Surgical Department at Saint Barnabas Medical Center

Melanoma

It is estimated that we will see 70,000 new cases of melanoma in the United States this year. One in 74 Americans will develop invasive malignant melanoma in their lifetime. This represents an explosive increase from the ratio of one in 600 in 1960 and one in 150 in 1993. It is one of the few remaining cancers with an increasing incidence rate. The number of Americans dying from melanoma is also increasing. The mortality rate has risen 2% annually since 1960 and 7,700 Americans will die of melanoma this year.

Fortunately, for the individual patient with melanoma, the outlook has never been brighter. The overall 5-year survival rate for the average patient with melanoma has increased from 40% in the 1940’s to almost 90% recently. This is mainly because we are diagnosing melanoma earlier when it is more likely to be curable. The key to early diagnosis is recognition of early melanoma. We have learned to identify features of moles that increase our suspicion of melanoma: asymmetry, irregular border, variegation in color and a diameter greater than 6 mm.(See pictures "early melanoma" below.)

The more advanced melanoma is easier to diagnose (See pictures "advanced melanoma below.)

We are also aware of individuals who are at high risk of developing melanoma, e.g. those with a family or past history of melanoma, those with blond hair, fair skin, blue eyes and with a tendency to freckle, those with numerous moles on their back etc.

Over the years, we also learned that not all melanomas behave in the same way. The thickness and presence of ulceration determine the aggressiveness of the tumor. When it is thin, it rarely spreads. However, as it becomes thicker, it has an increasing tendency to invade the draining lymph nodes. Then it may spread beyond the lymph nodes to other skin and subcutaneous tissue areas, lung, liver, brain, intestines etc. Therefore, appropriate treatment depends very much on the thickness of the melanoma. For thin melanomas, (less than 0.75 mm), excision of the melanoma with 1 cm of normal skin margin is adequate for cure. When the tumor is intermediate in thickness, (0.75 to 4 mm in thickness), a wider excision with 2 to 3 cm of normal skin around the melanoma is recommended and some of these patients may even benefit from removal of the draining lymph nodes. For thick lesions, (greater than 4 mm), there is need for still wider excision to prevent local recurrence but removal of draining lymph nodes is usually of no benefit since most of these thick melanomas will have already spread to other organs beyond the nodes.

In the past, we recognized that there are substantial side effects when the draining lymph nodes in the groin, axilla or neck are removed. Significant swelling of the involved arm or leg may develop. About ten years ago, the technique of identifying and removing the "sentinel" node was discovered. The sentinel node is the first lymph node in the draining area that will be invaded by the melanoma. If the sentinel node is not invaded by melanoma, it is unlikely that other nodes in the draining site will be involved. We now remove and examine the sentinel node routinely for all intermediate thickness melanomas. The remaining nodes in the draining area are removed only when the sentinel node contains melanoma. This minimizes considerably the number of patients that will be subjected to an operation that may cause severe swelling of the extremity.

For those patients who’s melanoma has spread to the lymph nodes or who have thick melanomas, further treatment with high doses of Interferon alpha 2b has been reported to be of some benefit and may be recommended. However, this therapy is quite toxic and its use must be individualized. Unfortunately, success with chemotherapy and other forms of immunotherapy are currently limited and most of these treatments are still experimental.

Finally, the best treatment is prevention. This is especially wise for those who have a high risk of developing melanoma. The key is to avoid direct sun or UV light exposure. One should wear protective clothing and regularly employ sunscreen with high sun protective factor on the exposed body parts. (See picture "proper dress under the sun".)

This will minimize the risk of melanoma and still allow us to safely enjoy our outdoor activities.

Patrick Chang, M.D., F.A.C.S.
Phone: (973) 972-3464

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