Malignant Melanoma

Signs and Symptoms

If a melanoma develops, patients usually notice a new brown or black lesion on their skin, or changes occur within an existing mole. About 70% of melanomas start from new, whilst 30% come from an existing mole. Although most are pigmented (brown) some 5% stay pink (called amelanotic melanomas). Melanomas can start anywhere on the skin but are most common on sun exposed areas. Men have a higher chance of developing melanoma on the head, neck and trunk whereas women have a higher risk on the legs. Other sites melanoma can occur include the soles of the feet, in between toes or fingers, and under the nails. Rare sites include areas that have not been exposed to the sun such as within the mouth, the eye, around the anus and vagina.

The ABCDE Check

Diagnosing melanoma can be difficult even for your doctor. The ABCDE system helps to identify changes that would make you suspicious that a melanoma could be developing. If any of the below signs are present, or you have other concerns, it is best to seek the advice from your GP or dermatologist. Skin lesions that are changing need to be checked

A	Asymmetry	One half does not match the other
B	Border	Irregular, crusted or notched
C	Colour	A change in colour- darker, lighter, varied
D	Diameter	6mm or more, but can be smaller
E	Evolving	Changes in the mole over time

Abnormal Nails

Brown colouration that occurs under a nail or at the base of a nail may represent a subungual melanoma. These melanomas are often picked up later because people mistakenly think that they have inadvertently trapped a finger or stubbed a toe, and it is only when things do not improve that they visit the doctor. Typically there is a colour change or pigmentation at the base of the nail or nail fold, with coloured streaking down the length of the nail. Sometimes the nail itself may become thickened and irregular ridged surface and even ulcerate.

A bruise on, or under a nail that is NOT growing out along with the nail needs to be investigated

Diagnosis

If you are concerned about a mole, either one that is new or has changed, you should visit your GP. If your doctor is concerned they will refer you to a skin cancer specialist urgently (within two weeks). The diagnosis of a melanoma is made by removing the abnormal mole (excision biopsy), which is easily done under a local anaesthetic.

Excision Biopsy

The excision biopsy will consist of removal of the mole with a rim of normal skin (2mm around the mole) to ensure it has been completely removed. This will be sent off for testing. Your consultant will explain the results and, if the mole was a melanoma, what further surgery is needed. This surgery will involve a wider excision of skin, from where your melanoma was, to try and ensure there are no roots left behind. In addition a further procedure, known as a sentinel node biopsy, may be recommended at the same time as your wider excision to see if the melanoma has spread.

Staging

Staging is an overall assessment of the patient with melanoma and is based on an internationally agreed classification. It describes the size of the melanoma and whether it has spread to other parts of the body. This assessment will help guide your doctor to offer the best treatment. Thinner melanomas generally behave more favourably than thicker melanomas, which is why it is important to seek advice as soon as possible. Remember, that even though staging is a statistical analysis of the available data, your melanoma is unique.

Staging and treatment is generally carried out at your regional skin cancer centre. Here your plastic surgeon or other consultant with an interest in skin cancer surgery will be able to discuss in detail what the options are for treating your skin and cancer and then reconstruction of the area.

Stage		Explanation
0	Melanoma in situ	This means that the melanoma cells have not invaded into the deeper tissues of the skin (the dermis) and is confined in the outer most layer of the skin (the epidermis)
1A	Melanoma is less than 1mm thick, not ulcerated (the surface of the skin is intact) and no signs of actively dividing (mitoses)	The uppermost layer of the skin has been replaced with melanoma cells and no signs of further spread, such as to the lymph nodes or other parts of the body
1B	Melanoma is less than 1mm thick but has ulceration (the surface of the skin is broken) or mitoses; Melanoma is 1–2 mm thick without ulceration or mitoses	The uppermost layer of the skin has been replaced with melanoma cells and no signs of further spread, such as to the lymph nodes or other parts of the body
2A	Melanoma is 1–2 mm thick and has ulceration; Melanoma is 2-4 mm thick without ulceration	The melanoma is only into the skin and no signs of further spread, such as to the lymph nodes or other parts of the body
2B	Melanoma is 2–4 mm thick without ulceration; Melanoma is 4mm thick or more but without ulceration	The melanoma is only into the skin and no signs of further spread, such as to the lymph nodes or other parts of the body
2C	Melanoma is 4mm thick or more, with ulceration	The melanoma is only into the skin and no signs of further spread, such as to the lymph nodes or other parts of the body
3A	Melanoma is not ulcerated but has spread to the local lymph nodes (up to three nodes)	Melanoma cells are seen in a lymph node using a microscope (microscopic deposit), but they have not increased sufficiently in number for the lymph node to be felt through the skin (macroscopic deposit). There is no evidence it has spread to other parts of the body
3B	Melanoma is ulcerated and microscopic deposits of melanoma have been found in no more than three lymph nodes; or Melanoma is not ulcerated and macroscopic deposits of melanoma have been found in no more than three lymph nodes; or Melanoma is not ulcerated and has not been found in the lymph nodes. Melanoma deposits have been found within the tissues in transit to the lymph nodes.	Cells have spread from the primary site of the melanoma to the local lymph nodes but only microscopically, as would only be determined by SLNB as the nodes would not be palpable to touch. There is no evidence it has spread to other parts of the body. Cells have spread from the primary site of the melanoma to the local lymph nodes and are now palpable. There is no evidence it has spread to other parts of the body. Cells have spread from the primary site of the melanoma along the lymphatic channels but have not reached the local lymph nodes. There is no evidence it has spread to other parts of the body.
3C	Melanoma is ulcerated and macroscopic deposits of melanoma have been found in the lymph nodes; or Melanoma is not ulcerated and macroscopic deposits have been found in at least four lymph nodes; or Melanoma has been found as in transit disease and in the lymph nodes.	Cells have spread to the local lymph nodes and are also in the lymphatics (in transits). There is no evidence it has spread to other parts of the body. In addition to being ulcerated at the primary site, cells have spread to the local lymph nodes and are now palpable. There is no evidence it has spread to other parts of the body. Cells have spread to the local lymph nodes which are now palpable and matted together. There is no evidence it has spread to other parts of the body.
4	Melanoma has spread to other parts of the body	There is evidence that the melanoma has spread from the primary site and gone beyond the local lymph node; these sites can occur in the skin well away from the primary melanoma, the liver, the lungs, and the brain. These latter sites can be picked up by radiological investigations such as CT scans, MRI and PET scans.

X-rays, CT Scans and Blood Tests

Once melanoma has been diagnosed, your specialist will guide you about whether any scans or blood tests are needed. Historically, chest x-rays have been used to assess whether disease has spread but we now use CT scans as they are more detailed. A CT scan is usually requested if there is a risk that melanoma may have spread to other parts of the body. An additional test that may be requested is a blood test to examine the function of the liver. Patients needing a general anaesthetic for surgery may have blood tests and x-rays as part of checking their overall health and fitness.

Sentinel Lymph Node Biopsy (SLNB)

Your doctor may offer this additional procedure to see if melanoma cells have travelled to the lymph nodes in the armpits, neck or groin region. Sentinel lymph node biopsy allows your doctor to locate the nearest lymph node to your melanoma and ‘map’ this with radioactive dye (in the x-ray department) before you come to the operating theatre. When your plastic surgeon completes the wider excision of the melanoma scar, this lymph node or nodes are also removed through a small scar and sent away for careful examination to look for tumour cells. It takes three or four weeks to complete this work whilst you recover from surgery.

Around 20% of patients will have a few has been removed. Currently it is recommended for these patients that the remaining lymph nodes at the same site are removed in case they too have microscopic deposits. We are not yet certain whether this test and subsequent surgery to remove the remaining lymph nodes, if the SLNB is positive, extends a person’s overall life expectancy. However, it gives the best information about the risks of your melanoma causing further problems

Treatment

Surgery is the main treatment to reduce the risk of melanoma coming back in the scar and surrounding area. The amount of skin your doctor removes will depend on the thickness of the melanoma (Breslow thickness) – the thicker the melanoma, the greater the amount of skin removed.

UK guidelines give these recommended excision margins:

In situ	5mm margin/all removed
Melanoma less than 1mm thick	1cm margin
Melanoma 1 to 2mm thick	1 to 2cm margin
Melanoma 2 to 4mm thick	2 to 3cm margin
Melanoma greater than 4mm thick	3cm margin

Sometimes it is not possible to obtain the recommended margins if the melanoma is in a difficult site (eg the face or fingers) but your surgeon will try to obtain the maximum margin possible, and rebuild the defect with a variety of methods

Topical Therapies

There are currently no approved topical therapies to treat melanoma

Radiotherapy

The use of radiotherapy or “x-ray treatment” is usually a second line therapy after surgery to the lymph glands if a tumour was very big, or to try and control disease in parts of the body where surgery may not be possible (such as the brain).

The use of radiotherapy is occasionally required after surgery to lymph glands in the neck, but less so if the glands have been removed from the axilla or groin

Chemotherapy

Chemotherapy for melanoma is a rapidly developing area for the treatment of melanoma, as better drugs are being developed. At present, chemotherapy is used for those patients who have advanced disease that cannot be treated by surgery, although there are some trials using new medicines early on for patients with high risk disease. Your specialist will guide you as to whether this applies to you.