Melanoma: Diagnosis & Treatment of Skin Melanoma

Pictured: Nancy Eastman & Allan Halpern Chief of the Dermatology Service Allan Halpern, pictured here with nurse Nancy Eastman, has pioneered the use of whole-body photography for early detection and prevention of melanoma.

Performing regular, complete head-to-toe skin examinations is the key to diagnosing melanoma at its earliest stage, when it is most easily cured. People who examine their skin regularly are more likely to notice changes in the appearance of their moles and bring them to the attention of a doctor, who will perform the appropriate diagnostic tests. To learn more, visit our Skin Cancer Screening Guidelines.

Video

Medical oncologists Paul Chapman and Jedd Wolchok describe two studies of promising new therapies for advanced melanoma.

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During a skin examination, you or your doctor can look for any changes in the appearance of moles. Signs of melanoma, often called the ABCDEs of skin cancer detection, may include moles that:

  • have an asymmetrical shape
  • have an uneven border
  • have more than one color
  • have a changing diameter
  • appear to be evolving over time

For people who have a personal or family history (two or more relatives) of melanoma and a large number of irregularly shaped moles, Memorial Sloan Kettering offers a Digital Imaging Screening Program. Our experts can create and store a computerized photographic record of your moles, so when you return for follow-up appointments your doctor can compare any suspected changes to the previous photographs.

Memorial Sloan Kettering also offers comprehensive skin cancer screening at our state-of-the-art facilities in Hauppauge, Long Island, and Basking Ridge, New Jersey. As at our Manhattan facility, doctors at these locations use the latest imaging technologies, including total-body photography and dermoscopy, in which a hand-held instrument is used to see structures below the top layer of the skin.

Diagnosis

To make an initial diagnosis of skin melanoma, the doctor will take your complete medical history and ask about your history of sun exposure, history of normal and abnormal moles, and family history of skin cancer. The doctor will also perform a skin examination and may check for enlarged lymph nodes, which can indicate that cancer has spread.

If your doctor is concerned about a particular mole or patch of skin, he or she will perform a biopsy, in which all or part of the growth is surgically removed. This is usually done in the doctor's office using a local anesthetic. A pathologist examines the removed skin under a microscope to determine whether melanoma cells are present.

Our doctors are also investigating another technique for examining live, intact skin cells with a confocal microscope, which provides sharply focused, magnified images of the outer skin layers. This would reduce the need to remove a skin sample to diagnose melanoma. In addition, our researchers are evaluating techniques to detect individual melanoma cells that may have broken away from a primary tumor to determine — before surgery — whether the cancer has spread.

Treatment of Localized Melanoma

For localized melanoma that is limited to the outer layer of skin (the epidermis), doctors at Memorial Sloan Kettering usually begin by surgically removing the tumor. We also remove some normal skin, called the margin, to ensure that all cancer cells have been taken out. The extent and shape of the excision depends on the thickness of the tumor, its location, and cosmetic concerns. In some cases, a skin graft from elsewhere on the body may be used to replace skin that was removed.

Sentinel Lymph Node Biopsy

Melanoma can metastasize, or spread, to other parts of the body. Memorial Sloan Kettering surgeons were among the first to use an advanced diagnostic procedure called sentinel lymph node biopsy to determine whether melanoma cells have spread.

For this procedure, doctors first perform gamma-probe-guided lymphatic mapping, in which they inject a radioactive substance near the tumor. By observing how the substance moves through the lymph fluid, doctors can tell where cancer cells are most likely to spread. The first lymph node that the radioactive substance reaches is called the sentinel node.

Doctors remove the sentinel node and examine it to determine whether cancer cells are present. If they are, the surgeon may need to remove additional lymph nodes. If no cancer cells are present, more surgery is not necessary. The sentinel lymph node biopsy can prevent the unnecessary removal of lymph nodes and can prevent lymphedema, a condition in which excess fluid causes tissues to swell.

Surgeons at Memorial Sloan Kettering are currently participating in a clinical trial to determine whether it is necessary to remove the remaining lymph nodes if the sentinel lymph node contains melanoma.

Treatment of Metastatic Melanoma

Metastatic melanoma is usually aggressive and has been difficult to treat effectively. In the past, most therapies have been successful for a limited number of patients. However, several treatments have been developed recently that may lead to significant improvements for people with metastatic melanoma. Today, our doctors have new options for managing the disease and preserving your quality of life, depending on how much and where the tumor has spread. You can also talk with your doctor about therapy options that are available through clinical trials.

Immunotherapy

Memorial Sloan Kettering researchers played a major role in developing an immunotherapy called ipilimumab (Yervoy™), which is a drug that activates the immune system. Studies have shown that ipilimumab, which was approved by the FDA in 2011, is the first treatment that prolongs overall survival of people who have metastatic melanoma.(1)

Chemotherapy

Chemotherapy, a systemic therapy that travels through the blood to cells in the entire body, often plays a central role in treating metastatic melanoma. You can receive chemotherapy by mouth or injection. Some chemotherapy for melanoma has only mild side effects, allowing you to continue to work full-time. More aggressive chemotherapy for melanoma is often associated with fatigue, poor appetite, and low blood counts that can make it more difficult to carry on your normal activities.

If you have melanoma that has returned after initial treatment, but is confined to an arm or leg, you may receive regional infusion therapy. In this procedure, doctors isolate the affected limb from the rest of the body by stopping blood flow with a tourniquet. They then expose the limb to high levels of chemotherapy. This maximizes the effect of chemotherapy on the tumor, while limiting the side effects of these drugs on the rest of your body. Researchers at Memorial Sloan Kettering were among the first in the country to use this technique to deliver regional therapy and are actively investigating ways to make the treatment more effective.

Radiation Therapy

Radiation therapy is another treatment option for advanced melanoma that may be used alone or in combination with other therapies. If you have melanoma that has spread to the brain, doctors may treat the tumor with stereotactic radiation. Through this procedure, doctors deliver a single high dose of radiation directly to the tumor. This technique has a high chance of killing the tumor with few side effects.

Investigational Therapy Approaches

Many patients are eligible to enroll in clinical trials of melanoma therapies, including people who have advanced melanoma and people who have had surgery but may be at risk for melanoma recurrence. Our experts are studying two main types of innovative therapies: drugs that boost the immune system in fighting against cancer and drugs that act on genetic pathways to prevent tumor progression.

Memorial Sloan Kettering experts are continuing to conduct clinical trials of the FDA-approved ipilimumab (Yervoy™), a molecule that promotes immunity against tumor growth, as well as other immunotherapies.

Researchers have also determined that 40 to 60 percent of melanomas have mutations in a gene called BRAF. These mutations are responsible for activating a pathway that leads to tumor growth. Memorial Sloan Kettering researchers are studying new drugs designed to turn off this pathway to stop melanoma from growing. One particular drug, called PLX4032 (vemurafenib), has decreased or eliminated metastatic melanoma tumors in some patients in a clinical trial.(2) Recently, Memorial Sloan Kettering led an international study comparing vemurafenib with standard chemotherapy, showing that people who took vemurafenib were more likely to have their tumors shrink and had better overall survival.

However, not all people with melanoma have a mutation in BRAF. Some have a mutation in another gene called KIT. You may be eligible to enroll in a clinical trial to receive a drug designed to inactivate the effects of the KIT gene.

Follow-Up Care

Even after the cancer is completely removed, melanoma can recur. Melanoma survivors are also at a higher-than-average risk for non-melanoma skin cancers. If you are a melanoma survivor, you should continue to perform self-examinations and contact your doctor immediately if you find a lump, a change in a mole, or other changes in your skin or general health that could indicate a recurrence of disease. It is critical for you to protect your skin from sun exposure as well.

In addition, Memorial Sloan Kettering offers comprehensive follow-up care for people who have been treated here as part of our institution-wide Survivorship Initiative.

Your follow-up care is provided by a physician assistant who is a specialist in the care of melanoma survivors. In addition to monitoring for signs of cancer recurrence, the physician assistant focuses on identifying, preventing, and controlling any long-term and late effects associated with cancer and its treatment.

A visit includes the following:

  • Review of your recent medical history and a physical examination
  • Assessment to detect recurrence of cancer
  • Identification and management of the effects of cancer and its treatment
  • Screening referrals for other cancers
  • Health promotion recommendations related to nutrition, exercise, and smoking cessation
  • Treatment summary and follow-up care plan
  • Consultation with your Memorial Sloan Kettering physician as needed

In addition to working closely with your treatment team, the physician assistant provides a treatment summary and survivorship care plan to you, your primary care doctor, and other medical providers. Your physicians can then incorporate this information into your overall medical plan. After each visit, the physician assistant will continue to update your other medical providers.

As your need for cancer care decreases, follow-up care may be transitioned to your primary care physician. The timing for this depends on your particular cancer and treatment. Memorial Sloan Kettering experts are always available if you or your doctors ever have a cancer-related question or if a new cancer-related problem arises.

Your Follow-Up Care Provider

Pictured: Kathleen Paisley Kathleen Paisley, PA I am a physician assistant with special training in melanoma survivorship issues. I graduated from Weill Cornell Medical College's Physician Assistant program and joined Memorial Sloan Kettering’s Melanoma and Sarcoma Service in 1997.