What is melanoma?
Melanoma is the most serious of the common skin cancers. The cancerous cells arise from melanocytes (nevi or mole cells), which gives your skin its color. Everyone has these pigment cells, but they can sometimes change, either spontaneously or when damaged by sun exposure. With time, this damage can result in cancer.

What causes melanoma?
Most melanomas are caused by sun damage. The greatest risk for developing melanoma probably comes from sunburns. People with fair skin or those who tend to burn easily are more at risk for sun damage as well as for melanoma. Other factors may also increase the risk, such as a genetic (inherited) tendency. There are rare types of melanomas that occur on places other than the skin, such as the lining of the inside of the eye, mouth, or rectum. Occasionally the site of origin of a melanoma in an individual patient cannot be found. In these melanomas, the cause is unknown.

Can you explain my pathology report and tell me how serious my melanoma is?
For patients with primary melanoma of the skin, the single most important part of the pathology report is the Breslow thickness. The likelihood that a person will be cured of melanoma after surgery is strongly related to this measurement. Your surgeon will recommend treatment based in part on your melanoma’s Breslow thickness as well as other factors:

Breslow thickness: a measurement in millimeters (mm) of how deep the cancer has penetrated. One millimeter is approximately 1/25 inch. A thickness of less than 1.0 mm is considered a thin or early melanoma. Melanomas between 1.0 – 4.0 mm are generally considered intermediate thickness. Melanomas more than 4.0 mm are considered thick.

Clark level: this is indicated by a Roman numeral from I-V. These numbers correspond to the different layers of the skin. Clark’s level I is the top layer (epidermis) of the skin, and melanomas confined to this layer are considered non-invasive and have not spread. Clark’s levels II-V are located in the dermis of the skin and are considered invasive with a tendency to spread. At level V, the melanoma has penetrated all the layers of the dermis into the subcutaneous fatty tissue. The Clark level is used for revised staging of patients with thin melanomas.

What is the best treatment for primary melanoma?
The main treatment for primary melanoma is surgery. A thin melanoma is usually treated with a wide local excision of the skin. In this procedure, an area surrounding the melanoma site is removed. For thin melanomas, this area is usually 1cm, or about 3/8 inch. The excision is carried down through the fatty tissue to the covering over the muscle (the fascia). The incision is usually made so that the wound can be easily closed. In order to do this, the wound usually needs to be lengthened in one direction at least 3 times its maximum width. For example, a 1cm margin excision can result in a linear or curved scar at least 6cm (2.4 inches) in length.

For melanomas 1mm or more in thickness, a larger area around the site is often removed. While many of these wider excisions can still be directly closed, in some cases a skin graft is necessary. Your surgeon will discuss this with you. Melanomas 1mm or more in thickness are considered somewhat more serious than thin melanomas, and may spread to nearby lymph nodes. A wide local excision is often done together with a sentinel lymph node biopsy to check for possible spread.

Can you explain intra-operative lymphatic mapping and sentinel lymph node biopsy?
This procedure is usually done at the same time as wide local excision for intermediate or thick melanomas. A small amount of radioactive material and blue dye is injected at the melanoma site. The lymphatic system picks up this tracer material and carries it to the lymph nodes close to the primary melanoma. These lymph nodes (called sentinel lymph nodes) are the ones most likely to contain cancer cells if the melanoma has metastasized (spread). The tracer will collect in one or more of these lymph nodes, which are then surgically removed through a small incision and examined under the microscope. The process of checking the lymph nodes for spread of melanoma can take up to two weeks.

After surgery, what is the next step?
For patients with thin melanomas who have a wide local excision alone, no further treatment is recommended if the pathology report is normal. Patients with successful surgical treatment for thin melanomas still need to be checked regularly with physical exams, lab work, and a chest
X-ray. Your melanoma health care team will discuss your follow-up schedule.

Patients with a wide local excision together with a negative sentinel lymph node biopsy (which showed no spread of melanoma) also generally need no further treatment. However, regular checkups are strongly recommended.

If you have a lymph node removed that indicates the melanoma has spread, your surgeon will recommend additional surgery to remove the rest of the lymph nodes in that area. This surgery is called lymphadenectomy or lymph node dissection. In addition, patients with spread of melanoma to lymph nodes sometimes take additional treatments (adjuvant therapy) after recovery from surgery to help prevent recurrence or further spread. These treatments can include medications, such as interferon-alpha; vaccine treatments; chemotherapy; or radiation therapy. Your health care team will discuss these options with you when indicated.

When will my surgery be scheduled?
Most procedures are scheduled within two to four weeks of your first clinic visit. It will not be done the same day as your first visit with your surgeon, but it will be scheduled in a timely manner. Please be aware that other patients are awaiting surgery as well. Your surgeon will not put your health in danger by postponing surgery.

How long will I need to be in the hospital for my surgery?
If you are having a wide local excision, this will be an outpatient procedure and you can go home the same day. This procedure is performed under local anesthesia. Sometimes, medications to relax you (sedation) are given through an IV tube.

If you are having a wide local excision with intra-operative lymphatic mapping and sentinel lymph node biopsy, you may stay in the hospital overnight. This surgery often is done under general anesthesia. If you have no side effects from the anesthesia and are feeling well, you may go home the same day.

If you are having an axillary lymph node dissection, which is done under general anesthesia, you will stay overnight.

If you are having a groin (or inguinal) lymph node dissection, you will stay in the hospital at least 3 days. This surgery is done under general anesthesia.

After surgery, you will be instructed on how to care for your incision. You will get an appointment to return to the Melanoma and Skin Center for a wound check, for drain or suture removal (if necessary), to discuss the results of your final pathology report, and make plans for any additional care. Most patients return to the Center about 1-4 weeks following surgery.

What about my other skin lesions?
People who develop one melanoma are at risk for developing additional melanomas. During your first visit, your skin will be checked for other suspicious lesions. If any look suspicious, a biopsy will be performed. Once you are diagnosed with melanoma, it's important that you become familiar with your skin to get a good idea of what your existing lesions look like. Every time you come for a check-up, we will examine your skin as well as your surgery site. However, you should still perform monthly skin self-exams.  There are 5 things to check for, called the ABCDEs of melanoma.

What are the ABCDEs of melanoma?

Asymmetry. Look for lesions that look different when one side is compared to the other. If you draw a line down the center of the lesion, do the two sides look the same?

Border. Look at the edges of the lesion. Are the borders smooth or jagged?

Color. Look for changes in the color of the lesion. Is it getting darker, is part of it changing color, or does it contain several different colors?

Diameter. Look at the size of the lesion. Is it more than 6 mm in diameter (the size of a pencil eraser)?

Elevation. Look for signs of the lesion becoming raised. Is it growing in height?

How can I prevent future melanomas?
Risk of developing melanoma is related in part to sun damage. Prior sun exposure, a natural tendency to develop melanomas, or both,  can sometimes cause melanoma patients to develop a separate, new melanoma elsewhere on their body. You cannot necessarily prevent this from happening. However, with regular skin self-exams, you may be able to identify suspicious moles in a very early stage. Individuals who have had melanoma should also limit their sun exposure. It is most important to avoid sunburn. We recommend that you limit your sun exposure during the peak periods of ultraviolet light exposure (10:00 a.m.-3:00 p.m.). When outdoors,  wear a sunscreen rated at least SPF 30, a broad brimmed hat and a long-sleeved shirt. You may also consider special sun protective clothing.

We also recommend you practice monthly self-skin examinations, and that you keep all of your follow-up appointments with your melanoma health care team and your dermatologist.