Malignant Melanoma


What is Malignant Melanoma?

Some General Facts About Melanoma:
  • Melanoma accounts for less than 1% of all skin cancers, but is responsible for the majority of skin cancer deaths.
  • The first sign of a melanoma is often a new, unusually looking growth on the skin or changes in a mole that has present for many years. Noticing an “ugly duckling” on your skin, or a lesion that stands out from the rest, is something to that should be assessed.
  • Darkly pigmented, lesions with irregular borders and color that have been changing or bleeding are the most common characteristics of melanoma. As melanoma progresses, flat dark moles can become elevated, change shape and take on additional colors such as grey, blue or red.
  • Melanoma usually develops in sun exposed areas. However, they can also develop in areas that are never exposed to the sun such as under the nails on the palms or toes, behind the eyes or in the genital region.
  • There is a rare sub type called an amelanotic melanoma that has no pigmentation.
  • Approximately 50% of melanoma develop in an existing mole and 50% develop as a new lesion.

Images from www.canadianskincancerfoundation.com


Early Detection of Melanoma

The following document is a guideline to use for early detection of melanoma


  • Breslow thickness – this is a measurement (in millimeters) of the vertical depth of the tumor from the granular cell (very top) to the base of the lesion
    • This is the most important determination for prognosis of the melanoma
  • Clark Level – This is a measure of the anatomical depth of the melanoma
    • Clark’s Level I – Confined to epidermis – also called “in situ” melanoma
    • Clark’s Level II – Invasion of the papillary dermis (upper)
    • Clark’s Level III – Filling of the papillary dermis (lower)
    • Clark’s Level IV – Extending into the reticular dermis
    • Clark’s Level V – Invasion of the subcutaneous tissue
  • Ulceration – term used to describe whether or not the top layer of the tumor has begun to break up or pull apart
    • Ulceration is another important determining factor for the prognosis.
  • Mitotic Rate– this is determined by counting the number of cells that are showing mitosis or cellular division per high power microscopic field
    • An increased mitotic rate shows evidence of active and dividing cells
    • Higher mitotic rates are associated with declining survival rates
  • Margin Status– this documents whether the entire lesion was removed with the excisional biopsy.
    • Both the peripheral and the deep margin will be commented on
  • Breslow depth consideration
    • Breslow depth < 1mm
      • Wide excision in our office with 1cm radial margin or referral for MOHS surgery in some cases.
    • Breslow depth > 1mm
      • Needs referral to the Melanoma Clinic at the Tom Baker Cancer Centre:
        • Sentinel lymph node biopsy consideration
        • Possible further investigation – PET SCAN, CT SCAN
        • Wide excision at melanoma clinic

Melanoma Stages

There are five stages of melanoma based on the thickness and other features of the tumor. These stages provide an important guide to treatment, indicate the risk of recurrence, and determine if other tests are needed. In Canada, most melanomas are found at an early stage. Other than stage 0 with a melanoma insitu or lentigo maligna, formal staging will be done at the Melanoma clinic.

Stage 0

Melanoma in situ or lentigo maligna is the most frequent stage, when the tumor is limited to the outer layer of the skin and has not spread. Surgery is done to remove the melanoma and the surrounding skin, which completes the treatment. The prognosis is excellent.

Stage 1

These are very early melanomas, less than 2 mm thick. Depending on the severity, a sentinel lymph-node biopsy is sometimes suggested. Treatment also includes a local re-excision.

Stage 2

The tumour is thicker than 2 mm. A sentinel lymph-node biopsy is usually suggested. After surgery there is a moderate risk of recurrence or spread to another part of the body because of the depth of the tumour.

Stage 3

The melanoma has spread to nearby lymph nodes. These will have to be removed.

Stage 4

This is an advanced stage of melanoma. The cancer has spread to another part of the body such as the lungs, liver, brain or abdomen. This situation is rare.


For Melanoma Insitu (MMIS)

  • Requires excision with 5mm radial margin

For Invasive Melanoma with Breslow depth of < 1mm

Requires excision with 1cm margin to deep subcutaneous fat:

  • Elliptical shaped excision to remove malignant cells and margins of healthy tissue
  • Sutures in place for 7 days on face and 14 days on body
  • Repeat biopsy will confirm “clear margins”
  • Will require ongoing follow-up every 6 months

Melanoma Clinic

Referral Process to Tom Baker Melanoma Clinic

  • Initial consultation is done once a week, usually on a Monday. Priority will be based on severity of diagnosis, but is usually within 1-4 weeks.
  • First visit will be consultation only and outline of recommended treatment plan
  • If warranted, additional tests such as Chest X-ray, CT Scan or PET scan may be ordered
  • Will still require wide excision, but if sentinel lymph node biopsy is recommended will often do prior to or on the same day as the re-excision
  • If sentinel lymph node biopsy is not required, they will arrange for the re-excision
  • Ongoing follow-up should be continued in our office every 6 months, alternating with Melanoma clinic
  • The melanoma clinic’s main priority is monitoring and treating the existing skin cancer. Our office tends to be more effective in monitoring for new sites. Please contact our office directly if you have any new or suspicious moles that you are concerned about.

Sentinel Lymph Node Biopsy

  • Radioactive dye is injected into the tumor site
  • Traced to the first draining lymph node (sentinel lymph node)
  • That node is removed and tested for melanoma
  • If not melanoma is present, then unlikely that the cancer has spread
  • If sentinel lymph node is positive, then lymph nodes from the region are removed
  • Sentinel lymph node biopsy does NOT change the prognosis, only used as a diagnostic tool
  • Removal of lymph nodes causes other problems such as lymphedema (swelling of extremities


Treatment for Metastatic Melanoma

In the past, there has not been effective treatment options for metastatic melanoma. However, there has been new and exciting developments in the past 5 years that have increased the survival rate dramatically. The melanoma clinic will determine the most appropriate treatment based on the size, location and specific markers within the melanoma.

Immunotherapy

Immunotherapy (also known as biological therapy) stimulates your immune system to help it fight the cancer. Biological medications are the same as, or similar to, natural immune chemicals your body produces. Some of the immunotherapy medications include interferon alpha, interleukin-2, and Yervoy™.

Chemotherapy

Chemotherapy uses powerful drugs to kill cancer cells. Chemotherapy may be given as a single drug or a regimen, or combination. These drugs may be given as pills or by injection or infusion into a vein. Chemotherapy is usually given in cycles, lasting between two and four weeks.

  • Chemotherapy is not used alone very often. It is not very effective in treating melanoma. It may be effective to treat symptoms or extend life. Some of the chemotherapy drugs include carboplatin, paclitaxel, and dacarbazine.

Radiation Therapy

Radiation therapy uses a high-energy beam to kill cancer cells. Radiation, when recommended, is usually used after surgery to kill any remaining cancer cells. To minimize damage to normal tissue, many beams of radiation may be aimed from different angles to meet at the tumor. This delivers more radiation to the tumour than to healthy cells around it. Postoperative radiation is considered in the following situations:

  • Radiation may be used to achieve local control of the melanoma if surgery is not possible.
  • Radiation may also be used to treat melanoma that recurs.
  • Radiation may be used to help treat pain or other symptoms of melanoma.

Targeted Therapy

Targeted therapy can be used for melanomas with a damaged BRAF gene. Testing the tumour can determine if the BRAF gene is normal or damaged.

  • Zelboraf (vemurafenib) is an oral targeted therapy for people with advanced melanoma with a damaged BRAF gene. This treatment can be given as an initial therapy for people with extensive melanoma.

Learn More

The treatments available for metastatic melanoma are ever changing at a rapid rate improving the response and the long-term prognosis.  Further information can be obtained at:


Schedule a Consultation

To learn more about our treatment for Malignant Melanoma, contact Remington Laser Dermatology Centre at 403-252-7784 to schedule a consultation.

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Our Office

Remington Laser Dermatology Centre

150 - 7220 Fisher Street SE
Calgary, AB T2H 2H8

Dr. Kent Remington ( Mon – Wed )

Tel: 403.252.7784 | Fax: 403 259 5245

Dr. Todd Remington ( Mon – Fri )

Tel: 403.255.1633 | Fax: 403 259 5245

Dr. Sharon Hackett ( Wed – Fri )

Tel: 403.255.1633 | Fax: 403 259 5245

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