Melanoma

Our team of internationally recognized experts customizes your melanoma care to ensure you receive the most advanced treatments with the least impact on your body.

Overview

Our internationally recognized Multidisciplinary Skin Cancer and Melanoma Clinic customizes your melanoma care to ensure you receive the most advanced treatments with the least impact on your body.

Each person and each melanoma are different, and at the UofL Brown Cancer Center’s Melanoma Clinic, we use our unique multidisciplinary approach to tailor melanoma treatment specifically to your unique situation.

More than 5,000 melanoma outpatient visits occur in our clinic per year –– among the most of any melanoma program in the world. Caring for these patients has helped us to develop an outstanding team of melanoma specialists with expertise and experience in treating all types of melanoma.

Your personal team of experts in melanoma includes melanoma surgical oncologists, melanoma medical oncologists, head and neck surgeons, neurosurgeons, plastic surgeons and other surgeons, radiation oncologists, diagnostic radiologists and other specialists, if needed. They work closely together, collaborating and communicating at every step of your treatment.

Understanding a disease is the first step toward finding the right care. Get the facts about melanoma, including the different types, how it starts and who’s at risk.

Tanning beds aren't safer than tanning outdoors. They emit the same harmful UV rays as the sun and put users at increased risk of melanoma.

Approximately 70,000 new cases of invasive melanoma are diagnosed in the United States each year. It’s one of the most frequently occurring cancers in young adults ages 20 to 30, and it's the main cause of cancer death in women 25 to 30 years old.

While melanoma accounts for only 3 percent of all types of the skin cancer, it has the highest death rate of all types and is more likely to spread (metastasize) in the body. It is becoming more much more common.

What is melanoma?

Melanoma is a skin cancer that starts in melanocytes (cells that make melanin), which give skin its pigment, or color. Sometimes these cells change, often because of damage caused by sun exposure. Over time, this damage may result in cancer. 

Melanoma usually appears as an:

  • Irregular brown, black and/or red spot or
  • Existing mole that begins to change color, size or shape

Melanoma appears most commonly on the trunk area in fair-skinned men and on the lower legs in fair-skinned women. In dark-skinned people, melanoma appears most frequently on the palms, the soles of the feet and the skin under nails. If caught early, melanoma is often curable.

Melanoma types

Melanoma is divided into several types. The treatment and outlook for each is different.

Cutaneous melanoma

There are four major types of cutaneous melanoma:

Superficial spreading melanoma:

  • Most common form of melanoma
  • About 70 percent of cases
  • Usually starts in a pre-existing mole

Nodular melanoma:

  • Second most common type
  • 15 to 30 percent of cases
  • More aggressive and usually develops quicker than superficial melanomas

Lentigo maligna melanoma:

  • Appears as large, flat lesions
  • Most commonly found on the faces of light-skinned women over 50
  • 4 to 10 percent of cases
  • Lower risk of spreading than other types

Acral lentiginous melanoma:

  • Occurs on the palms, soles of the feet or beneath the nail beds
  • 2 to 8 percent of melanomas in fair-skinned patients
  • Up to 60 percent of melanomas in darker-skinned patients
  • Large, with an average diameter of 3 centimeters

Mucosal melanoma

  • About 1 percent of melanoma cases
  • Occurs in mucosal tissue, which lines body cavities and hollow organs
  • Most common sites are head and neck region (including the nasal cavity, mouth and esophagus), rectum, urinary tract and vagina
  • Can be very difficult to detect
  • Even when diagnosed and treated, the outlook is often poor

Melanoma of the eye (ocular melanoma)

Because the eyes contain melanocytes, they can be susceptible to melanoma. There are two types of ocular melanoma:

  • Uveal Melanoma
  • Conjunctival Melanoma

Risk Factors

Anything that increases your chance of getting melanoma is a risk factor.

Sun damage, especially a history of peeling sunburns, is the main risk factor for melanoma. Artificial sunlight from tanning beds causes the same risk for melanoma as natural sunlight.

Other risk factors for melanoma include:

  • Fair complexion: People with blonde or red hair, light skin, blue eyes and a tendency to sunburn are at increased risk.
  • Previous melanoma
  • Moles (nevi): Having a lot of benign (non-cancer) moles
  • Family history of melanoma
  • Atypical mole and melanoma syndrome (AMS): Previously known as dysplastic nevus syndrome, AMS is characterized by large numbers of atypical moles. If you have AMS, you and your family members should be screened regularly

Not everyone with risk factors gets melanoma. However, if you have risk factors, it’s a good idea to discuss them with your health care provider.

Most cancers have the same symptoms as other, less serious conditions. Still, it’s important to know the signs.

While signs and symptoms of melanoma vary from person to person, the ABCDEFs of melanoma symptoms are an easy way to learn the early signs of melanoma.

Asymmetry: Is one side of the mole different than the other?

Border irregularity: Are the edges ragged or irregular?

Color variation: Is the mole getting darker? Is part of it changing color or does it contain several colors?

Diameter: Is the mole bigger than the diameter of a pencil eraser?

Evolution: Is the mole growing in width or height?

Feeling: Has the sensation around a mole or spot changed?

Show any suspicious skin area, non-healing sore or new or changing mole or freckle to your doctor right away.

Blood tests, imaging exams and even surgical procedures are used to check for cancer.

Early and accurate diagnosis is important in melanoma care. This helps find out if the cancer has spread and helps your doctor choose the most effective treatment.

UofL Brown Cancer Center has the most modern and accurate technology to diagnose melanoma and find out if it has spread. This helps increase the likelihood that your treatment will be successful. Our staff includes pathologists and diagnostic radiologists who are highly skilled in diagnosing melanoma.

Diagnostic tests

If you have signs or symptoms that may signal melanoma, your doctor will examine you and ask you questions about your health, your lifestyle and your family history. If your doctor suspects a spot may be melanoma, a biopsy will be done.

Biopsy

Skin cancer can't be diagnosed just by looking at it. If a mole or pigmented area of the skin changes or looks abnormal, your doctor may biopsy the mark, taking a tissue sample for a pathologist to examine. Suspicious areas should not simply be shaved off or cauterized (destroyed with a hot instrument, an electrical current or a caustic substance). A biopsy should be performed first to determine if the area is malignant.

Your doctor may use one of these biopsy methods:

Local excision/excisional biopsy: The entire suspicious area is removed with a scalpel under local anesthetic. Depending on the size and location of the suspicious area, this type of biopsy may be done in a doctor's office or as an outpatient procedure at a hospital. Your doctor will put in stitches to close the excision and cover the area with a bandage.

Punch biopsy: The doctor uses a tool to punch through the suspicious area and remove a round cylinder of tissue.

Shave biopsy: The doctor shaves off a piece of the growth.

The sample of skin is sent to a pathologist, who looks at it under a microscope to check for cancer cells. Your tissue may be judged normal or abnormal. Abnormal results may include:

  • Benign (non-cancerous) growths such as moles, warts and benign skin tumors
  • Squamous cell carcinoma (cancer)
  • Basal cell carcinoma
  • Melanoma

Because melanoma can be hard to diagnose, you should consider having your biopsy checked by a second pathologist.

Biopsy side effects

As with any time the skin is cut, there is a small risk of infection after a biopsy. You should call your doctor if you have a fever, an increase in pain, reddening or swelling at the infection site, or continued bleeding.

If your skin usually scars when injured, the biopsy may leave a scar. For this reason, a biopsy on the face might be better performed by a surgeon or dermatologist who specializes in methods that reduce scarring.

Before you have a skin biopsy, you should tell your doctor what medications you are taking, including anti-inflammatory medication, which may make your biopsy look different to the pathologist, or blood thinners like Coumadin or aspirin, which could cause bleeding problems.

Other tests

After melanoma has been diagnosed, tests may be recommended to find out if cancer cells have spread within the skin or to other parts of the body. These may include imaging tests such as:

  • Chest X-ray
  • Lymphoscintigraphy
  • Ultrasound
  • CT or CAT (computed axial tomography) scans
  • MRI (magnetic resonance imaging) scans
  • PET (positron emission tomography) scans

Melanoma staging

If you are diagnosed with melanoma, your doctor will determine the stage (or extent) of the disease. Staging is a way of determining how much disease is in the body and where it has spread. This information is important because it helps your doctor determine the best type of treatment for you and the outlook for your recovery (prognosis). 

Melanoma staging is based on:

  • Location(s) of the melanoma
  • Primary melanoma tumor thickness as well as other microscopic features
  • If it has spread to nearby lymph nodes – if so, how many and what size
  • If it has spread (metastasized) to other parts of the body
  • A blood test called lactate dehydrogenase (LDH) for stage IV melanoma

Melanoma stages

Stages I and II are based mainly on the thickness of the primary melanoma and other microscopic features. Stages III and IV are based on how far the melanoma has spread from the skin; stage III signifies regional spread and stage IV is based on distant spread.

Stage 0 (Melanoma in situ):

  • Does not reach below the surface of the skin
  • Tumor thickness is not recorded for melanoma in situ

Stage IA: Melanoma:

  • Is less than 1 millimeter thick
  • Without ulceration
  • Has less than 1 mitosis (dividing cell) per square millimeter

Stage IB: Melanoma:

  • Is less than 1 millimeter thick and with ulceration and/or has at least 1 mitosis (dividing cell) per square millimeter or
  • 1 to 2 millimeters thick without ulceration

Stage IIA: Melanoma is either:

  • 1 to 2 millimeters thick with ulceration or
  • 2 to 4 millimeters thick with no ulceration

Stage IIB: Melanoma is either:

  • 2 to 4 millimeters thick with ulceration or
  • More than 4 millimeters thick without ulceration

Stage IIC: Melanoma is more than 4 millimeters thick with ulceration

Stage III: Melanoma:

  • Has spread through the lymph system (eg, satellites and/or in-transit metastasis) or directly into the regional lymph nodes (ie, lymph nodes that receive lymph drainage from primary tumor site)
  • Has not spread to distant organs

Stage IV: Melanoma has spread (metastasized) to more distant lymph nodes and/or to other distant organs

Common cancer treatments include chemotherapy, radiation treatment and surgery. Doctors select a treatment plan based on your diagnosis and disease stage.

Melanoma is not a “one-size-fits-all” type of cancer. The molecular and cellular changes are different for each person.

The experts at UofL Brown Cancer Center tailor your treatment to be sure you receive the most advanced therapies with the least impact on your body. We have an extensive menu of choices to treat all stages and types of melanoma.

If melanoma is caught early, it is highly treatable. Surgery is the main treatment for early melanomas, and may be used as part of the treatment approach for advanced melanomas.

Because the UofL Brown Cancer Center leads one of the most active melanoma treatment programs in the nation, our surgeons have extraordinary expertise and experience that can help increase your chances for successful treatment.

Several innovative treatments for melanoma are offered at UofL Brown Cancer Center. Your personalized treatment may include:   

  • Lymphatic mapping and sentinel node biopsy
  • Minimally invasive isolated limb perfusion, which delivers cancer drugs directly to the arm or leg if melanoma has spread
  • Adjuvant immunotherapy to help reduce the risk of melanoma coming back after surgery
  • Immunotherapy and gene therapy to stimulate your immune system to eradicate the melanoma
  • Tumor infiltrating lymphocyte infusions to stimulate your immune system to eradicate the melanoma
  • Treatments for rare forms of melanoma, such as those that begin in the eye (uveal melanoma) or mucosa (for example, vaginal, rectal or sinonasal)

And we’re constantly researching ways to help the body fight the cancer, including:

  • Targeted therapies
  • Immunotherapy, including interleukin-2, interferon, adoptive T cell therapy
  • Vaccines
  • Monoclonal antibodies
  • High-dose cytokine therapies

If you are diagnosed with melanoma, your doctor will discuss the best options to treat it. Your treatment for melanoma at UofL Brown Cancer Center will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptom.

Surgery

The type of surgery your doctor uses to treat melanoma depends on the thickness of the melanoma tumor and if it has spread.

Melanomas less than 1 millimeter thick

The most often-performed procedure is a wide excision of the primary tumor. The surgeon carefully cuts out the melanoma and a predetermined area around it. The amount of skin that is removed and the degree of scarring depend on the tumor thickness of the melanoma. Most patients usually do not need more treatment.

Depending on the size of the melanoma, the local excision may be an inpatient or outpatient procedure, often with local anesthesia. The area may require stitches, and recovery can take a few weeks. The severity of the scar depends on the size, depth and location of the melanoma.

Your surgeon may discuss a procedure called lymphatic mapping and sentinel lymph node biopsy (see illustration below right). It is a minimally invasive surgical approach in which the regional lymph node(s) that receive lymph drainage from the primary tumor site is/are removed and carefully checked for cancer spread to the regional nodes. These "sentinel" lymph nodes represent the most likely nodes to contain spread, if any are involved. If the sentinel lymph node is cancer free, then the other lymph nodes do not need to be checked or removed. If the sentinel lymph node contains melanoma spread (metastasis), your doctor may discuss further surgery and other treatment.

Melanomas more than 1 millimeter thick

The principal procedure is a wide excision of the primary tumor. The surgeon carefully cuts out the melanoma and a predetermined area around it. The amount of skin that is removed and the degree of scarring depend on the tumor thickness of the melanoma. Most patients usually do not need more treatment.

If a large area of skin is removed during surgery, a skin graft may be done to reduce scarring. The surgeon numbs and removes a patch of healthy skin from another part of the body, such as the upper thigh, and then uses it to replace the skin that was removed. This is done at the same time as the skin cancer surgery. If you have a skin graft, you may have to take special care of the area until it heals.

In addition to a wide excision, your melanoma surgical oncologist will often discuss a procedure called lymphatic mapping and sentinel lymph node biopsy, a minimally invasive surgical approach in which the regional lymph node(s) that receive lymph drainage from the primary tumor site is/are removed and carefully checked for cancer spread to the regional nodes. These “sentinel” lymph nodes represent the most likely nodes to contain spread, if any are involved. If the sentinel lymph node is cancer-free, then the other lymph nodes do not need to be checked or removed. If the sentinel lymph node contains melanoma spread (metastasis), your doctor may discuss further surgery and other treatment.

Regional lymph node metastasis

If melanoma has spread to the regional lymph nodes, a surgical procedure known as lymph node dissection (also termed lymphadenectomy) is often performed. This procedure consists of removal of the “compartment” of lymph nodes related to the location of where the tumor-containing lymph node was identified. This procedure is performed under general anesthesia; one or more drain tubes are usually placed at the completion of surgery to facilitate recovery.

Depending on the extent of spread to the lymph nodes, radiation therapy may also be recommended to try to reduce the chance of the melanoma recurring in the regional nodes.

Metastatic Melanoma (Stage IV)

Surgery may sometimes be used to treat melanoma that has spread to distant parts of the body.

Radiation therapy

In collaboration with skilled radiation oncologists, cancer radiation therapy be used as a component of your melanoma treatment plan. Radiation therapy may sometimes be combined with chemotherapy.

Targeted therapies

These innovative treatments take advantage of a new understanding of the molecular alterations that sometimes occur within melanoma tumor cells. Treatment may include:

  • B-RAF inhibitors
  • KIT inhibitors
  • Other treatments in clinical trials

Immunotherapy

These innovative treatments help the body’s natural immune response fight the cancer. Immunotherapy generally is used in advanced melanoma when the cancer has spread to other parts of the body. Treatment may include:

  • Interferon-alpha
  • Anti-CTLA-4
  • Anti-PD1
  • Talimogene (T-VEC)
  • Vaccines
  • Interleukin 2
  • T Cell therapy (i.e. tumor infiltrating lymphocytes)
  • Biochemotherapy

In some cases, chemotherapy may be combined with interleukin 2, interferon and/or T-cell therapy.

Follow-up after treatment

If you have had a melanoma, you are at higher risk of developing new melanomas than someone who has never had a melanoma. You may be at risk of the cancer coming back in nearby skin or in other parts of the body. The chance of recurrence is greater if the melanoma was thick or had spread to nearby tissue. Your family members also should have regular checks for melanoma.

To increase the chance of finding a new or recurrent melanoma as early as possible, follow your doctor's schedule for regular checkups. If you are at high-risk for recurrence, follow-up care may include X-rays, blood tests and imaging scans of the chest, liver, bones and brain; if you have very early stage melanoma, these tests are generally not performed unless specific situations arise.

Our doctors at UofL Brown Cancer Center are proudly part of UofL Physicians and the UofL School of Medicine.

We believe knowledge comes from questioning the status quo, discovering more about disease and using that knowledge to improve the health of our community. Our physicians are the teachers and researchers at the UofL School of Medicine, involved in the research and development of new treatments and cures for cancer. This means you receive the most advanced and appropriate treatment, even for complex or rare conditions.

To learn more about the physicians who make the academic difference in melanoma treatment, visit the UofL Physicians website here.