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DERMATOPATHOLOGICAL INSTITUTE

DR. PABLO UMBERT

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Description and risk factors

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The main risk factors for developing melanoma cancer are genetic factors, having a light skin type (phototype I-II), intense and intermittent sun exposure, having many pigmented nevi (acquired melanocytic nevi), atypical or dysplastic nevi, or large pigmented nevi from birth (congenital nevi).

If diagnosed early before it has spread (metastasis), the prognosis is very good, with a 75-85% survival rate over 10 years. Melanomas with a thickness of less than 1 mm have a much better prognosis than those with more than 1 mm of thickness. However, if the lymph nodes are affected, the 10-year survival rate drops to 30-70% (micrometastatic) and 20-40% (clinically palpable lymph nodes), with distant metastases occurring in 6-9 months.

Recently new treatments have appeared for this malignancy once it has metastasized, which allows extending survival up to years in some cases; but the best treatment is undoubtedly early diagnosis in initial stages when it is still curable with surgery.

Symptoms of melanoma-type skin cancer

Melanoma can appear on a mole (melanocytic nevus) that we already had or it can appear again in a healthy skin area where there was no mole before, which is more frequent.

We should be concerned if we see a mole that changes or grows, or if a new "mole" appears and starts to grow in a relatively short period of time (months).

Identifying the usual signs of melanoma

The ABCDE criteriafor melanoma is a method that helps us to identify the lesions that we should be concerned about and for which we should consult a specialist.

  • A: Asymmetry. One half of the mole or birthmark is not symmetrical to the other half.
  • B: Borders. he edges of the mole are irregular, jagged or poorly defined.
  • C: Irregular color / various colors. Color is not uniform and includes shades of different colors (brown, black, pink, red, white or blue).
  • D: Diameter or size greater than 6 mm (although sometimes some melanomas can be smaller than this measurement).
  • E: Evolution. The size, shape or color of the stain changes over time.

We should not wait for the "mole" to itch or bleed, as these symptoms usually appear in more advanced stages, and our goal is to diagnose melanoma at an early stage when these symptoms are not yet present.

Photos melanoma cancer

Types of melanoma

Acral melanoma

This type of melanoma appears on the palms, soles or under the nail. It represents 10% of all melanomas. In palmo-plantar localization, a poorly demarcated light brown spot is observed, which gradually spreads flat and can later acquire darker brown areas or become palpable with nodules.

On the nail it appears as a longitudinal band of brown pigment, usually first narrow, about 2-3 millimeters, which widens over time and irregular bands composed of various colors and even small hemorrhages appear on the nail.

The fact that pigment appears in the cuticle is a sign to suspect nail melanoma. These types of melanoma usually have a worse prognosis because they are diagnosed later, so it is important to consult with suspicious lesions in these locations, because if they are diagnosed in time they are curable by surgical excision.

View image acral melanoma cancer

Nodular melanoma

It is the most aggressive and dangerous subtype of melanoma,, and accounts for 10-15% of cases.

This type lacks a horizontal phase, and appears directly in the vertical growth phase, in the form of a brownish-blackish or even pinkish papule or nodule, with a tendency to bleed.

This type of melanoma has the capacity to spread to the lymph nodes and subsequently metastasize to other organs.

View image nodular melanoma cancer

Melanomal lentigo maligna

The treatment of choice is wide surgical excision with 0.5 mm margins, although recurrences are frequent since the edges of the lesion are usually poorly defined and it is difficult to excise the lesion in its entirety.

Delayed Mohs surgery can also be used, with fewer recurrences since all the margins are analyzed more precisely. In recurrent cases or when it is not possible to remove the lesion in its entirety, an alternative is treatment with imiquimod cream or radiotherapy.

Good results are achieved with a complete response of approximately 75-85%, although they are not considered to be the first choice because they do not guarantee complete cure. Once the lesion has been removed, close follow-up is necessary to detect possible recurrences.

View image Lentigo maligna melanomata

Superficial spreading melanoma

It is the most frequent type, representing 70% of all melanomas. It can affect both sexes, being more frequent in men on the back and in women on the legs.

It is a lesion with a horizontal growth phase, in which the lesion grows on the surface (we see a spot or mole that grows flat) for a variable time (usually months), followed by a vertical growth phase in which it grows in depth and the flat spot becomes a lumpy or nodular lesion. It is then that the melanoma acquires the potential to spread to the lymph nodes and subsequently to other organs (metastasis).

View image superficial spreading melanoma

Diagnosis Melanoma

The dermatologist will suspect melanoma by observing the lesion and using a dermatoscope a tool that allows us to see the structures of the skin at high magnification and avoiding the reflection of the superficial layer of the skin), but the confirmation of the diagnosis will be given by the study of the sample under the microscope (histological confirmation).

In order to make an early diagnosis, it is advisable to perform periodic reviews of moles, in order to see lesions that show dermoscopic characteristics of atypia that are not yet visible to the naked eye.

In patients with multiple nevi or nevi with atypical features, it may be convenient to perform a digital control of the nevi (digitized epiluminescence microscopy), using a machine to take images of the whole body and magnified dermoscopy images, which will detect the appearance of new lesions and changes in pre-existing lesions. This is very useful and avoids unnecessary excision of lesions that, although they may appear atypical, remain stable over time. It also allows early removal of a very early melanoma that does not yet have typical melanoma characteristics, and whose only sign of suspicion is that it changes with respect to the previously recorded images.


Differential Diagnosis

Melanocytic nevi, commonly known as moles, are the lesions that can primarily be mistaken for melanoma. Unlike melanoma, nevi are usually small in size, regular in shape, one color and remain stable over time.

There are different types of melanocytic nevi, among which the following stand out:

Congenital melanocytic nevi

They are moles that appear at birth or in the first 3 years of life. About 1% of newborns are born with nevi. They are usually lesions of a few centimeters, brown in color with darker hairs inside. Depending on their size and number they may have a higher risk of melanoma.

Large lesions (>20 cm) and with satellite lesions are those that confer a higher risk of developing melanoma on the nevus.

Acquired melanocytic nevus

These are nevi that appear progressively during childhood and youth (5 to 35 years). A variety of these nevi is the atypical or dysplastic melanocytic nevus, which is characterized by being larger than 6 mm and having characteristics of atypia (asymmetry, irregular borders, various colors). The presence of multiple atypical nevi in the patient or in first-degree relatives is associated with an increased risk of melanoma.

View image congenital nevus
View image congenital nevus

Treatment and management of melanoma

The treatment of choice is complete surgical excision of the lesion. Once excised, the thickness of the melanoma and other histological characteristics that confer more or less risk will be determined, and depending on this the attitude to follow will be decided:

  • Melanomas in situ (non-invasive) or very thin melanomas <0.75 mm thick without other risk factors: A new surgical intervention will be performed again to widen the margins of the scar and thus ensure that the area is clean. 0.5 cm will be removed in the case of melanoma in situ, and 1 cm in the case of other melanomas.
  • Melanomas > 0.75 mm thick or with other poor prognostic factors: The patient will be offered the possibility of performing a selective sentinel lymph node biopsy. This technique allows the identification of the first lymph node where the lymph drains from the area where the melanoma was located, it is considered that this node would be the first station where the melanoma cells would go if they had spread from the skin. If this node is healthy, no further surgery is necessary, but if the node is affected with melanoma cells, a lymphadenectomy will be performed, which is the removal of all the nodes in that territory. In the same operation the area of the melanoma scar will be enlarged, 1-2 cm laterally depending on the thickness of the melanoma, and also in depth up to the muscular fascia.
  • Melanoma + nodal involvement detected by palpation, nodal ultrasound or nodal puncture:: A complete staging by scan (CT or PET-CT + brain MRI) will be performed to detect involvement of other organs. If the involvement of other organs is ruled out, lymphadenectomy + enlargement of the melanoma scar will be performed. If other organs are affected, the patient will be referred to oncology to evaluate systemic treatment with the new drugs for metastatic melanoma.
  • Melanoma + organ metastasis: The patient will be referred to oncology to evaluate systemic treatment with the new drugs for metastatic melanoma. In recent years several therapies have been developed for the treatment of metastatic melanoma. These are target therapies (anti-BRAF, anti-MEK) and immunotherapy (Ipilimumab, anti-PD1).

In all cases, the patient should be closely monitored by his dermatologist to detect possible recurrences, progression of the disease or the appearance of new melanomas. Depending on the stage of your melanoma, in addition to the clinical visits, complementary tests (laboratory tests, X-ray, ultrasound, CT scan, MRI) will be requested to detect possible progression of the disease.

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