Saturday, September 21, 2013

A Quick Primer on Malignant Melanoma

This is only one type and one appearance of malignant melanoma.   (Photo: Mayo Clinic)

                        Malignant melanoma is the most dangerous type of skin cancer.  There are other types of skin cancer.  Basal cell is the most common variety.  Squamous cell carcinoma is also another very curable variety.  The one that has the potential to kill rapidly is the one I am choosing to discuss today.
                        Malignant melanoma is caused by DNA changes which occur in response to the radiation to which we are exposed in the sun. Most of the time, our bodies repair these skin changes which occur as a result of DNA damage, but sometimes, our body misses one or some, and they grow into melanoma.  Although many cases of malignant melanoma occur in light skinned individuals, this is not always the case. African Americans and others with darker skin types may also develop it.   Asian people can also develop a particular type of melanoma.  Since darker skin types may not be as aware of melanoma, then it may get farther in them before they notice, and is is detected and treated. Also, the longer we have been on the Earth exposed to the radiation of the sun, then the greater our chances are that we may develop malignant melanoma. This is why older people rather than younger people seem to develop melanoma more frequently.  However, this does not mean that young people can't develop melanoma, because they do.
                      Many moons ago, in nursing school, we were taught that melanoma is a blue or black mole that is assymetric. (This means that if you draw an imaginary line through it that it should be the same on both sides. If it isn't then it is assymetric, and assymetric lesions have a greater incidence of being malignant melanoma.)  However, most of us took that to mean that if a skin lesion wasn't blue or black, that it wasn't melanoma, that it could be some other type of skin cancer or non-cancerous lesion, and so although we referred patients to doctors, or called the lesion to a physician's attention, we were perhaps less alert than we could have been.  I remember thinking that because I am so fair skinned and sun intolerant that this could be an issue for me when I am older.
                   I still remember the first patient I had in the general hospital who died of malignant melanoma. She was a lovely young red haired young woman who had her entire life ahead of her. Her original lesion had been red, and not black or blue. It was detected on her back during a routine physical and found to have spread through muscular regions and then, and through her body.  In 1981 the treatments we have now did not exist. I remember being very upset at the passing of this young woman who had been someone so close to my own age.
                 Many years later I was quite shocked to hear that my father had a basal cell carcinoma and a melanoma removed from his face.   I had not noticed anything that I thought demanded attention. Fortunately, he did.   At the same time, a friend of mine who worked with me as a nurse had a small lesion pop up on the side of her nose. It was scaly, and clear.  She showed it to me and I wondered if it might be eczema.  I told her that since I am not a dermatologist and it's on such a prominent location on her face, she should see a dermatologist.   They biopsied the small lesion and the pathology report came back malignant melanoma.  My friend is fine, but neither of us thought that this new lesion was melanoma.
                In the interest of getting these lesions noticed by you, seen by a dermatologist, detected, treated and cured, I am going to provide some factual data and references on melanoma.  First of all, some physicians are quite good at visually detecting melanoma. However some are not.  Your best chance at detecting a melanoma visually is probably at a dermatologists or plastic surgeon's office.   The same is true of nurse practitioners.  Some received special training and rotations in this and others did not specialize in this way, so again the best chance for detection is by having a dermatologist look carefully at any lesions you have.  Persons who have greater than 100 moles are at greater risk of melanoma and therefore should be seen annually for a quick check of these by a dermatologist.  120,000 new cases of melanoma are detected each year in the US and early cases are almost always fairly easily curable.  The longer it takes to notice and treat a melanoma, then the greater the chances are that it has invaded muscle, bone or organs and will not be able to be cured.
              Clinicians may use something called the "Ugly Duckling Sign" as a way of helping the public to detect malignant melanoma on themselves and on family members.  In people with multiple moles, which often occur as we age, melanomas are usually the ones which stand out and are different than the other moles. They might be "uglier" than the other local lesions. They might have grown on one side, or simply be different than the other moles in the region.  These are the lesions that must be seen by a dermatologist for furthur review.
           There are also the "ABCDE s of melanoma detection.

  A.  First, we are looking for assymetry, which I mentioned before.

 B.   Next, look at the borders.  Melanoma has uneven borders.

C stands for colors.   Melanoma often has more than one color in the lesion.  There may be shades of brown in different parts of the lesion.  A melanoma may be black or blue, but it can also be red or different shades of brown or even pearlescent.

D. Stands for diameter.   Melanomas are usually larger than the pencil tip on your eraser, although they aren't when they first occur.

E    Stands for evolve.    Melanomas evolve.  They either bleed, crust, or itch, but they are in a state of change.

           There are also different types of melanoma.  Seventy percent of these are the superficial spreading type which can occur in young people. There are other types, and the potential variety of these lesions are what can make this difficult for us to recognize as melanoma.   If four people with melanoma, their lesions may look and behave quite differently.  Melanoma can be on hands and arms, but it can also be on backs where the patient himself cannot see it.  It can also be on the back of the scalp, particularly in men whose hair might be a little thinner there than it was when they were younger.  Wearing a hat outside has great value.

More information on the types of melanoma

        There are excellent treatments for early melanoma that can result in a complete cure.  However, the longer we wait for treatment the less likely a complete cure is.

         Just this week, several of my friends were diagnosed as having malignant melanoma.  If you have any skin lesions you have questions about, this might be a great time to have them checked.

In 1996, Eva Cassidy, a young fair skinned woman died of malignant melanoma. Her passing deprived the world of so many more songs. Her rendition of "Danny Boy" is my favorite.

References and more reading on this:

Pictures obtained from: 

Update:       September, 2014

This post is now dedicated to:  (Flora) Marie McKinney Stone who passed on September 10, 2014.
Marie's fight with malignant melanoma was the original impetus for this post.   We send condolences and best wishes to her children.