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At Boston Medical Center (BMC), the care of patients with melanoma is a collaborative, multidisciplinary process, offering the full spectrum of services for early to advanced stages of the disease and involving dermatologists, specialized surgeons (including neurosurgeons and thoracic surgeons), medical oncologists, and radiation therapists. BMC’s Cancer Care Center organizes its services around each patient, bringing together the expertise of diverse specialists to manage care from the first consultation through treatment and follow-up visits.
The Cancer Care Center is dedicated to providing treatment that is effective and innovative in curing and controlling cancer, while managing its impact on quality of life. The NCCN Guidelines for treatment based on stage of disease are fully supported. In addition, clinical trials of new agents or combinations of agents are offered to try to prevent recurrence and to treat metastatic disease. Melanoma molecular tests and genetic screening are being used routinely to help direct and personalize treatments.
As the primary teaching affiliate of the Boston University School of Medicine, BMC combines personal, patient-focused care with the state-of-the-art-expertise and technological advances of a major teaching hospital. BMC is at the forefront of clinical practice, surgical expertise, and research in oncology.
To schedule an appointment or refer a patient, call 617.638.7420.
What Is Melanoma?
Melanoma is a type of skin cancer caused by the cancerous growth of pigment producing cells in the skin called melanocytes.
The body’s largest organ is the skin. It performs several functions. It covers and protects the organs inside the body from heat, injury, germs, infections, and damage caused by ultraviolet (UV) radiation. It also stores water and fat, helps control body temperature, and produces vitamin D.
The skin consists of three layers: the epidermis, the dermis, and the subcutis.
The epidermis is the thin top layer of the skin. It consists mostly of flat cells called squamous cells. Round cells called basal cells are found below the squamous cells. Melanocytes are found among the basal cells in the deepest part of the epidermis. Exposure to UV radiation causes melanocytes to produce more of the brown pigment melanin, which causes the skin to darken (tan).
The dermis is the middle layer of the skin. It is much thicker than the epidermis and contains hair shafts, blood vessels, lymph vessels, glands, and nerves. Some glands produce sweat, which helps keep the body cool. Other glands produce an oily substance called sebum, which helps prevent the skin from drying out. Tiny openings in the skin called pores allow sweat and sebum to pass through the surface of the skin.
The subcutis is the deepest layer of skin. It contains proteins and fats, which help the body retain heat. It also functions as a shock absorber to keep the body’s organs safe.
There are several kinds of benign (noncancerous) growths of the skin. These include moles (melanocytic nevi), seborrheic keratoses, hemangiomas, lipomas, and warts. Benign growths are typically not life threatening. They can usually be removed and don’t tend to regrow. They don’t invade surrounding organs or tissues, nor do they spread to distant sites around the body.
Malignant growths (such as melanoma, basal cell cancer, or squamous cell cancer) may be life threatening. They can usually be removed but sometimes regrow. These growths may invade and damage nearby organs or tissues and may spread to distant sites around the body.
Melanoma begins in the melanocytes. The disease can occur on any surface of the skin, including, in rarer cases, the hands and feet (acral sites); mucosal (wet) sites, such as the mouth or genital area; and within the eye. In men, it is commonly found on the head, neck, or between the shoulders and hips. In women, it is commonly found on the lower legs or between the shoulders and hips.
The disease is rare in people with dark skin, but when it does develop, it is often found in acral areas, such as under the fingernails or toenails, or at mucosal sites.
Melanoma is less common, but far more dangerous, than other skin cancers. It accounts for only a small percentage of skin cancers but causes the most deaths of any skin cancer type.
According to the American Cancer Society, melanoma is on the rise in the United States, with the number of new cases increasing for the past 30 years (American Cancer Society 2015).
Melanoma is prevalent among the young. It is the most common form of cancer in the 25-29 year age group and the second most common form of cancer in the 15-29 year age group.
It is more likely than other skin cancers to spread (metastasize) to other parts of the body.
Symptoms of Melanoma
Melanomas may arise from preexisting moles, but they more commonly originate within normal looking skin.
A change in the color, shape, or size of an existing mole is many times the first symptom of melanoma. The ABCDE rule can help determine if a mole is suspicious and should be checked by a physician.
ABCDE stands for the following:
- Asymmetry: The shape of one half of a mole is different from the other half.
- Border: If a mole has edges that are irregular, blurred, notched, or ragged, or it has a border that is not clearly defined, it may be cancerous.
- Color: Color that is uneven may be a sign a mole is cancerous. Shades of black, brown, or tan may be present in the mole, as well as areas of white, gray, pink, or blue.
- Diameter: A change in the size (usually an increase) of a mole may be cause for concern. Melanomas can be small but are generally larger than the size of a pea (bigger than 6 millimeters or about a ¼ inch).
- Evolving: If a mole has changed over the course of a couple of weeks or months, have it looked at by a physician.
(American Cancer Society 2015)
Melanomas vary in appearance. Some melanomas may have more abnormal features than others. Not all of the features named in the ABCDE rule need to be abnormal for a mole to be cancerous.
The texture of a mole may also change. This generally happens in the more advanced stages of melanoma. The skin on the surface of the mole may look broken down or scraped. It may feel hard or lumpy and ooze or bleed. Melanomas may be itchy, painful, or tender.
Causes of Melanoma
Although the exact causes of melanoma remain unknown certain risk factors—things that increase an individual's chances of developing a cancer—have been identified. While risk factors may be useful in identifying high-risk individuals, they do not determine whether a person develops a disease. Some risk factors, such as sun exposure, are within a person’s control, while others, such as age, are not.
Possible risk factors for any type of skin cancer include
- Exposure to ultraviolet (UV) radiation: Too much exposure to ultraviolet (UV) radiation is a major risk factor for skin cancer. The most common source of UV radiation is sunlight. UV radiation from the sun’s rays can damage the skin and cause cancer. Severe sunburns (in both childhood and adulthood), lifetime sun exposure, and tanning all affect a person’s chance of developing skin cancer. Sand, pavement, water, snow, and ice all reflect the sun’s rays. The sun’s rays can penetrate clouds, light clothing, windows, and windshields.
- Sunlamps and tanning booths: Sunlamps, tanning booths, and other sources of artificial radiation are just as dangerous as natural sources. People under age 30 who use sunlamps and tanning booths are at an even greater risk of developing skin cancer, melanoma included.
- Personal history: People who have had melanoma in the past are at an increased risk of developing it again in the future. People who have had basal cell or squamous cell cancer in the past are at an increased risk of developing another skin cancer of any kind.
- Family history: People with two or more close family members who have or have had skin cancer are at increased risk of developing the disease.
- Having certain physical traits: Having certain physical traits, such as pale skin, red or blond hair, light-colored eyes (blue, green, gray), or freckles, increases a person’s risk of developing skin cancer.
- Certain medical conditions or medications: Having certain medical conditions or taking certain medications (such as some antibiotics, hormones, or antidepressants) can increase the skin’s sensitivity to the sun, thereby increasing the risk of developing skin cancer. Having a weak immune system or taking medications that stop the immune system from working to its full potential also increase a person’s risk.
- Gender: In the United States, skin cancer is more common in men than in women. However, this statistic varies with age. The risk is higher for women under age 45 and for men above age 45. (American Cancer Society 2015)
Possible risk factors specific to melanoma include
- Age: A person’s risk of developing melanoma increases with age. However, it is also one of the most common cancers found in people under 30 years old.
- Moles: A common mole is round or oval shaped with a smooth, evenly-colored (pink, tan, brown) surface and is usually smaller than the size of a pea. The risk of developing melanoma increases with the number of common moles an individual has. Individuals with more than 50 moles are at increased risk of developing melanoma.
- Atypical nevus: An atypical nevus is an unusual looking benign mole that may have some features resembling a melanoma. People with multiple atypical nevi are at increased risk of developing melanoma.
- Xeroderma pigmentosum (XP): Xeroderma pigmentosum (XP) is a rare genetic disorder that inhibits a person’s ability to repair damage caused by sunlight. People with XP have a greater risk of developing melanoma and other skin cancers at a young age.
Stages of Melanoma
Staging is the process of determining how widespread or advanced the cancer is. It is an important part of diagnosis because it is used to determine the most appropriate treatment options for patients and provide them with a prognosis.
The stage of melanoma is based on several factors, including how deeply it has penetrated the skin, whether it has ulcerated (broken open), and whether the cancer cells have spread to nearby lymph nodes or other organs.
To determine the stage of the disease, physicians need to remove the entire melanoma. The regional lymph nodes are assessed by a clinical exam, and a sentinel lymph node biopsy is advised for melanomas that have certain microscopic characteristics that take into account their depth, whether they are ulcerated or not, and how rapidly they are proliferating. A fine needle aspiration biopsy may be performed instead if the regional lymph nodes are enlarged on the clinical exam. The physician may also perform a series of blood and imaging tests based on the results of these tests.
The clinical stage of melanoma is based on the findings of the physical exam, skin biopsy, lymph node biopsy, and any imaging or blood tests that are performed.
Stage 0: Cancer is present in the top layer of skin (epidermis only). This stage is also referred to as melanoma in situ.
Stage I - II: The melanoma is localized to the skin with no evidence of spread to the lymph nodes or other organs. Stage II melanomas have more adverse features compared to Stage I melanomas.
Stage III: The melanoma has spread to the regional lymph nodes.
Stage IV: The melanoma has spread to distant organs, such as the lungs, liver, or brain.
For more detailed information on stages of melanoma, visit the staging section of the American Cancer Society’s melanoma website.
American Cancer Society. 2015. Overview Guide: Melanoma Skin Cancer Overview.
National Cancer Institute. 2010. What You Need To Know About™ Melanoma and Other Skin Cancers. PDF. Bethesda: National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services.
Patient Resource, LLC. 2014. Patient Resource Cancer Guide: Understanding Cancer Immunotherapy. Overland Park: PRP Patient Resource Publishing.
Treatments & Services
The most common treatment for melanoma is a surgical procedure called a wide local excision. During this procedure the melanoma is completely removed together with a margin of the surrounding healthy skin. How much healthy skin is removed depends on the depth of the growth. The margin is examined under a microscope for any remaining cancer cells. If no cancer cells are found, no further surgery is necessary. Many times, a wide local excision can cure early-stage melanoma.
Mohs surgery removes less healthy tissue than excisional skin surgery. The Mohs surgeon cleans and numbs the area of skin to be operated on. Then he or she removes the visible portion of the tumor and a very small margin of healthy skin. The Mohs surgeon examines the tissue under a microscope for cancer cells. If part of the tumor is still present, the Mohs surgeon carefully maps out the area where the tumor remains and only removes additional skin in the area where the margin shows the tumor. The process is repeated until the tumor is completely removed. This type of surgery is typically reserved for melanomas on the face where it is beneficial to conserve as much healthy skin as possible during surgery.
Reconstructive Surgery for Melanoma
If the surgeon is required to remove a large piece of skin in order to remove the melanoma in its entirety, a reconstructive surgical procedure may be required to close up the skin. This may involve removing skin from another part of the body, such as the upper thigh, to cover the site where the skin cancer was removed. This is called a skin graft. Alternatively, the surgeon may rotate a portion of skin from a neighboring area to cover the site. This is called a skin flap.
Lymph Node Dissection
If the physician performs a sentinel lymph node biopsy, and cancer is found in the sentinel nodes, it is likely a lymph node dissection will be advised to remove the other lymph nodes in the area.
Treatment for Advanced Metastatic Disease
The term metastatic disease refers to disease that has spread from its original site to distant organs in the body. At this advanced stage of the disease, it is unlikely that surgery can be used to cure the cancer, although it may be used to improve a patient’s quality of life and help him or her live more comfortably.
Chemotherapy is a medication or combination of medications used to treat cancer. Chemotherapy can be given orally (as a pill) or injected intravenously (IV).
For patients with advanced-stage melanoma, immunotherapy may improve the body’s natural immune response to cancer. Immunotherapy recruits the body’s own immune system and uses it to fight cancer all over the body, making it difficult for cancer cells to hide or develop defenses against it. Immunotherapy has the potential to keep working even after the patient has completed treatment.
Targeted therapy is a type of cancer treatment that uses drugs or other substances to precisely identify and attack cancer cells. Usually, targeted therapy does less damage to normal cells than other cancer treatments.
Drugs that target melanomas carrying C-KIT gene mutations
Mast/stem cell growth factor receptor (SCFR) is a protein in humans that is encoded by the KIT gene. Active mutations in this gene are associated with a small percentage of melanomas. C-KIT mutations also help the melanoma cells to grow and divide more quickly. The mutations are commonly found in melanomas that originate on the palms of the hands, the soles of the feet, or underneath the fingernails (called acral melanomas); inside the mouth or other mucosal (wet) areas; and on parts of the body chronically exposed to the sun.
Cytokines are proteins in the body that activate the immune system. Interferon and interleukin-2 (IL-2) are man-made versions of cytokines that are sometimes used to treat patients with advanced-stage melanoma. Interferon is injected intravenously or under the skin and can slow the growth of melanoma cells. It may be offered in addition to surgery for patients with melanoma that has spread to regional lymph nodes (Stage III disease) in order to help prevent further spread of the disease and help prolong survival.
Isolated Limb Perfusion
In rare cases, melanoma may spread as multiple deposits to the skin that are local to the original melanoma. Isolated limb perfusion is a localized form of chemotherapy used for treating these multiple metastatic melanomas that have spread to the skin on one arm or one leg. The treatment allows high doses of the chemo drug to be administered to the cancer site without endangering the rest of the body. It separates the blood flow of the limb with cancer from the rest of the body for a short period of time. During this period, high doses of the chemo drug are given into the limb.
Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Radiation (also called radiotherapy, irradiation, or x-ray therapy) can be delivered internally through seed implantation or externally using linear accelerators (called external beam radiotherapy, or EBRT).
Intensity-Modulated Radiation Therapy (IMRT) is a type of external beam radiation therapy that delivers beams of radiation customized to the shape and size of the tumor. Unlike 3D-CRT, which delivers the same amount of radiation to both the tumor and the surrounding tissue, the intensity of the beams can be adjusted (modulated) for IMRT, enabling the radiation oncologist to deliver different amounts of radiation to different areas of the tumor and the surrounding tissue. This allows the radiation oncologist to deliver the maximum amount of radiation to the tumor while sparing the surrounding healthy tissue.
CyberKnife delivers highly targeted beams of radiation directly into tumors, in a pain-free, non-surgical way. Guided by specialized imaging software, we can track and continually adjust treatment at any point in the body, and without the need for the head frames and other equipment that are needed for some other forms of radiosurgery.
Diagnostics and Tests
Personal and family medical history
Your doctor will likely ask you a series of questions relating to your personal medical history and your family's medical history.
Your physician will ask you a series of questions and is likely to do a physical exam. The physical exam will including examining any specific areas of concern, especially as they relate to the reason for your visit to the office.
For a skin biopsy, the physician may remove part or all of the skin in the area of concern, so it can be thoroughly examined under a microscope by a physician called a pathologist. The skin around the area being biopsied will be numbed using a local anesthetic before the biopsy. The anesthetic may sting slightly as it enters the body, but you should feel no pain during the biopsy itself.
A sharp, thin blade is used to shave off the abnormal growth. To stop the biopsied site from bleeding, the physician applies an ointment or cauterizes the wound with a small electric current.
The physician uses a sharp, hollow, round tool to remove a circle of tissue from the area of concern. The physician rotates the tool on the surface of the skin until it cuts through all of the different layers of skin and removes a tissue sample. This allows for better sampling of the depth of the lesion. The edges of the skin are typically stitched together following the biopsy.
A scalpel is used to remove part of the growth.
A scalpel is used to remove the growth in its entirety and some of the surrounding tissue. Excisional biopsies are generally performed on growths that appear to be melanomas.
Fine Needle Aspiration (FNA) Biopsy
FNA uses a thin, hollow needle (thinner than the needles used to draw blood) to draw out fluid or tissue from a lump. Depending on the size and location of the lump, the needle is sometimes directed into the lump simply by feeling it. Other times it may be guided into the lump with the assistance of an ultrasound.
Surgical (excisional) lymph node biopsy
The physician removes an enlarged lymph node through a small cut in the skin. If the lymph node is close to the surface of the skin, a local anesthetic will be used to numb the area being biopsied. If it is located deep under the skin, you may be given drugs to make you drowsy or be put to sleep (using general anesthesia). Surgical lymph node biopsies are generally performed if the lymph node’s size indicates the melanoma has spread, but an FNA was not performed or did not yield conclusive results.
Sentinel lymph node biopsy
If a patient has been diagnosed with melanoma, a sentinel lymph node biopsy may be performed to see if the disease has spread to nearby lymph nodes at a microscopic level (i.e., the lymph nodes are not enlarged on the exam but contain small numbers of melanoma cells that have spread from nearby skin).
Lab tests for Melanoma
In cases of advanced melanoma, physicians may perform tests on a biopsy specimen to see if certain genes in the cancer cells are mutated, as this may help determine which treatment options will work best for the patient.
Chest x-rays provide an image of the heart, lungs, airways, blood vessels and bones in the spine and chest area. They can be used to look for broken bones, diseases like pneumonia, abnormalities, or cancer.
Computed Tomography (CT) Scan
CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut.
Magnetic Resonance Imaging (MRI)
This test uses a magnetic field, radiofrequency pulses, and a computer to produce detailed images of body structures in multiple places. You may be asked to drink a contrast solution for better imaging, and you will most likely lie on a moving table as pictures are taken.
Positron Emission Tomography (PET) scan
A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream.
Melanoma Blood Tests
Physicians may perform certain blood tests before or during treatment. For example, physicians frequently test for levels of lactate dehydrogenase (LDH) in the blood prior to treatment. Melanoma may be more difficult to treat in patients with elevated levels of LDH, particularly if the disease has spread to distant sites in the body.
BMC’s comprehensive melanoma team includes physicians who work in dermatology, dermatopathology, surgical oncology, medical oncology, radiation oncology, plastic surgery, and head and neck surgery. The team’s patient-centered, multidisciplinary approach assures each patient benefits from the collaborative expertise of physicians uniquely focused on their individual needs.
Surgical Oncology, Liver, Pancreas and Biliary Cancers, Cancers of the Stomach, Sarcoma, Melanoma
Head and Neck Surgeons
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