancer and currently bowel cancer unfortunately had serious "management" difficulties, to put it mildly. Remember, just because a company has impressive technology (even in the eyes of an expert) does not mean that it will make money or even survive for that matter.

Up to five percent of melanomas disappear from sight on the skin after a period of time. Thus they may have already spread into the body before doctors ever have a chance to view them. This five percent "invisibility" or surface loss of visible melanoma cells results from the body's attempt to kill the melanoma cells with its own immune cells and antibodies. However, in addition to melanoma cells, some of the surrounding normal melanocytes may be killed. This causes the halo effect, i.e., a white ring around the melanoma. The halo effect may cause the destruction of an original melanoma, but many times this result will not be reached before the original melanoma has sent its malignant seeds elsewhere in the body. Again, this phenomenon may account for the five percent of melanoma patients with no apparent primary (original seeding) tumor. Melanoma vaccines, which are used in more advanced-stage melanomas, work on this principle and have had some success.

SAMPLING OR PROVING BY BIOPSY

A properly performed biopsy (sample for microscopic exam) is critical in deciding whether or not a spot is a melanoma. The appearance of the skin cells under the microscope is "gold standard" for diagnosing/determining whether the patient has an abnormal mole or a melanoma. The depth in the skin to which the melanoma cells have invaded is the greatest determining factor in the patient's chances of survival, as well as in the type of treatment the patient will receive.

 

The NIH (U.S. National Institutes of Health) advises that "an excisional biopsy with a narrow margin of normal-appearing skin is recommended for any suspicious lesion. . . . [The biopsy] should include a portion of the underlying subcutaneous for accurate microstaging." The NIH allows an incisional biopsy for any "formidable . . . large lesion." The author of this Web site would like to temper this NIH instruction: when the initial lesion will not be totally exhausted by a small inverted-pyramidal biopsy, then the pyramidal biopsy can be done first for the purpose of scouting somewhat atypical lesions. (See Biopsy in glossary.) This way, patients will not end up with large unproductive biopsies causing much scarring and costing much money and discouraging future investigation of suspicious moles.

 

Studies have shown that dermatologists like to take biopsies of suspected melanomas by several means: 60% like to excise (cut out totally) with borders of normal tissue, 15% choose punch biopsy (small cookie-cutter samples the size of a pencil eraser), 10% choose shaving (cutting with a razor along the skin's surface), 10% choose incision by taking an incomplete piece from within the melanoma and 2% use some other method. Just because the majority of dermatologists choose to use one technique does not mean that it is the best. After all, 49% of dermatologists score in the bottom half of their dermatology boards. In fact, dermatologists practicing for less than a decade are more likely to use a shave or punch on suspected melanoma than dermatologists who have been in practice for over 10 years. (Ackermann) Practicing more years does not mean that a doctor or dermatologist is better. The experience in numbers or time perpetuating a bad habit or treatment does not make it right. An older doctor's saying "4 + 4 = 9" for a dozen years does not make him "more correct" than a younger doctor's saying that "2 + 2 = 4" for only 6 months.

What kind of conclusion can we draw here? Are the younger dermatologists trained with the newest methods? Do they believe that INcision does not spread melanoma, as most modern studies suggest? (Griffiths) Or have older dermatologists heard stories of their comrades' personal experiences suspecting the spread of melanoma by INsional biopsy? Or are the dermatologists and plastic surgeons who perform EXcisional-biopsy surgery (total cutting out with margin for microscopic examination) are just looking for more money, because this procedure pays at least five to ten times what any other method pays? These questions are probably best answered on a case-by-case basis, in other words on an individual basis.

The Web-site author prefers to biopsy in several varied ways. If it is an obvious melanoma, excisional surgery is used. If it is a large, irregularly colored dark lesion, very suspicious for melanoma with several thicker and highly unusual zones, the lesion is drawn and mapped and several inverted-pyramidal biopsies are taken. If the lesion could be an atypical mole or melanoma, but no certainty exists, the Web-site author uses the inverted-pyramidal biopsy technique that removes about 80% of the visible lesion, if it is smaller that 1cm at the surface.

The proposed small incisional (inverted pyramidal) biopsies that the Web site author discusses do not apply to all patients or all moles. Your doctor will likely have good reasons for recommending his/her approach. Nothing is etched in stone when it comes to biopsying moles and suspected melanomas. Some moles are so obviously "bad looking" that the surgeon should excise (cut all around) these moles so as to make it easier for a good dermatopathologist to inspect it under the microscope for deep invasion. Some patients "want it all over with at once" and demand the spot be completely cut out, whether or not it is benign or malignant. Again, there are many different factors that go into the choice of whether to cut around or into a "pigmented lesion" or for the purposes of this chapter a "colored, irregular spot or bump." No one treatment or type of biopsy is right for everyone. There are sometimes more than "two sides to a story" and in some circumstances it may be fair to criticize the use of an incisional biopsy (such as a punch, inverted pyramidal, shave, etc) in evaluating/sampling pigmented lesions.

Certain well-respected dermatopathologists such as Dr. Barnhill believe that every suspicious pigmented lesion (mole) should be biopsied by completely cutting the growth or spot out of the body. This argument has its merits. First of all, not all "visibly bad" pigmented lesions (spots) have the most severe abnormal cells in the areas that most doctors can easily identify as "bad" portions of the mole. Second, the bigger excisional biopsy may "cure" the spot if it is mildly atypical and also of course if it was benign from the beginning. Third, dermatopathologists are heavily looked upon following the reading of a melanoma to come up with "a number" (representing the Breslow level) which indicates a patient's chances for survival. It would of course be impossible for dermatopathologists to provide a reliable thickness answer if they have been given only a small portion (INcisional biopsy) to represent the entire "bad spot". It is true that reading only partial or INcisional biopsies of spots suspicious for melanoma is an extra burden for dermatopathologists who pride themselves on accuracy. These are extremely valid reasons for performing EXcisional samples or biopsies. Many dermatopathologists are purists; but most dermatopathologists do not ever touch a live patient so their practical view of the world may be slightly distorted. Again, this approach however may be one that takes only the individual mole into consideration and not the public in general or individual patients.

The Web site author must respect the philosophy of these expert dermatopathologists, at least in some segment of patients. However, the Web site author is at odds with the above philosophy in the majority of his patients for the following reasons. First of all, cutting out all moles on patients who have anything "suspicious" costs a lot of money, patient transportation, lost work, lost wages, lost productivity, pain of needles (although this can be made extremely minimal), wound care, stitching, etc. Many times "managed care" only compounds these problems. Not all melanomas are extremely or even moderately abnormal looking. Performing EXcisional surgeries that cause scarring sometimes an inch or more long limits the amount of moles most patients will want checked or tested in a lifetime. Remember, even in the age of epiluminescence microscopy, the best test for melanoma is STILL and WILL LIKELY BE FOR DECADES a skin biopsy that is read under the microscope. The public and especially the cosmetically conscious patients of the Web site author do not want numerous noticeable scars on them if at all possible. Tiny incisional biopsies used by the Web site author have many uses. These incisional biopsies act as a simple "screening tool" because they leave almost unnoticeable marks, allow patients to immediately cover them with make-up, allow immediate return to sports and other activities, are low cost, take less than 20 seconds to do, allow immediate return to work, do not upset the patient's looks, require no stitch removal and still provide some very useful information. Larger excisional biopsies are less of a "screening tool" because they do not share the benefits we just mentioned of tiny incisional biopsies. Judging from the A, B, C, D's put out by the Skin Cancer Foundation and the American Cancer Society and all the other screening programs. And judging from the fact that melanoma is most curable when found early. It seems only logical that the more screening methods, the better.

If an incisional (inverted pyramidal) biopsy is read as "moderately" or "severely" atypical under the microscope, which is rare in itself (only 5 ­ 10% of Web site author pigmented lesion biopsies) then an excisional surgery mole removal (which becomes a biopsy and is checked by the laboratory) will be scheduled. If original incisional mole biopsy is read "mild" then the mole will be observed indefinitely (if the patient desires) with annual body checks or suggested to be removed if the mole is in a location that cannot be easily seen by the patient. Since so few incisional biopsies would result in some sort of follow-up excisional surgery, incisional biopsies can be thought of as a tool of mass screening that may end up gaining more information (by wider acceptance and use) than they lose (less ability to determine depth on initial sample). Additionally, since the samples are so small, especially at the deeper portions, when discussing the inverted pyramidal technique the mole is not disrupted much for a later excisional biopsy. Since the inverted pyramidal technique acts as a scout while causing minimal distortion to the remaining mole or melanoma it may best be considered a special type of INcisional biopsy. Additionally, the Web site author has been very fortunate in telling which areas of a mole may be "bad", never having lost a patient to melanoma in practice dedicated to skin cancer and skin cancer surgery spanning into three decades. Warning: not all doctors may be good at the inverted pyramidal technique.

The Web site author can certainly agree with the dermatopathologists concerns when it comes to incisional biopsy techniques that may damage or partly destroy what remains of a suspicious pigmented lesion "bad mole." In those cases it may be better to "scout" with the more involved excisional methods to avoid disasters like missing the worst section of the mole, etc. Additionally, when the varying skills of other doctors come into play using the inverted pyramidal technique come into play there may be difficulties as well. We again must humbly respect the thoughts of the puristic dermatopathologists who recommend only excisional removal of moles. Perhaps they have seen too many serious problems as a result of reading thousands of other dermatologists' and plastic surgeons' mole and melanoma biopsies. Consider this logical natural progression of a possible melanoma analysis of a suspicious mole. An unusual looking mole is subject to incisional biopsy. By chance the least bad portion of the mole is sampled revealing moderate or severe atypia. This requires an excisional removal with stitching; the now complete or larger specimen can now be step-sectioned to search for all levels of atypia thus possibly revealing any melanoma. One might argue that it may have been "better" to have gotten it all over with by cutting out the entire unusual looking mole in the first place. However, a more logical argument is that a well-trained dermatologist with a high level of proper suspicion for melanoma may avoid doing a lot of unnecessary mole surgery by using small sampling biopsies to find out which of the moles actually needs the surgery (usually < 10%) in most volume practices.

WHICH SPECIALISTS HAVE THE MOST APPROPRIATE TRAINING?

Unfortunately, certain surgical subspecialists, like the average general plastic surgeon, usually spend only a small fraction of the formal training time in diagnosing skin cancers and lesions as the average dermatologist. Plastic surgeons are more likely to take it upon themselves to do excisional surgery on any patient who has what they consider to be an "abnormal mole." Since general plastic surgeons have little formal training in judging/diagnosing moles accurately, their drive to perform excisional surgery may be skewed, especially since they are paid by the amount of skin removed. The Web-site author alone sees 10-20 cases per year of excisional (deep, inch-long cutting out) surgeries performed by plastic surgeons, many times just for benign, colored age-related warts that the plastic surgeons said were "suspicious for melanoma." Some of these unnecessary surgeries cost over a thousand dollars and are performed on the tip of an unsuspecting patient's nose for a seborrheic keratosis (benign, colored age-related wart). Such a wart could have been diagnosed easily by a dermatologist and treated superficially, without scarring, for ten dollars. By the way, the flaps or grafts the plastic surgeon(s) must use to repair the tip of the nose will, by definition, cause a scar.

MAIN TYPES AND STAGES OF MELANOMA

There are four main types of malignant melanoma (melanoma, for short). They differ from each other in how they start, how they grow, how they are treated and chances for patient survival. They are usually graded by the depth of the skin to which they penetrate, from Clark's level I - V. (We will learn about these Clark's levels later in this section. For now, just note them, later understand them and refer to the next paragraph again for greater clarity.)

......Beyond the skin levels, melanomas are graded by where they have gone, i.e., to which organs the melanoma has spread in the body, also known as a "stage." An example of one of the early staging systems developed for skin melanoma and adopted by the American Joint Committee on Cancer (AJCC) is as follows:

"Older" AJCC Staging for Melanoma

Stage 0 =	Clark's level I
Stage I =	melanomas less than 1.5mm deep (Clark's level II or III), which have not been detected by current medical instruments to have spread.
Stage II =	melanomas which have not spread but are greater than 1.5mm deep (Clark's level IV or V)
Stage III =	melanomas which have spread only to the regional (close-by) lymph nodes (clusters of immune cells that filter the body's fluids through a system of non-blood thin tubes) or are in transit
Stage IV =	the most serious stage, in which melanoma has spread beyond the nearby lymph nodes, distantly to other nodes or other organs or parts of the body (for example; lungs, liver, brain, heart, bones, etc.)

As with all medicine, times change and ways of describing melanoma and the locations to which it spreads have changed as well. We may, however, still be in a period in which some doctors and some publications refer to the old system. Therefore, we are reviewing the older system and drawing some comparisons. As of 1998, there are currently two major systems used to stage malignant melanoma. Here is a comparison presented in table format:

STAGING METHODS

TRADITIONAL AJCC		NEW AJCC
Clinical stage I	Localized melanoma	Stage I-II Stage 1A.. Stage IBA Stage IIA. Stage IIB.	Also called localized melanoma Less than 0.75mm thick 0.76-1.5mm thick 1.51-4mm thick Greater than 4mm thick
Clinical stage II	Regional lymph node spread	Stage III	Regional lymph node spread or in-transit metastases
Clinical stage III	Distant metastases (spread)	Stage IV	Distant metastases (spread) beyond the regional lymph nodes
Dr. Breslow, a world-renowned melanoma expert, defined a patient as having a high-risk melanoma when that patient has a tumor thicker than 4mm or has melanoma cells in the lymph nodes.

 

Staging or determining where melanoma has gone in the body is critical in life-planning and treatment. Because groups of melanoma cancer cells are so metabolically active (use much body fuel such as glucose or blood suger) melanoma is a very favorable tumor to show up on a PET scan, if the melanoma has spread beyond the skin. Thus, PET scans are now useful tools in melanoma staging. Another valuable tool to assess spread of melanoma is sentinel lymph node biopsy (removing the most likely lymph node draining the area which the melanoma was found) with thorough step sectioning of the node. Much progress is currently being made in treating the late stages of melanoma, but the battle is not easy for patients or their doctors. Most of the battle is non-surgical (involves no cutting), conducted in research labs. Interferon alpha 2b was the first agent to result in at least a one-year prolongation in relapse-free survival (melanoma could not be detected for at least a year), as well as an overall survival of high-risk melanoma. A year may not seem like much to the casual observer, but every day of life is important to a melanoma patient. Some distant hope may be seen in anti-angiogenesis treatments such as troponin. See Future Treatments. We will address the issue of non-surgical treatment, which is usually reserved for melanoma that is not early or thin, later in this Web-site subsection.

Let us return to discussing the four main types of melanoma. Superficial spreading melanoma is the most common, occurring in 70% of the cases. Nodular melanomas occur 15% of the time; acral lentiginous melanomas 6% of the time and lentigo maligna 5% of the time. Interestingly, two percent of the cases are unclassifiable, i.e., doctors do not know in which group to place them. The classical melanoma is a black or brown, irregularly colored, irregularly bordered, flat or raised area. When the colors of red, white, blue or pink are present in the mix as well, doctors must definitely biopsy the suspicious lesion.

 

This is where a good dermatopathology lab and Board Certified Dermatopathologist come in handy. If the specimen is read wrong, either as too benign or too malignant, there may be either unnecessary surgery or not enough surgery to save your life. Always double check a diagnosis of melanoma with an excellent independent dermatopathology lab such as those at the Mayo Clinic and New York University, the University of Pennsylvania, Harvard, Stanford, Jefferson University and The Johns Hopkins University Departments of Dermatology.

Once you have been diagnosed with melanoma, it is important for you and the doctor to check your lymph nodes. Pay attention when your doctor checks the nodes in the neck, underarms, armpits, side of the groin and elsewhere; remember how and where he/she checks the nodes. Feel these areas periodically yourself on a monthly or bi-monthly basis. Immediately report anything unusual to your doctor. Usually the best way to feel for lymph nodes is by symmetrical comparison (feeling right and left at same time, or one right after the other, and comparing sides for any differences; this is not so easy to do under the arms). Symmetrical comparison is useful because it is not very common for metastatic melanoma to involve the exact same nodes on the right and left equally, which would cause nodes of the exact same size. Therefore, a difference from one side to the other would be cause for concern, and should be reported to your doctor right away.

Superficial spreading melanoma (SSM) is an appropriate name because it starts high up in the skin in the melanocytes, where the dermis meets the epidermis, and spreads along the surface of the skin while, or before, it penetrates deeply. If the SSM has not penetrated the basement membrane, the layer that separates the dermis from the epidermis, then it is called in situ. (In situ means "inside" when used in dermatologic applications, rather than the more common meaning of "natural or original position.") In situ SSM is good news, i.e., easy to treat with a great chance for survival. Unfortunately, in situ SSM is not common..

 

SSM is usually, but not always, a colored spot like that described previously, but it tends to grow flat or only slightly elevated. It is also noted by several authorities that SSM's usually have elevated edges that can be felt and touched with the fingers. These authors also state that SSM grows in a radial (non-metastasizing, horizontal, non-vertical) growth phase for between one to five years. The fact that SSM does not grow vertically and therefore does not invade deeply for a significant period of time gives properly educated patients a chance to detect and treat SSM.

Nodular melanoma (NM) invades more rapidly than SSM and therefore usually has a poorer prognosis. NM is so named because tends to grow as a ball or knot rising up out of the skin. In the case of NM, what grows up, also grows down, tending to invade the body, spread and cause death. From the beginning, it spreads both vertically and horizontally. Keep in mind that the vertical component of a melanoma's growth is one of the greatest determining factors in patient survival.

Acral lentiginous melanoma (ALM) has the highest mortality (lowest five-year survival) of all forms of melanoma. "Acral" means located on the palms of the hands or the soles of the feet; and "lentiginous" means flat and colored or freckle-like. Patients diagnosed with ALM have a five-year death rate of 85 percent. This means that patients survive five years only 15 percent of the time. ALM is the most common type of melanoma occurring among black (of African descent) patients. Recent studies have indicated that the high mortality of ALM is due not to any special property of ALM but rather mostly to late detection of this type of melanoma. In other words, ALM is not more aggressive than other SSM or NM; it is just not caught soon enough. It may be that the patients in whom ALM is most commonly found are less aware of the problem and consult a doctor too late, as compared to patients with other types of melanoma.

Lentigo maligna melanoma (LMM) usually has the most benign prognosis (outlook) of all of the forms of melanoma. LMM oridnarily arises from a lentigo maligna (LM). LM is an absolutely flat (unable to be felt with the eyes closed) form of atypical (unusual) freckle, which is usually slow growing and long-standing. The diagnosis of LM can presently be confirmed only by a skin biopsy. LMM can be suspected in a LM when a raised bump, no matter how small, develops in any part. The bump part is the LMM. Of course, chance collision between an LM and some underlying benign growth, for example, sebaceous hyperplasia (benign hair oil-gland tumor), can also cause such a bump. Therefore, a biopsy is especially necessary in the area of the bump. Because of the tumor's slow rate of growth, lateness of metastasis (distant spread) and tendency of metastasis at first to be limited to the regional lymph nodes, the five-year survival rate is relatively high, 90 percent. This form of melanoma is most commonly found in the elderly.

 

All patients with a history of melanoma arising on the skin are at about a five percent risk of developing another separate, unrelated melanoma of the skin. This process is called multiple primary (occurring on the skin) melanoma formation. This phenomenon underscores the importance of constant body self-examination with a mirror and/or inspection by another of other hidden areas like the scalp and groin. If a second melanoma of the skin develops in a patient with a history of melanoma, it is very important to determine whether it is a new skin melanoma (second primary) or a metastasis to the skin from the original melanoma. If it is a metastasis, the disease must be classified as Stage III and the likelihood of death in five years rises significantly.

Although melanoma many times arises without the presence of a mole, it most frequently, but not always, arises inside a "bad mole." Interestingly, melanoma can arise within all three major categories of moles: atypical (dysplastic, unusual) nevus, congenital (existing at birth, sometimes not erupting to the surface skin for months or years) nevus and plain ordinary garden-variety moles, which are totally different from seborrheic keratoses. (See Moles in the glossary.) This phenomenon of a mole giving rise to a melanoma is evidenced by finding mole cells next to melanoma cells under the microscope 35 percent of the time.

SSM's are ten times more likely to show adjacent (nearby) mole cells under the microscope than NM's, and SSM's are 20 times more likely to show adjacent mole cells under the microscope than LMM's. Melanomas of the trunk are more likely to be associated with a mole than melanomas of the legs. To make matters even more confusing, melanoma has even been reported to arise in a seborrheic keratosis, although this is an extremely rare event and likely the result of a "chance collision." On a more positive note, studies have shown a more favorable outcome for patients whose malignant melanomas were associated with acquired moles. See Moles or Nevi.

Before 1980, diagnosing melanoma was based mostly on symptoms such as bleeding or growth. Then, in 1983, Drs. Kopf, Friedman and Rigel developed the A, B, C, D technique for diagnosing early melanoma. Remember, early melanoma is the most curable phase. The A, B, C, D's are surface characteristics that can be seen by all, patients and doctors alike. "A" stands for asymmetry, "B" stands for border irregularity, "C" stands for variation in color and "D" stands for diameter over 6mm (1/4 of an inch).

.

The author of this Web site partially disagrees with looking for a "D" of 6mm (the size of a pencil-eraser) because he knows from personal experience that melanomas can start in moles or other growths much smaller than 6mm. Why miss any patients just to simplify a set of relatively crude rules or to save screening dollars? Some prominent dermatologists like to include an "E" for elevation. The author of this Web site strongly disagrees with the inclusion of an "E" because many melanomas are not elevated, either to the naked eye or to the touch. The public might be be misinformed by narrowing their scope of concern. It is obviously important to find melanoma when it is small, because melanomas larger than a dime have a 50 percent chance of having already spread internally (inside the body).

Table Further Explaining A, B, C, D's of Pigmented Lesions

Asymmetry	=	not regularly round or regularly oval
Border	=	notched, scalloped or poorly defined at the edges
Color variation	=	shades of brown, tan, red, white, blue or black alone or in any combination
Diameter	=	6mm (the size of a pencil eraser)

As noted above, this Web-site author believes the "D" tool is misleading and advises the public to be wary of even the smallest of spots with A, B and C characteristics.

Studies have shown that, even when doctors use the A, B, C, D's, if they require that three of the four letters be present to diagnose melanoma, 17 percent of melanomas are missed! (Maize) This fact is not presented here to scare patients but to point out that about one in five melanomas may not look like the classic description and even trained dermatologists may not have all the answers. Again, an ounce of suspicion may be lifesaving in finding these non-classic melanomas. Any unusual lesion may merit a small biopsy as a "scout."

Fancier ways for doctors to diagnose melanoma include using epiluminescence to check how a suspicious lesion looks slightly below the surface of the skin and digital computer analysis. See Atypical Moles and Doctor & Patient Examination.

Melanoma in children is relatively rare and the previous advice in this Web site to have the biopsy specimen viewed by Board Certified Dermatopathologists from two separate university-type institutions with good reputations is strongly reiterated. If the author's child had anything more than a mildly atypical mole, the specimen would be sent to one of the previously mentioned institutions and then to Dr. Raymond Barnhill (at Johns Hopkins), currently the world's expert on pigmented lesions, following the retirement of Dr. Wallace Clark (of the University of Pennsylvania where Dr. Weber, the author, trained). With children, check and recheck the diagnosis.

About two percent of melanomas occur in patients who are younger than 20 years old. Less than 0.4 percent of melanomas occur in children before puberty. Sometimes melanomas in children can be related to organ transplants, Hodgkins disease and a rare genetic disease called xeroderma pigmentosum. As with adults, melanomas in children can run in families or be related to or arise in congenital moles. It is much more common for a child to have a totally benign Spitz nevus (mole with very unusual and strangely-shaped cells) than to have a melanoma.

Some, perhaps only a few, surgeons are all too happy to cut, say they saved a life and collect the fee while not knowing that their diagnosis (interpretation) of what they're treating was all wrong in the first place. If the suspicious lesion was a Spitz nevus, surgery may not have been necessary. Over-diagnosing in children can be a large problem because, although true melanomas are few, no doctor would want to miss one. There are, as well, significant legal considerations in missing a melanoma in a child, especially since there have been several reports of lesions originally misdiagnosed as Spitz moles in children, only later discovered to be metastasizing melanomas.

As was stated before, melanoma is best predicted by levels (depth of invasion into the skin) and stages (if we can detect with current technology whether it has spread anywhere). In 1969, Dr. Clark, a pioneer in melanoma research, described the original five "levels" based upon the thickness or penetration of a given melanoma in relation to the depth of certain structures in the skin. From these levels, estimates were made of a patient's chance of surviving or dying from a given melanoma. The CLARK's levels, area of skin penetration in medical terms and resulting five-year chances of survival are shown in the following table:

As you can see, Clark's levels rely on a dermatopathologist (or excellent general pathologist) to determine how deep melanoma cells descend in the skin by estimating their location in relation to other skin structures. A good dermatopathologist is best to help discern between SSM and LMM. The difference between SSM and LLM greatly influences a patient's chances of survival. Knowing the chance of survival may help patients plan important events and take care of a family's financial matters.

Breslow, in 1970, decided to measure with a microscopic ruler how deep melanomas penetrate, to see if depth predicts survival. Breslow did succeed, to a large extent, finding that melanomas smaller than 0.75mm (3/4 of a mm or 1/30th of an inch) USUALLY did not metastasize. This finding supports not surgically removing the lymph nodes for microscopic inspection in patients with melanomas measuring less than 0.75mm. In addition, some studies have indicated that, in melanomas larger than 1.5mm (double the 0.75mm), cutting out the lymph nodes filtering the area of the original melanoma doubled the survival rate of patients.

Both Clark's and Breslow's systems were landmarks. Dr. Bagley, a world-renown skin-cancer specialist, attempted to combine the best ideas of the Clark and Breslow systems. The Breslow method was a more accurate predictor of prognosis (patient outcome) than Clark's, it is easy to measure, reproducible and objective. Clark's level of skin invasion was eventually found to be less predictive of survival than tumor thickness. One would think that Clark's levels would be of additional help because it would take the relative thickness of skin into account, for example, back skin is thicker than eyelid skin. Bagley felt that by combining both systems, and reducing the number of categories, he could improve the predictive power. Nonetheless, several multivariate analysis studies have indicated that Clark's levels are of no prognostic significance once Breslow's thickness has been taken into account. Another potent predictor of patient outcome has been reported to be the mitotic rate, i.e., the number of melanoma cells seen under the microscope to be in a state of division in a unit of area. More than six "mitotic figures" (cells in division) in every square millimeter (pinhead) of microscope viewing space is a bad sign. A high number of lymphocytes (certain white blood cells) seen under the microscope invading the melanoma, possibly indicating the body's attempt to kill the melanoma, is a good sign. Unfortunately, regression or receding of cells in melanoma bears little on the outcome.

In a 1992 NIH communication, the following melanoma categories and survival rates were given as:

Massachusetts General Hospital/New York University study provides the following categories and survival rates for melanoma:

What kind of surgery is necessary for a particular melanoma? The answer depends upon the thickness or depth of penetration of the melanoma being treated. In the Web-site author's opinion, it also depends upon the type of melanoma in the patient. The Web-site author treats lentigo maligna melanoma (LMM) differently from any other type of melanoma. If the LMM is large and has been biopsy-mapped in the areas of strangest color and greatest protrusion (biggest bump), and the greatest penetration is Breslow <1mm, then the author will perform Mohs Surgery from the center out to the edges of the LMM. The central part of the removed LMM will be sent for traditional (vertical section) analysis by a dermatopathologist. The edges are treated with Mohs Surgery. Mohs Surgery will provide the highest cure rate in removing the lentigo maligna (malignant "freckle") cells that gave rise to the LMM. Currently, LMM is the only type of melanoma that the Web-site author will treat with Mohs Surgery. The use of an immune-system chemical stain called HMB-45 may make the Mohs even more accurate. Depending upon the depth and stage of any melanoma found, the Web-site author prefers a team approach involving the medical oncologist, the surgical oncologist and the patient's internist in the decision-making process.

What many plastic surgeons and even a suprisong number of dermatologists do not know, until they have missed lentigo maligna on enough patients, is that lentigo maligna is not always black or brown, but may be skin colored and invisible to the naked eye. Some plastic surgeons will tell the patients just to watch what was left behind if the biopsy report shows remaining abnormal cells. But the remaining abnormal cells can give rise to melanoma. The Web-site author suggests, if the remaining lentigo maligna cannot reasonably be treated surgically, that "scouting" biopsies be taken around the area of failed surgery and that other treatments such as cryosurgery (freezing) and azaleic acid be used to clear the cells. Biopsies can be taken after treatment to determine success. The only problem with these treatments is that lentigo maligna cells may hide in hair pores and resist the treatment. Unlike many plastic surgeons, the author treats all LMM deeper than 1mm, as he would any other melanoma.

What kind of surgery is necessary for the all the rest of the melanomas? For melanoma in situ, excision with a 1/2cm (1/5 inch) border is all the NIH (United States National Institutes of Health) recommends for a cure. Dr. Barnhill recommends that microscopically severe atypical moles be removed by standard excisional surgery and receive the same margin as melanoma in situ.

What about melanomas that penetrate deeper than in situ but less than 1mm in thickness at their greatest point? The cure statistics of the now-famous Veronesi (World Health Organization (WHO) and Italian National Cancer Institute) study show that survival rates following 1cm (3/8 inch) margins for excision of early melanoma (less than 1mm thick) are usually excellent, with about 95% of patients surviving eight years! For the purposes of this text, early melanoma will also be called thin melanoma and refers to melanomas less than 1mm thick. The Veronesi recommendation is a relatively new treatment when it comes to melanoma, removing early melanomas with smaller margins than were traditionally used. Also noteworthy, in these early melanoma patients, elective (prophylactic) lymph-node-removal surgery for lymph-node exam by microscope is NOT necessary.

Let us briefly discuss the Veronesi study, which may have a seemingly simple result and recommendation, but is truly a triumph of modern medicine. Many melanoma patients have been saved from additional scarring and mutilating surgery by the results of this study. In a way, the Veronesi study may be thought of as a new treatment for melanoma in that, prior to the study, many doctors were unsure of just how much extra normal tissue to remove around a melanoma of less than 1mm thickness to save a patient's life. New treatments have to start somewhere, but sometimes it may take many decades to overturn the arbitrary guesswork or dicta from the past. In this case, thin-melanoma-removal surgery is an excellent example. Remember, to do a five-year survival study takes at least five years of following the patients, in addition to the time to select the patients, and to analyze and publish the data. This is one of the reasons it took so long to overturn the previous wisdom regarding removal of thin (< 1mm) melanomas.

In the early 1900's, doctors decided that all melanomas needed a 3-5cm (about 1-2 inches) border. That means at least a 3-4 inch-wide hole if grafted, not to mention a wound length of 12-16 inches, if the sewing is done with a straight-line closure! The use of wide margins to remove all melanomas was largely the work of Dr. Sampson Handley in 1907. Dr. Handley published the need for 5cm margins in the famous British medical journal called the Lancet, without ever studying even one primary (initial) melanoma. He drew his conclusion from studying only a single patient whose melanoma had metastasized (spread)! Handley concluded, after his study of only one patient, that margins around primary melanoma must be "about an inch" of skin or a "safe and practicable distance." The 5cm excision advice from Handley resulted from stretching Handley's recommendation of removing two inches of fat from below and around the melanoma, beneath the shelf of the skin left by cutting away the one inch of upper skin. Handley's conclusions, resulting in the recommendation of 5cm margins around melanomas, persisted for decades.

Finally, in 1977, Breslow called into question and studied the need for such wide surgical margins. However, it wasn't until the late 1980's that Veronesi published that, for thinner (but greater than level I) melanomas, a mere 1cm (3/8 inch) border of normal-appearing tissue could produce a survival rate similar to that of a much larger border. This famous international study has spared many patients much unnecessary and painful surgery, but it took years to design and complete. Fortunately, melanoma patients are now able to reap the benefits of a study that asked the simple questions, "Why are we (doctors) doing surgery this way? Who originally thought of it? What were their original reasons? If the reasons were somewhat arbitrary, then what if we do it a bit differently?"

You can see how difficult it might be to do a study on a deadly tumor by skimping on the treatment. Many international cooperating medical centers and doctors were necessary to complete this study. Both the patients and the doctors are to be commended. Now that the results have been published and debated in reputable medical journals with good peer review, it is acceptable to use the new smaller margins in practice in the United States. Articles in medical journals such as the Lancet that are reviewed by doctors before publication is allowed are especially believable because these other doctors usually check and criticize the works and publications as much as possible to see that the articles are likely truthful, accurate, and presented properly.

Having said all that, how much surgical removal of a margin of normal tissue is recommended for melanomas? Surgical margins for melanoma thicker than 1mm usually depend upon the depth of the melanoma being treated and varies from surgeon to surgeon. There is, as well, some variation in recommendations in the medical literature. The following table attempts to summarize some recommendations for melanoma over 1mm in depth:

The Massachusetts General Hospital guidelines for patients with clinical stage one melanoma differs from the above material in two areas. For melanomas 1-1mm thick, an excision margin of 1cm is recommended. For melanomas between 1-4mm thick, 3cm margin is recommended, if possible. The Massachusetts General Hospital guidelines do not recommend elective regional-lymph-node dissection in any of the groups except the 1-4mm thick melanoma group. In this group, the elective regional-lymph-node dissection is presented as an option and done only when the lymphatic drainage pattern of the melanoma is well defined. This is because the elective regional dissection allegedly improves survival rates for certain intermediate thickness melanomas ranging from 1-4mm thick.

We have discussed the width (margin) of melanoma surgery, but what about the depth? Just how deep in the body should the melanoma surgery go? Some medical authorities feel that the depth of melanoma-removal surgery should extend through the subcutaneous fat down to the muscle fascia (fibrous material encasing muscles). Other authorities feel that less excision (cutting), only into the middle of subcutaneous fat is sufficient.

Dr. Zitelli studied melanoma removal and made some new surgical-margin-removal recommendations based upon the visible width of the melanoma. Zitelli still takes into account that melanoma depth is important. However, this was a relatively new way to look at larger melanomas and to make some additional helpful recommendations. After studying the removal results of various-sized and relatively large melanomas in hundreds of patients, Zitelli stated that the following sites and melanoma widths were best treated with the margins shown in the following table:

Lymph-node involvement from a skin melanoma is a critical factor in determining how long a melanoma patient will live. If lymph nodes are able to be felt by hand and later shown by microscope to contain melanoma, there is a about a 75% chance that melanoma has spread distantly to involve other organs, e.g., the lungs, heart, brain. Only 30% of these patients will survive five years. Complete lymph-node dissection (surgical removal) might be useful to stage melanoma patients to know where the cancer has spread. However, it is fraught with some of the problems just described. Some studies indicate that there is a small group of patients with stage I and II melanoma 1-4mm thick, less than 60 years of age, who may actually benefit from complete lymph-node dissection.

The lymph system is made up of duets (tubes) and nodes (filter bulbs) that are believed to drain and filter the body. Doctors presume that melanoma cells spreading to the rest of the body will first be filtered at the lymph nodes in the group relatively near the location of the skin melanoma. IF this is true, then the lymph nodes that drain the location of the skin melanoma will trap or hold some of the melanoma cells. There are many groups of lymph nodes in the body with many surprising and relatively unexpected drainage patterns from the skin. To better detect which lymph nodes will filter the area from which a melanoma is removed during surgery, a blue dye or radioactive tracer is injected at the site of the melanoma and followed into the draining lymph node(s). Studies have shown that the main lymph node concentrating the dye or tracer represents all the nearby nodes (basin) draining the surgical site. By finding out which few nodes really drain the skin area where the melanoma first arose, certain melanoma patients may be spared from the relatively greater surgery of complete lymph-node removal (surgery).

In 1991, Dr. Morton introduced the concept of sentinel lymph-node biopsy for melanoma patients. Morton felt that the lymph node at greatest risk for collecting melanoma cells would be in the primary basin of nodes draining the skin melanoma. Several studies support the thought that a sentinel lymph node may represent all of the lymph nodes in the draining basin. This especially true if the sentinel lymph node is negative, meaning that it does not contain any obvious melanoma cells when examined by microscope. If the sentinel lymph node can be found and mapped, about 85% of patients would avoid suffering the problems that may arise from more extensive complete lymph node dissection. For the present, it appears that the prime use of this technique will likely be in staging patients for new melanoma studies.

What about non-surgical treatments for melanoma? As we can see how effective surgery is in curing thin melanomas, the non-surgical treatments for melanoma are CURRENTLY discussed only in relation to thick melanoma and metastatic (spread to another part of he body) melanoma. The future may hold non-surgical (not cutting) treatments, including vaccines, for all melanomas, but that time has not yet come. The non-surgical treatment for melanoma is a hot topic and in a constant state of change. However, for the present, in this Web site we will discuss the non-surgical therapies in several of the following paragraphs.

Early diagnosis and removal of melanoma may be the only completely effective way of treating the disease. However, researchers are making great strides in helping later stage patients as well. More and more chemotherapy agents are being added to the arsenal to be tested against melanoma.

Chemotherapy agents such as dacarbazine, cisplatin and nitrosoureas (Taxol and carboplatinum), show response rates between 10-15%. Such drugs may work even better when used in combination. It appears that some combination of these drugs may have response rates that are much greater than either agent used alone. For example, Tamoxifin in combination with other drugs may enhance the effects of the other drugs; however, as a single agent, it has very little activity. Researchers have also been able to make great advances using biologic agents, monoclonal antibodies and tumor vaccines.

In recent years, many different biologic agents have been tested against melanoma. The drug interleukin-2 (IL-2) is a cytokine (cell-activity chemical) that:

1. causes the multiplication of both helper T (lymphocyte white blood) cells and cell-toxic T cells;
2. can stimulate certain lymphocytes (type of white blood cells) to recognize and kill cancer cells;
3. may be combined with lymphocytes from the blood to activate them as killer cells that can target a wide a variety of cancer cells in the body without hurting normal tissues;
4. can be used to produce tumor infiltrating lymphocytes (TIL), derived from culturing portions of tumors themselves in IL-2 for several weeks.

Unlike the LAK (lymphokine-activated killer cells), TIL cells are potent cells that are very specific and kill only the tumors from which they were generated. IL-2 is not like the interferons or other biologic agents in that it possesses no direct anti-tumor activity. In a test tube, IL-2 has no ability by itself to inhibit the growth of tumor cells, but in live humans and animals it does somehow cause melanomas to shrink by exciting the immune system. Interferon is a biologic drug that both directly and indirectly affects melanomas. Interferon directly reduces the growth of melanomas and indirectly affects melanomas by stimulating the immune system to increase natural killer-cell activities and melanoma antigens (markers that the immune system can recognize) or other antigens. The interferon alpha has enjoyed some success in advance melanoma by showing partial or complete responses in about 15% of patients. Patients are noted to improve even with very low-dose interferon alpha.

Monoclonal antibodies are proteins made by lymphocytes, and look like miniature, molecular slingshots. These proteins are very special and usually attached to a very special variety of substances or things. Antibodies either work alone or spark the patient's immune system into action. They can even be used to carry toxic agents to the tumor directly. Some of the monoclonal antibodies made thus far attach to sugar-protein parts of the melanoma cells. Monoclonal antibodies, thus far, have not been as exciting as the other therapies that have just been discussed.

Adjuvant therapy is meant to excite the immune system into awareness of the melanoma. Stimulants such as BCG, corynebacterium and transfer factor have unfortunately thus far failed to demonstrate much of a benefit. It is possible that adjuvant agents may see use with tumor vaccines, which will now be discussed.

The discovery of special melanoma-cell antigens (markers that the immune system can recognize) offers promise of making a vaccine some day. A vaccine, when given to a patient, alerts the patient's immune system early enough to combat the introduction or arising of a disease that has some similarity to the vaccine. Certain patients produce certain types of melanoma cells that seem to be very rich in a coating of antigens, many of them attach to the sugar proteins that were discussed earlier. It is beneficial to combine the most common and strongest antigens into the vaccine, producing a polyvalent (many sites of binding) vaccine. Some polyvalent vaccines, with up to six different antigens in them, have shown some promise. Polyvalent vaccines stimulate immunity, relying on the fact that many and perhaps all melanoma cells lines share common antigens. It is the sharing of these common antigens that allows a patient to mount an immune response against his own tumor when exposed to antigens from another human melanoma. A different melanoma vaccine has been tested in patients with widespread melanoma of the body. Results have been rather modest, and the response rates are about 20%. Fortunately, vaccines usually have relatively few side effects and seem very well suited as an adjuvant therapy for patients with high-risk stage one melanoma.

A drug that has entered the fight against melanoma is paclitaxel (Taxol). Taxol stabilizes the miniature tubes within cells and has been shown to fight several types of solid tumors. When tested alone against melanoma, it appears to have a response rate of around 20%. This suggests that Taxol would be a good agent to combine with other chemotherapy drugs against melanoma in the future.

Another potential anti-melanoma drug is Levamisole. This drug is used to treat worms in patients and animals. It has also been found to alter the immune system. Although most U.S. studies have shown no benefit from this drug, but a Canadian study did show that it was a possible benefit to older women with melanoma.

Gene therapy is currently being brought to bear in the fight against melanoma, as well. There are many different ways in which genes can be used to fight melanoma. In one approach, infiltrating lymphocytes are genetically engineered by infecting them with a retrovirus carrying special DNA. This forces the lymphocytes to secrete a factor called tumor necrosis factor. It is hoped that tumor necrosis factor will kill tumor cells. Another approach is the injection into a patient's melanoma of a genetically engineered type of DNA to cause the melanoma cells to express more antigens. It is hoped that the body's immune system will recognize these antigens by reacting strongly against the foreign material now expressed on the melanoma cells. Still another approach that is currently being tested is the genetic engineering of melanoma cells to secrete certain chemicals such as cytokines, e.g., IL-2, IL-4 and interferon-gamma. These cytokines secreted by melanoma cells are then injected into patients as tumor vaccines. The possibilities of genetic engineering are endless and well beyond the scope of this particular Web site chapter. Future events along this line will be presented in Quarterly Updates.

Please remember that melanoma is a very curable cancer, if found early. The high cure rate may be due more to doctor and patient suspicion resulting in finding more melanomas early than any improvements in the simple surgery necessary to remove a thin, early melanoma. In melanoma, an ounce of prevention such as sun avoidance, self-inspection and dermatologist inspection, is worth a pound of cure.

What types of non-surgical tests and studies will likely be done once a patient has been diagnosed with melanoma? Internal tests are not usually ordered for in situ melanoma (Clark's level I). Chest X-ray with LDH (blood lactic-acid dehydrogenase enzyme) and liver-function tests are usually ordered for stages I, II and III on initial visit and as follow-up. (Beahrs, 1992) For early (less than 1mm) melanoma, CAT scans, MRI's (magnetic resonance imaging) and nuclear scans have been called wasteful by the NIH (1992); in fact, the NIH says there is no good evidence for having chest x-rays or blood-liver tests, either. However, the author still sends even early melanoma patients to a medical oncologist for a good physical examination and whatever tests the oncologist believes are necessary, which could include any of the tests mentioned above.

Information gathered as part of a survey by Provost, Huang and Kopf, in 1997, showed significant variations in the tests ordered for patients who are asymptomatic (showing no outward signs of melanoma). Drs. Huang, Provost and Kopf recommend that blood LDH, chest X-ray and CAT scans of the chest, abdomen and pelvis be considered, especially if the patient has enlarged lymph nodes in the neck or underarm areas. CAT scans of the pelvis should be considered if the site of the skin melanoma is below the belt-line or if the patient has enlarged lymph nodes in the groin or inner thighs. Baseline CAT scans or MRI's of the chest, abdomen, lower belly and brain are usually ordered for stage III. In melanoma patients who show no brain symptoms (seizures, headaches), CAT scan or MRI rarely have revealed any sign of spread. However, if the original melanoma was found in the skin of the head or neck, some consideration may be given to obtaining a head and neck CAT scan or MRI.

Drs. Huang, Provost and Kopf initially considered chest X-ray screening of all melanoma patients as "worthwhile because it detected . . . 6% of all reported recurrences in patients with AJCC stage I or II melanoma" (with no symptoms). However, a recent 3,000-patient study has found a chest-X-ray-screening yield of only 0.1%. (Terhune) Thus the true chest-X-ray-screening yield may be 60 times less than that noted by Huang. Nonetheless, the Web-site author feels, as does Kopf, that because chest X-ray and LDH are inexpensive and can save lives, these tests are worth obtaining on all melanoma patients, with the exception of the in situ variety. Times change, studies change and results change. For example, a more recent study by Dr. Rigel and others, published in JAM Coll Surg, 1995, on Stage IV melanoma, revealed a concerning five-year survival rate of only 6% and a mean (middle of expected duration) survival of seven months.

How often should patients who have had a melanoma be seen by a doctor? If a patient has had one melanoma already, or has a family member with a history of melanoma, that patient may be genetically at risk for melanoma. For people who have had a thin melanoma, it is reasonable to be seen by a dermatologist every six months or less. For patients with atypical moles and/or a family history of melanoma, it is reasonable to be seen once every six months to every year or so.

There is some controversy regarding sunscreens and melanoma. Current sunscreens may not protect against melanoma, but wearing a sunscreen could lead to extra time in the sun, which could increase the chances of trouble. See Sunscreens. Although the author recommends high-SPF sunscreens and short sun-exposure for physically active outdoor functions for all other skin-cancer patients, he strongly recommends sun avoidance for melanoma patients. In other words, melanoma patients and those with many severely atypical moles (by biopsy) receive a recommendation of high-SPF sunscreen and sun exposure only in the first two hours after dawn and the final two hours before sunset. This recommendation will stand until more data has been gathered regarding melanoma and sunscreen and may change based upon any new well-studied findings. Please weigh these thoughts carefully.

The take-home message is that, in its early phases, melanoma is one of the most curable diseases in the world. Finding melanomas early requires public education, knowledge and a huge amount of suspicion. Currently, the average time lapse between when a patient recognizes the presence of a lesion that, eventually is found to be melanoma and the time the patient becomes suspicious of the lesion is six months. For 20% of patients in one study, at least two months elapsed between a doctor's seeing a patient's suspicious lesion without diagnosing it correctly and ultimately making the correct diagnosis of melanoma! (Cassileth) This is a sad commentary on doctor training. It appears that patient vigilance may be helpful when doctor training is lacking regarding melanoma detection.

Keeping suspicion from bordering on paranoia is another issue. In patients with a history of atypical moles, personal history of melanoma or family history of melanoma, the Web-site author believes that their level of suspicion should not ever be thought of as paranoia, yet that all of these patients' suspicions must be taken seriously. In conclusion, "an ounce of prevention is worth a pound of (melanoma) cure" and the prevention may not be sunscreen. That "ounce of prevention" is more likely to be a combination of knowledge regarding melanoma and moles, suspicion about changing or new spots and avoidance of excessive sun exposure.

.

Paul J. Weber, M.D., P.A. 5353 North Federal Highway, Suite 400 Fort Lauderdale, FL 33308 Tel: 954-489-9800 | Fax: 954-489-0401