HEALTH - MELANOMA (SKIN CANCER) SYMPTOMS
What is Melanoma?
Melanoma is a dangerous form of skin cancer. It begins when color-producing cells, called melanocytes, become abnormal and begin to grow uncontrollably, forming a mass of cells called a tumor. Melanoma can appear in an area no different from surrounding skin, or it can develop from or near a mole. It is found most frequently on the backs of men and women or on the legs of women, but melanoma can occur anywhere on the body, including the head and neck. This section describes melanoma of the skin.
The skin, the body's largest organ, protects against infection and injury and helps regulate body temperature. The skin also stores water and fat and produces vitamin D. Skin is made up of two main layers: the epidermis (outer layer of skin) and the dermis (inner layer of skin). The deeper layer of the epidermis contains melanocytes. Melanoma starts in melanocytes and is the most aggressive type of skin cancer. It can grow deep into the dermis, invading lymph and blood vessels. The initial type of treatment is determined by the size of the tumor as measured in thickness.
People diagnosed with melanoma may face more extensive treatment than those with non-melanoma skin cancer. Treatment of the primary (initial) melanoma usually involves surgery, which often cures early stage or thin melanoma. Chemotherapy, radiation therapy, and/or immunotherapy may also be part of the treatment for more advanced disease. Researchers are also investigating new approaches to treating advanced melanoma, including targeted therapy, gene therapy, and vaccine therapy.
Health: Risk Factors of Melanoma (Skin Cancer)
The following factors increase the health risk of developing melanoma:
Individual health history. People with increased numbers of moles or those with unusual moles called dysplastic nevi (flat, large moles that have irregular color and shape) are at higher risk for developing melanoma. About 50% of melanoma cases occur in people who have dysplastic nevi. Also, people who have weakened immune systems or those who use certain medications that suppress immune function are at higher risk for developing skin cancer. In addition, people who have had one melanoma are at increased risk for developing additional new melanomas; overall, in the general population, 2% of people who develop one melanoma develop other new melanomas. People who have had a non-melanoma skin cancer are also at a somewhat increased health risk for developing melanoma.
Family health history. Approximately 10% of melanoma occurs in individuals who have a family history of melanoma. Therefore it is recommended that close relatives (parents, brothers and sisters, and children) of a person with melanoma routinely have their skin examined. Alterations in two genes (CDKN2A and CDK4) that may lead to melanoma have been identified. These genes, however, only account for a small proportion of families with melanoma. Genetic testing for these two genes is not currently used in clinical practice. It is likely that other genes and environmental factors also affect risk of melanoma.
Exposure to ultraviolet (UV) radiation. Ultraviolet B (UVB) radiation from the sun produces sunburn and plays a role in the development of both melanoma and non-melanoma skin cancer. Ultraviolet A (UVA) radiation penetrates skin more deeply and may also play a role in the development of both melanoma and non-melanoma skin cancer. People who live in areas with bright sunlight year-round or at high altitudes have a higher risk of developing skin cancer, as do those who spend significant time outside during midday hours. People who use tanning beds, tanning parlors, or sun lamps are also at increased risk for skin cancer. Even people who tan well increase their risk of melanoma with more sun exposure.
Fair skin. Less pigment (melanin) in skin offers poorer protection against UV radiation. People with light hair and light-colored eyes who have skin that tans poorly or freckles, or those who burn easily, are two to three times more likely to develop melanoma.
Sunburn. According to many scientific studies, multiple, severe, blistering sunburns increase the risk of developing melanoma.
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Health: Symptoms of Melanoma (Skin Cancer)
People with melanoma may experience the following symptoms. Sometimes, people with melanoma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. The skin features that frequently occur in melanoma are listed below. If you are concerned about a symptom or skin feature on this list, please talk with your doctor or health care provider.
Changes in the skin are often the first warning sign of melanoma. An accurate diagnosis by a doctor or other health-care professional is critical. Often, the diagnosis can only accurately be made after a lesion is removed and examined. Melanoma can appear anywhere on the body, even on areas that are not exposed to the sun, and can appear in a number of different ways:
- A new, possibly large, irregularly shaped, dark brownish spot with darker or black areas
- A simple mole that changes in color (particularly turning darker),
size (growing), or texture (becoming firmer), and/or flakes or bleeds
- A lesion with an irregular border and red, white, blue, gray, or bluish-black areas or spots
- Shiny, firm, dome-shaped bumps anywhere on the body
- Dark lesions under the fingernails or toenails, on the palms, soles, tips of fingers and toes, or on mucous membranes (skin that lines the mouth, nose, vagina, and anus)
Early detection of melanoma (skin cancer)
The earlier melanoma is detected, the better the chance for successful treatment. Periodic self-examinations may help find melanoma early.
Self-examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and back of the neck.
Include the following steps in a skin self-examination:
- Examine the front and back of the entire body in a mirror, then the right and left sides, with arms raised.
- Bend the elbows and look carefully at the outer and inner forearms,
upper arms (especially the hard-to-see back portion), and hands.
- Look at the front, sides, and back of the legs and feet, including the soles and the spaces between the toes.
- Part the hair to lift it and examine the back of the neck and scalp with a hand mirror.
- Check the back, genital area, and buttocks with a hand mirror.
A doctor should be consulted for:
- A growth on the skin that matches any feature on the above list
- New growth on the skin
- A suspicious change in an existing mole or spot
- An unusual sensation in a mole, such as itching or tingling
- A sore that doesn't heal within two weeks
Often, the first sign of melanoma is a change in the size, shape, or color of an existing mole. It also may appear as a new or abnormal-looking mole. The "ABCDE" rule can be used to help remember what to watch for:
Asymmetry: The shape of one half of the mole does not match the other.
Border: The edges are ragged, notched, or blurred.
Color: The color is often uneven. Shades of black, brown, and tan may be present. Areas of white, gray, red, or blue may also be seen.
Diameter: The diameter is usually larger than 6 millimeters (mm) (the size of a pencil eraser) or has grown in size.
Evolving: The mole has been changing in size, shape, color, appearance, or growing in an area of previously normal skin. Also, when melanoma develops in an existing mole, the texture of the mole may change and become hard, lumpy, or scaly. Although the skin may feel different and may itch, ooze, or bleed, melanoma usually does not cause pain.
Health: Diagnosis of Melanoma (Skin Cancer)
If a person shows signs of melanoma, the doctor will take a complete medical history, noting the symptoms and risk factors. The doctor may order various tests to confirm a diagnosis of melanoma and/or determine if or where the disease has spread.
Physical examination. A physical examination should include examining the person's skin for lesions.
Biopsy. A doctor who suspects a skin spot is melanoma will perform a biopsy. In this procedure (usually performed with a local anesthetic to numb the area), the doctor removes the suspect lesion using techniques that preserve the entire lesion so that the thickness of the potential cancer and its margins (healthy tissue around the lesion that is removed to make sure no cancer cells remain) can be carefully examined. The tissue is sent to a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease), who determines if it is melanoma.
Sentinel lymph node biopsy. This type of biopsy is a surgical procedure and is used to determine if cancer cells have spread to the regional lymph nodes.
X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
Blood tests. The patient's blood may be tested to help determine if the cancer has spread.
Occasionally, the following tests may be performed to diagnose melanoma and/or help determine the extent of the disease:
Ultrasound. An ultrasound uses sound waves to create pictures of the internal parts of the body, including collections of lymph nodes (called basins) and soft tissue.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body.
Positron emission tomography (PET) scan. In a PET scan, radioactive sugar molecules are injected into the body. Cancer cells usually absorb sugar more quickly than normal cells, so they may light up on the PET scan. PET scans are often used to complement information gathered from CT scan, MRI, and physical examination.
Health: Staging of Melanoma (Skin Cancer)
The following are brief descriptions of the treatment most often used for each stage. (Other treatments may sometimes be appropriate.)
Stage 0
People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.
Stage I
People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.
Stage II or stage III
People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.
Stage IV
People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better—physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.
The patient may have one of the following:
- Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body.
- Radiation therapy, biological therapy, or chemotherapy to relieve symptoms.
People with advanced melanoma can find helpful information in the National Cancer Institute booklet Pain Control: A Guide for People with Cancer and Their Families.
Recurrent melanoma (skin cancer)
Treatment for recurrent melanoma depends on where the cancer came back, which treatment the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatment to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.
The patient may have one of the following:
- Surgery to remove the tumor
- Radiation therapy, biological therapy, or chemotherapy to relieve symptoms
Heated chemotherapy drugs injected directly into the tumor
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Natural Alternative Treatment Option: NATURAL CANCER TREATMENT
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Health: Conventional Treatment for Melanoma (Skin Cancer)
The treatment of melanoma depends on the size and location of the tumor, whether the cancer has spread, and the person's overall health.
Surgery
Melanoma can be successfully treated in almost all cases if it is diagnosed and treated when the tumor is relatively thin. Surgery to remove the tumor is the standard treatment.
Most melanomas are found when they are thin (less than 1.0 mm), when outpatient surgery is often all the treatment required. A doctor will remove the tumor and some healthy tissue around it to make sure no cancer cells remain; the amount of normal tissue that should be removed depends on the thickness of the melanoma. If the melanoma has grown deep into the skin, lymph nodes near the tumor may be removed and examined for cancer cells. In some cases, the doctor may recommend a sentinel lymph node biopsy (see below); this may be an outpatient procedure or require an overnight stay in the hospital.
Typically, the complete excision (surgical removal) of the melanoma requires the removal of 1.0 centimeters (cm) (3/8 of an inch) to 2.0 cm (3/4 of an inch) of normal-appearing skin surrounding the melanoma in all directions, called the margin. In addition, the underlying fat tissue is removed. The specific size of the margin taken depends on the size, stage, and potential aggressiveness of the melanoma. If it is staged as melanoma in situ (Stage 0), a margin of between 0.5 cm to 1.0 cm may be recommended. In general, a thin melanoma (measuring 1.0 mm or smaller in thickness) can be safely excised with a 1.0 cm margin of skin, while a thicker melanoma requires a 2.0 cm margin of skin.
Depending on the site of the surgery, a skin graft (using the skin from another part of the body to both close the wound and reduce scarring) may be necessary. Since melanoma surgery for primary melanoma is usually limited to the removal of the skin and subcutaneous tissues, rehabilitation is rarely necessary for this procedure.
To determine if the melanoma has spread to regional lymph nodes, the doctor may perform a procedure known as lymphatic mapping and sentinel lymph node biopsy. In this surgical procedure, the doctor removes one or a few sentinel lymph nodes to check for cancer cells. A sentinel lymph node is the first node into which the lymph system drains from the primary melanoma site. If cancer cells are detected in the sentinel lymph node, it means that the disease has spread to the regional lymph node basin. Other lymph nodes in the region are also at risk for spread.
When melanoma has spread to lymph nodes, surgical removal of the remaining lymph nodes in that region is usually recommended. This is called a lymph node dissection. The number of lymph nodes removed varies depending on the area of the body while the likelihood of finding additional affected lymph nodes that contain metastatic melanoma is due in part on the stage of the melanoma. People who have had a lymph node dissection around an arm or leg are at higher risk for fluid build-up in that limb, a side effect called lymphedema. In general, the risk of spread to areas of the body beyond the regional lymph nodes (distant metastasis) is greater in patients who have involved lymph nodes than in patients whose lymph nodes do not contain disease.
If the melanoma has spread to distant organs (Stage IV) or recurs (comes back after treatment), surgery may be a treatment option to help control the disease.
After surgery, the surgeon or medical oncologist may also recommend adjuvant treatment (treatment given after the primary treatment) based on what information was learned about the disease during surgery. This may include immunotherapy, chemotherapy, and/or radiation therapy. See more information below on each treatment.
Immunotherapy
Immunotherapy (also called biologic therapy) works by helping the body's immune system find and attack cancer cells. It uses materials either made by the body or in a laboratory to boost, target, or restore immune function. Immunotherapy works well in treating melanoma, particularly in reducing the risk that the melanoma will recur. Immunotherapy may be used in combination with surgery and/or chemotherapy, or as part of a clinical trial. Many immunotherapies are being evaluated for melanoma in clinical trials.
Only one adjuvant therapy has been shown to consistently reduce the likelihood of a recurrence of melanoma, and this treatment is called high-dose interferon alfa-2b. This treatment, given intravenously (injected into a vein) in the doctor's office for 20 doses (five days a week, for four weeks) in the first month, and then under the skin three times a week at home for 11 months, has been shown to reduce recurrence and, in two clinical trials, has prolonged survival significantly. This is the only therapy that is currently approved as adjuvant therapy, except as part of a clinical trial. Adjuvant therapy for melanoma is often recommended when the primary melanoma is found at a later stage or if there is involvement of lymph nodes.
Interleukin-2 (IL-2) is another immunotherapy used to treat melanoma. High-dose IL-2 treatment is used with patients when cancer has spread beyond the scope of surgery. In clinical trials, the therapy does not significantly increase a patient's life span, but it delays the time it takes for cancer to reappear after treatment. A few patients have had long-term disappearance of detectable melanoma with this approach.
Some cancer centers offer an experimental treatment for melanoma in the form of a therapeutic vaccine. Certain proteins that are unique to melanoma tumors are given as an injection. The person's immune system then recognizes these proteins and destroys the cancerous cells. Vaccines may be given to patients as part of a clinical trial. Another type of experimental immunotherapy involves altering the patient's lymphocytes (white blood cells) in the laboratory to enhance their ability to fight the tumor. The changed cells are given back to the patient, often in combination with chemotherapy. These types of treatments are only available as part of a clinical trial.
Side effects of these treatments vary widely. They can include fatigue, fever, chills, headache and some memory difficulties, muscle ache, and skin irritation. Occasionally, side effects from immunotherapy can include a change in blood pressure or cause increased fluid in the lungs. Side effects of immunotherapy can be greater than or less than side effects from other types of treatment. Patients should discuss with their doctors the benefits and risks of each treatment option.
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. For melanoma, this is typically used when there is a high risk that the melanoma may spread or to control advanced disease, although cure of widespread melanoma is rare. There are several combinations of chemotherapy that are currently being tested in clinical trials.
In addition to systemic chemotherapy, there are also chemotherapy techniques to focus on a specific region, if melanoma has spread but not beyond a limb (an arm or a leg). Isolated limb perfusion (ILP) is an approach that involves both surgery and chemotherapy. First, a surgeon separates the limb's blood circulation from the rest of the body. Then, a high dose of chemotherapy is injected to the limb's bloodstream to kill cancer cells. Isolated limb infusion (ILI) is similar to ILP, but in order to isolate the limb's blood circulation from the rest of the body, pressure is applied above the area using a tourniquet; a high dose of chemotherapy is then injected into the bloodstream of the limb to kill cancer cells via catheters inserted into the major blood vessels entering and leaving the limb.
The side effects of chemotherapy depend on the individual and the dose used but can include fatigue, risk of infection, nausea and vomiting, some nerve damage resulting in alterations in sensation, and hair loss. These side effects usually go away once treatment is finished.
Common systemic chemotherapy used for melanoma include dacarbazine (DTIC), carboplatin (Paraplatin), cisplatin (Platinol), and temozolamide (Temodar). ILP/ILI may use melphalan (Alkeran). The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body.
Radiation therapy for melanoma can be used in several ways. Radiation therapy is most commonly used to relieve symptoms caused by melanoma that has spread, especially to the brain and bones. It may also be used when cancer has spread to the lymph nodes, following a lymph node dissection (see above). Radiation therapy is also used when the extent of surgery for a larger melanoma is limited by the location of the tumor. And, research is being done to test the effectiveness of chemoradiation, a combination of radiation therapy and chemotherapy, to treat melanoma.
Radiation therapy can cause skin irritation, nausea, and fatigue. A patient may experience hair loss if radiation therapy is used on the scalp. If radiation therapy is used around the head and neck, side effects, such as altered taste and dry mouth, may occur. These side effects usually go away once treatment is finished. If lymph nodes near an arm or leg were affected, the person may be at higher risk of fluid build-up in that limb, a side effect called lymphedema. Lymphedema can be a long-term, ongoing side effect health wise.
Health: Prevention of Melanoma (Skin Cancer)
Reducing exposure to UV radiation, particularly through sun exposure, lowers the health risk of melanoma. This is important for all age groups, and it is especially important for people who have risk factors for melanoma. Sun damage is cumulative, meaning it builds up over time. Steps to reduce sun exposure, avoid sunburn, and help prevent many cases of melanoma include:
- Limiting or avoiding sun exposure between 10:00 AM and 4:00 PM
- Wearing sun-protective clothing, including a hat that shades the
face, neck, and ears. Clothes made of fabric labeled with UPF (UV
protection factor) may provide better protection. UV-protective
sunglasses are also recommended.
- Using sunscreen with a sun protection factor (SPF) of 15 or higher
throughout the year and reapplying it often, especially after heavy
perspiration or being in the water
- Examining skin regularly (examinations by a health-care professional and self-examinations)
- Avoiding use of sun lamps, tanning beds, and tanning salons
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Sources: NIH News In Health/National Institutes of Health/National Library of Medicine/Dept of Health and Human Services_______________________________________________________________________________________________________
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