melanoma

melanoma, a spreading and frequently recurring cancer of specialized skin cells (melanocytes) that produce the protective skin-darkening pigment melanin. An estimated 132,000 new melanoma cases are diagnosed worldwide each year. In the United States melanoma represents nearly 5 percent of all cases of cancer. Melanoma is a deadly disease; it is responsible for nearly three-quarters of all skin cancer deaths and is increasing in frequency. Unlike other skin growths, melanoma is always malignant.

Causes and symptoms

People vary in their susceptibility to melanoma. White people are 20 times more likely to develop melanoma than are Black people. People who have fair skin or who freckle easily are particularly susceptible. Individuals with a large number of moles or with several very large moles are also at increased risk. Similar to all cancers, melanoma is caused by changes in DNA that alter a cell’s ability to control its growth. The most common cause of DNA damage in melanocytes is ultraviolet radiation from sunlight. In some cases DNA mutations that cause melanoma or that increase the risk of the cancer can be inherited.

About 50 percent of melanomas are associated with spontaneous mutations in a gene known as BRAF, which produces a protein called B-raf. B-raf is a kinase—a type of enzyme specializing in the transmission of intracellular signals from cell surface receptors to proteins that communicate with the cell nucleus. B-raf plays a central role in the carefully regulated transmission of cellular signals that result in the stimulation of cell differentiation and in the suppression of programmed cell death (apoptosis). However, activating mutations in the BRAF gene result in the production of a constantly active, unregulated B-raf kinase. This mutant enzyme is programmed to transmit signals continuously, regardless of whether or not it is instructed to do so by cell surface receptors. This aberrant activity results in uncontrolled cell proliferation, thereby initiating the generation of cancer cells that give rise to melanoma. Mutations in BRAF appear to be acquired as a result of overexposure to ultraviolet radiation.

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A number of mutations in a gene called MC1R occur in association with mutations in BRAF. Certain variations in MC1R also are associated with red hair, freckles, and fair skin, traits that are linked to a marked increase in melanoma risk. Tumours from melanoma patients who carry even only a single allele of one of those variants (which can result in hair colour varying from brown to blond) exhibit 42 percent more sun exposure-related mutations than tumours from patients who do not carry the variants. MC1R mutations also are sometimes involved in melanomas that develop independent of exposure to ultraviolet light. Other genetic variants linked to melanoma include mutations in a tumour suppressor gene known as CDKN2A, which produces a kinase involved in regulating the cell cycle and cell division. CDKN2A variants have been associated with cutaneous malignant melanoma, an inherited form of the disease.

The earliest symptoms of melanoma are often visual. Large or abnormally coloured moles on the surface of the skin are early indicators. Melanoma can be detected in its early stages by regular self-assessment of moles, using the ABCD system. ABCD stands for asymmetry, border, colour, and diameter. Moles that are asymmetrical, have irregular borders (edges) or colour, or are greater than 5–6 mm (about 1/4 inch) in diameter are suspect. Any mole that changes in size, shape, or colour should be examined by a physician immediately.

Diagnosis and treatment

Following the identification of a potential melanoma, diagnosis is made by skin biopsy. A sample of the skin is examined under a microscope for signs of cancer growth and for measurement of the thickness of the growth. An approach known as reflectance confocal microscopy (RCM), sometimes described as “optical biopsy,” may be used to diagnose melanoma. RCM allows doctors to examine suspicious moles and skin abnormalities without cutting into the skin. Another diagnostic approach that does not entail cutting into the skin is adhesive patch testing, in which a patch that sticks to the skin is used to collect the top layer of skin cells when removed.

If melanoma is diagnosed, several treatment options are available. The most widely used treatments include surgery, chemotherapy, and radiation therapy. In addition, some patients receive biological therapy, in which agents designed to mimic substances naturally occurring in the body are used to fight cancer or to counter side effects of certain anticancer drugs.

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The treatment approach to melanoma is based on the severity or stage of the disease. Stage 0 through stage II melanomas are confined to the skin, and most of these can be cured by excision of the tumour, especially if caught early. Some patients with stage II melanoma may undergo selective sentinel lymphadenectomy, which entails the removal of lymph nodes most likely to be the first affected by metastasizing (spreading) cancer cells. Stage II patients also may be treated with biological agents, such as interferon or bevacizumab (Avastin; a monoclonal antibody), following surgery. Stage III melanoma has spread to nearby lymph nodes, and surgical removal of the cancerous nodes is required. This may be followed by biological therapy or chemotherapy. Stage IV melanoma has spread beyond the regional lymph nodes to other tissues in the body and is extremely serious. No cure for stage IV melanoma is available, but disease progression may be delayed by surgery and by the administration of chemotherapy, biological therapy, or radiation therapy. Unfortunately, the survival rate for stage IV melanoma is extremely low.

Prevention

The risk of melanoma is greatly reduced by avoiding exposure to ultraviolet light. Exposure can be reduced by staying out of direct sunlight during periods of peak intensity (11:00 am to 3:00 pm), protecting the skin with clothing, or using a sunscreen with an SPF rating of 15 or higher. Children should be particularly careful to avoid sunburns, as an increased risk of developing melanoma has been linked to severe sunburns during childhood. Ultraviolet-sensitive devices that warn of potential overexposure to sunlight in order to prevent sunburn are being developed. These devices, which could be worn around the wrist, indicate the increasing risk of sunburn by using simple colour changes that are induced by ultraviolet rays.