Cutaneous Melanoma

Cutaneous melanoma is a malignant tumor originating from melanocytes. The incidence of disease has been steadily rising over the past decades.

The main predisposing factors for the appearance of skin melanoma are:

  • the light skin (Fitzpatrick I or II phototype)
  • the history of excessive exposure to the sun or artificial sources of “tanning”
  • multiple common (> 100) or atypical (> 5) melanocytic nevi
  • the family history of melanoma
  • immunosuppression
  • the history of malignant neoplasm (basal cell or squamous cell carcinoma)
  • the existence of a large-sized or gigantic congenital nevi

There are four main types of melanoma:

  • superficial spreading melanoma – SSM (57%)
  • nodular melanoma – NM (20%)
  • lentigo maligna melanoma – LMM – appears on a preexisting lentigo maligna(10%)
  • acral lentiginous melanoma – ALM – appears under the nails or on the soles of the feet or palms of the hands (5%)

Other less common types are the amelanotic, the desmoplastic, the spitzoid, the malignant blue nevus and the mucosal melanoma.

The most common early signs of a melanoma are increasing of the size or changing of the color or shape of preexisting nevi. The most common early symptom is the onset of itching. Later symptoms such as sensitivity, bleeding and ulceration are added. The clinical image of the pigmented lesions may change slowly over months or years or show sudden changes.

All pigmented skin lesions should be examined at regular intervals by both the patient and his physician. Regular monitoring of lesions is particularly important in patients at increased risk of developing melanoma. The location, color, size and morphology of the lesions must be accurately recorded. Photographic records help capture the above elements. Dermatoscopy helps to determine how melanin is distributed in the lesions. Regional lymph nodes should be checked and findings are recorded.

Cutaneous Melanoma Treatment

When a pigmented lesion of the skin is considered suspicious, based on the clinical image or history of the patient, it should be surgically removed following by histological examination, to determine whether or not malignant melanocytes are present. Since the melanoma is confirmed by the biopsy, it is required an additional surgical procedure, namely a wide excision that is performed in the primary site, with surgical margins determined by the Breslow infiltration depth. The reconstruction of the resulting tissue defect is done either by direct closure or by skin graft or by skin flap, especially when the deficit is located in the face.

Simultaneously with the wide excision and when deemed necessary, sentinel lymph node biopsy (SLNB) is performed to locate the first regional lymph node(s).

In patients with a negative SLNB, no additional surgical procedure is required and further treatment is based on melanoma staging.

In patients with positive SLNB, radical lymph node dissection is recommended. Radical lymphadenectomy is also performed in the presence of clinically palpable and traceable lymph node metastases, without prior biopsy of the lymph node. Supplemental therapy (immunotherapy) is given to patients without distant metastases but with an increased risk of spreading the disease (Stage II or III).

After completion of the surgical treatment, all patients should be monitored for any recurrence of the disease or the occurrence of a second melanoma.

Patients should be trained to be able to examine the skin on their own and, if they detect any suspicious lesion, they should resort to their physician.

Ultimately, despite the progress made, the most important element remains early detection of the melanoma and its correct treatment. With the timely diagnosis and treatment, it is even possible to cure the disease.

Before & After