Melanoma
A melanoma is a malignant cancer of the melanocyte cells, which produce pigmentation and are found within the skin. They account for about 9% of all skin cancers and the rate of people developing melanoma is the fastest increasing rate of any cancer in the UK. Melanoma accounts for 2% of all cancer related deaths, with 90% of people with melanoma surviving 10 yrs or more. If melanoma is detected early a cure can be virtually guaranteed.
Melanoma most commonly arises from the skin, but can also arise from the wet skin (mucosa, perineal areas, eye). Typically melanomas are pigmented (brown colour), however in those people who do not tan easily, melanomas are commonly pink. This can cause difficulty in identifiying them can lead to a delayed diagnosis. Generally if you have a mole that has changed - darker, paler, larger, smaller different to your normal moles or is new, then you should ensure it is looked at by a qualified doctor.
Melanoma management has changed radically over the last 5 yrs, both surgical options and drug treatments. Mr Peach will be happy to discuss these with you in clinic and make recommendations.
Why
Melanoma appears to relate to frequent intense UV rays, either from outdoor exposure or tanning beds, particularly if it associated with sunburn. The combination of UV radiation particularly in those people with a genetic predisposition appears to increase the risk developing a melanoma.
Who
This skin cancer is more commonly seen in white caucasian skin population, although melanoma can be diagnosed in people of afro-caribbean origin. The other factors associated with melanoma development include:-
- If you have red hair, fair skin, lots of freckles
- Lots of moles particularly if they are not of uniform shape and size
- Large mole like birthmarks particularly if over 20cm in diameter
- Previous history of severe sunburn especially if blistering
- Family history - this is uncommon but family groups of melanoma are seen
- Previous melanoma or other cancers notably: Breast cancer, non-hodgkins lymphoma, kidney, prostate, thyroid, leukaemia
- Immunosuppression
- Several other medical conditions are also being investigated for links with melanoma
Features
Melanoma commonly presents as a changing mole which may contain various shades of brown. However melanoma can be pink, black, blue or red or grey, either within an existing mole or suddenly appearing. There are several recommended ways which aim to help identify abnormal moles. The commonest is the ABCDE rule:-
A. Asymmetry (is the mole the same on both sides of an imaginary central line)
B. Border (is it irregular)
C. Colour (is it a uniform colour)
D. Diameter (is it >6mm)
E. Evolving (is the mole changing)
Most benign (not cancer) moles are symmetrical, have a smooth border, a single uniform colour, generally less than 6mm and are static so not changing. If you have a mole that clearly does not fulfil all these characteristics then you should get it assessed by a doctor.
Mr Peach believes the most important feature is the evolving or changing mole which then stands out when compared to the rest of your moles. This mole certainly should be checked and examined with a dermatoscope.
Treatment
The treatment for primary melanoma is surgery. A biopsy is not normally recommended for melanoma, as this only represents a small part of the lesion and commonly does not reflect the whole lesion. In addition the biopsy can adversely affect specific details that the pathologist needs to see to help understand the make up of the melanoma. Treatment therefore normally involves a narrow margin excision of the whole lesion, waiting for the pathology report and then planning the definitive treatment. The secondary treatment will involve a further excision (Wide Local Excision - WLE) and may involve sampling of one of the nearby lymph nodes (sentinel node biopsy - SNB). The WLE can be carried out under local anaesthetic including any reconstruction required, however if a SNB is recommended this will need a general anaesthetic. Mr Peach has extensive experience in removing melanomas, reconstructing the defect to achieve the best aesthetic result and in sentinel node biopsy. He is able to discuss the results and implications with you as well as recommending any further treatment.
Diagnosis
The diagnosis of melanoma is usually based on a careful history of what has happened to the mole, a clinical review and examination of the mole using a dermatoscope. Typically melanomas are brown in colour, however melanoma is recognised as being a very good mimic of many other skin lesions, so diagnosis is not always straight forward. Therefore experience is vital and Mr Peach has been looking after patients with melanoma and skin cancer for over 20 yrs. Ensuring the correct diagnosis, and hence treatment, can be equally difficult for the pathologist which is why all melanomas are doubly reported by two separate pathologists and review in the regional multi-disciplinary team meeting.
Staging
Once the diagnosis of melanoma has ben confirmed it is then normally staged. Stages I & II are for melanomas which are confined to initial site on the skin and have not spread to other parts of the body; Stage III is when the melanoma has spread to the lymph nodes only and Stage IV is for when the melanoma has spread to internal organs or sites away from where the melanoma started. These stages are subdivided further and Mr Peach will discuss this with you further during any consultation.
Follow-up
The current recommendations for early (Stage Ia) melanomas is to be followed up just for 1 yr. All other stages of melanoma should be followed-up for at least 5yrs, 3 monthly for the first 3 yrs and then 6 monthly after that. During this follow up, scans may be recommended depending upon any specific features noted, which may impact of your risk for having a recurrence of your melanoma. Again Mr Peach will discuss this with you. It is not a standard of care to have a regular CT scan every ‘X’ months. CT and PET CT scans are associated with significant doses of radiation which in the long term can cause their own problems. In addition waiting for an appointment for a scan, having a scan and then waiting for the results, many people find stressful and without proven benefit of having routine scans Mr Peach believes a scanning schedule should be tailored to individual patient’s requirements.
Survival
There are many figures available predicting the likelihood of an patient with a certain stage melanoma surviving 1, 5 and 10 yrs. These figures are produced by averaging out figures from many people and so cannot be representative of the individual. The figures quoted are also often based on data which was calculated before current targeted therapies and immunotherapies and so are grossly inaccurate. Mr Peach will take into account your personal preferences regarding treatment and discuss all options with you, including any relevant current trials and then help manage any problems, should they arise.
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Based in Leeds
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