Diagnosing and Treating Melanoma

Diagnosis of melanoma is most often done by a simple skin exam. The exam should be thorough, as melanoma can occur in any part of the skin. Some tools can aid in the diagnosis, such as magnification or special types of light, and photographs are often helpful for follow up exams of the skin over time. The most important part of the evaluation, though, is the experience of the examiner and the dedication to doing a thorough job. Most often, this is done by a dermatologist or primary care physician, and when in doubt a biopsy with evaluation by an experienced pathologist is recommended.

Once a melanoma has been found, a great deal of information can be obtained by a full assessment of the skin biopsy. At the Melanoma Program at Providence Saint John’s, our pathologists are very practiced in evaluating melanomas and provide all of the relevant information to help guide treatment decisions in a standard synoptic report. If the initial biopsy was done elsewhere, they are able to provide an expert review rapidly upon receipt of the biopsy slides.

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 melanoma is suspected, 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, a doctor may biopsy the mark, taking a tissue sample for a pathologist to examine. Suspicious areas should not simply be shaved off or 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.

Local excision/excisional biopsy

The entire suspicious area is removed with a scalpel under local anesthetic. This is usually done as an outpatient procedure.

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 and checked for any abnormal results. Abnormal results may include:

Sentinel Node biopsy

Some melanomas carry a risk of spreading or metastasis. This is what makes melanoma potentially dangerous. We can make an estimate of this risk for each patient based on their characteristics, and the characteristics of their melanoma seen on biopsy. If melanoma is going to spread, the most likely first place for it to go is to a lymph node in the area of the primary tumor. In the past, this spread could only be determined by removing all of the lymph nodes in the area. Today, sentinel lymph node biopsy, a technique originally developed at John Wayne Cancer Institute, is used instead to give the same or better information, in a minimally invasive way.

The technique involves injecting a blue dye and radioactive substance into the lymphatic system near the tumor. These tracers pass through the same pathways (lymphatic channels) that tumor cells might use and travels to the first, at-risk lymph node. If that first lymph node is clear, it means the other lymph nodes in the same area should be clear as well, and the likelihood of the melanoma recurring in lymph nodes or elsewhere in the body is markedly less.

If the the lymph node shows spread of melanoma, it suggests higher risks that may require more aggressive treatment.  The sentinel node technique has become the international medical standard for melanoma surgery, and is being adapted to many other cancers.

If you do receive a diagnosis of melanoma, your initial treatment can make all the difference. We encourage you to be sure you’re treated at a center with enough experience and expertise. The Melanoma Program at Providence Saint John’s is one of the most experienced centers in the world, and our physicians are comfortable selecting the best treatment option, even for unusual cases.

Your doctor may request tests to help determine if melanoma has metastasized, which means to have spread to other parts of the body. Many patients with melanoma have sufficiently low risk to require only minimal testing beyond a medical history and physical examination. Others should have more testing including more thorough radiology tests. Our physicians will help you balance the value of information that can be gained from tests with the potential risks or costs of testing. This balance will be different for different patients.

Blood tests

Your blood may be tested to help determine if the cancer has spread. For melanoma, this may include a complete blood count and chemistry panel, which is a test that evaluates blood electrolytes like potassium and calcium and enzymes or specialized proteins that can be abnormal if the melanoma has metastasized. Your level of lactate dehydrogenase (LDH; an enzyme that can help signal tissue damage) may also be checked since it is a tumor marker. It can be produced by the tumor or even by the body in response to a present cancer.

X-ray

An x-ray (usually of the chest) can show us the inside of your body, using a small amount of radiation.

Ultrasound

An ultrasound uses sound waves to create pictures of the internal organs, including collections of lymph nodes and soft tissue.

Computed tomography (CT or CAT) scan

A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a special dye is injected into a patient's vein to provide better detail. This test provides much more detailed information than a simple x-ray, but also uses more radiation.

Magnetic resonance imaging (MRI)

An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient's vein to create a clearer picture. This is often the best way of seeing the brain.

Positron emission tomography (PET) scan

A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into the patient's body. This substance is absorbed mainly by the organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance making it visible on this type of scan. This scan might be used instead of or in addition to a standard CT scan.

Treatment for melanoma

Treatment for melanoma is not “one size fits all.” The type and extent of treatment that is appropriate for each patient must be tailored to their needs and should involve careful consideration by your physician in consultation with you. Many patients can be treated extremely simply with excellent results; others require more extensive treatment. We offer many treatments for every type and stage 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.

The Melanoma Program at Providence Saint John’s has one of the most active melanoma treatment programs in the Western United States. Our surgeons have extraordinary expertise and experience that can help increase your chances for successful treatment.

Treatments may include:

  • Lymphatic mapping and sentinel lymph node biopsy
  • Resection (removal) of primary melanoma or melanoma metastases by surgery
  • Regional treatment involving infusion of chemotherapy to specific, affected areas of the body while avoiding the rest of the body.
  • Radiation therapy to help reduce the risk of melanoma coming back after surgery or relieve symptoms
  • Treatments for rare forms of melanoma, such as those that begin in the eye (known as uveal melanoma) or mucosa (vaginal, rectal or sino-nasal)

Targeted therapies may include:

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