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Melanoma of the Head and Neck

This information explains melanoma of the head and neck including staging and treatment.

Melanoma is a tumor that arises in the cells that contain pigment. These are in the outer layer of skin and they give skin its color. While the exact cause is not known, we do know some of the risk factors. These include:

  • Spending a lot of time in the sun
  • Using tanning lamps and booths
  • Having moles
  • Having fair skin
  • Being blond or red-headed
  • Having family members with the disease

Diagnosis of Melanoma - ABCDEs

Warning signs of melanoma are often called the “ABCDEs” of melanoma. Look for the following on any moles or spots on your skin:
 
A – Asymmetry: One half doesn’t match the appearance of the other half. 
B – Border: The borders (edges) are uneven and irregular. 
C – Color: The color is not uniform. A number of different shades of brown, tan, or black could appear.
D – Diameter: The diameter is more than 6 millimeters (about the size of a pencil eraser).
E – Evolution: There is a change in the size, shape, symptoms (such as itching or tenderness), surface (especially bleeding), or color.
 

If melanoma is suspected based on how the mole looks, your doctor will do a punch or incisional biopsy. Both are usually done in the office. A punch biopsy uses an instrument that takes a core of tissue. An incisional biopsy involves a small cut in the skin. Tissue is removed from the suspicious area. The tissue is examined under a microscope. This will tell the doctor if it is cancer or not. More tests may be done if the biopsy is positive. These may include a chest x-ray, CT scan, MRI, or PET scan. All are done to see if the melanoma has spread to other areas of the body.

Stages of Melanoma

Cancers are usually staged. Staging for melanoma is based on:

  • How thick the tumor is. It is measured in millimeters (mm).
  • Whether it has spread to lymph nodes or other sites.

Staging helps determine the best treatment approach. The staging for melanoma is based on the TNM Classification. T stands for tumor, N for node, and M for metastasis.

Types of Melanoma

Your doctor will discuss your treatment options with you. These depend on the type and stage of melanoma.

  • Superficial spreading melanoma is the most common type of melanoma. Forty to sixty out of 100 tumors are this type. It occurs most often in young and middle-age adults. They often have a history of sun exposure. It can occur anywhere on the body.
  • Acral lentiginous melanoma is rare. It occurs equally in light and dark skinned people, suggesting that sun exposure is not involved in the cause. It most commonly appears on the palms or soles.
  • Nodular melanoma usually appears as a strange but solid colored raised nodule. It, too, occurs most often in young and middle-age adults who have a history of sun exposure.
  • Desmoplastic melanoma is a type that lacks color. It is often mistaken for a benign lesion.
  • Mucosal melanoma is found in the lining of the nose, sinuses, oral cavity, or genitals.

Treatment

Treatment for melanoma is based on:

  • How thick the lesion is.
  • Whether it is in the lymph nodes.

Lymph node mapping and sentinel lymph node biopsy

The head and neck area has many groups of lymph nodes. Tumor cells can spread to any of these. If the melanoma is superficial, meaning it is not deep in the skin, you will have a wide excision. If the melanoma is thick, your lymph nodes will need to be evaluated.

If the doctor can feel the lymph node(s), he or she may do a fine needle aspiration. This can be done quickly in the office. A needle is inserted into the lymph node and tissue or fluid is withdrawn. If cancer cells are present, then the regional lymph nodes are removed. The doctor will need to operate to do that. You may need the operation even if cancer cells are not present. That is because the needle withdraws tissue or fluid only from the area where it was inserted.

The body has regional lymph node networks. When cancer cells leave the main tumor, they can go to one of these regions. Lymph node mapping is done to find the first lymph node in the region that the cancer cells would go to. That lymph node is marked and taken out. If the node does not have cancer, it is unlikely that any other nodes have cancer. This type of biopsy predicts whether the cancer is in other nodes 98 out of 100 times. If the node does have cancer, more lymph nodes will be removed. This is called a lymph node dissection. Your nurse will give you a card explaining the procedure if you need lymph node mapping.

Stages I and II

Stage I or II lesions are best treated by removing them. This means the entire lesion is removed with a margin of normal tissue around it. Even if the surgeon has already taken out the tumor that he or she could see, you will have a second operation. This is to remove a wider margin around the tumor. This is done to make sure no cancer cells remain.

Stage III

The head and neck surgeon will remove the melanoma with a wide excision. Depending on the size and depth of the lesion, a skin graft may be needed to close the wound. Sometimes a local flap can be used to cover the wound. In this case, the skin over an area surrounding the place where the tumor was removed is brought over the wound. Your surgeon will give you more details about exactly what you should expect. You can be in the hospital from two to ten days, depending on the extent of surgery. You may have a drainage tube in place for three to four days. It prevents the fluid from collecting under the suture line. That helps to keep the incision flat. If the melanoma is inside your nose, you will have nasal packing for at least five days. You may need to breathe through your mouth while the packing is in place. You will have a humidifying vent to prevent you from getting very dry. Pain medicine will be ordered. Ask for it whenever you begin to feel any discomfort. You may still be having pain as you get close to your discharge day. If so, you will be given a prescription for pain medicine to take home. If you will have any home care needs, the case manager and your nurse will make arrangements for you.

Your doctor will tell you when to return for a post-operative visit. Call the office to schedule this appointment. This visit will include an exam, review of the final pathology, and a discussion of any further treatment. Your doctor will also ask about any symptoms or problems you have had at home. Be sure to write down any questions you have so you don't forget to ask them when you see your doctor. You will also be given an appointment for your next follow-up visit.

Stage IV

Surgery may or may not be done for stage IV melanoma. Other treatments may be required.

Additional treatment

Your doctor will discuss additional treatment options with you if you have stage IV melanoma. These include:

Your doctor will discuss the options that are most likely for you. You will then have an appointment to see the oncologist(s) who specializes in these treatments.

Stage

Thickness

T1a

1 mm or less in thickness without ulceration

T1b

1 mm or less in thickness with ulceration

T2a

1.01 - 2.0 mm in thickness without ulceration

T2b

1.01 - 2.0 mm in thickness with ulceration

T3a

2.01 - 4.0 mm in thickness without ulceration

T3b

2.01 - 4.0 mm in thickness with ulceration

T4a

More than 4.0 mm in thickness without ulceration

T4b

More than 4.0 mm in thickness with ulceration

N0

No regional lymph nodes involved

N1

Metastasis (spread) to one lymph node

N2

Metastasis to 2 or 3 lymph nodes

N3

Metastasis to 4 or more lymph nodes

M0

No distant metastasis

M1

Distant metastasis

Conclusion

Any cancer diagnosis can cause worry and anxiety. You may find that you are more anxious just before follow-up visits and tests. Support groups can be very helpful after treatment ends. Our Resources for Life After Cancer (RLAC) Program runs support groups for head and neck patients. The American Cancer Society also has support groups that you can join. Online support groups can be found on the Internet. We also have other professional staff that you can see, including psychiatrists, psychologists, and social workers. They specialize in dealing with cancer patients' concerns. Please ask your doctor or nurse for suggestions if you think any of these resources may be helpful.