Approach to Melanoma at Anew Dermatology, Skin Cancer & Reconstruction
The first step in melanoma is to have all of your skin checked by a doctor who is trained in doing exams like a dermatologist. Although most melanoma cases are found on sun exposed skin, it can also develop on skin where the sun doesn’t shine. If you have been previously diagnosed with melanoma it is good to let your other health care providers know so that they can help keep an eye on things, especially your eye doctor, dentist, hair dresser and OB-GYN, for women.
If your doctor finds a concerning lesion on your skin during your skin check, they will want to perform a biopsy. There are three different ways to perform a biopsy and all of them are good in different situations. It is important to see a doctor who is experienced in treating melanoma because you want the right biopsy technique used for your case. If improper technique is used during a biopsy, you may lose valuable information that is needed to make subsequent treatment decisions.
The biopsy sample is then sent to the lab for a pathology diagnosis. It is important to have a well-trained dermatopathologist read the slides. Studies suggest that a change in diagnosis occurs in as many as 20% of cases when pathology slides are re-read by a melanoma expert.
If the pathologist determines your biopsy contained melanoma, the next thing they determine is how deep it goes. They measure from one of the outer layers of the skin down to the deepest melanoma cell. This depth is called a Breslow Depth. It is initially the most important factor in determining how aggressive the skin cancer could be and what the next steps are to treat it. The pathologist also looks for dividing cells called mitoses and for breakdown of the skin called ulceration. These factors help us understand how the cancer will act.
Remember, to adequately stage a melanoma, an adequate initial sample is needed. If only a small part of the melanoma was biased initially, then there is a risk that the deepest part of the melanoma actually wasn’t seen yet. Studies show that if there is >5% left behind after the initial biopsy, there is a 15-20% risk the pathologist didn’t see the deepest part. This would lead to a change in stage and potentially the best treatment choice.
In cases where there is a significant amount of visible melanoma left after the first biopsy, a second sample is needed before treating the area with surgical safety margins. It is important to do the second sample. The second sample is called a microstaging sample. Microstaging will assure the correct treatment is utilized because you can’t “just go back afterward and re-do the procedure with the correct treatment.”
Once your doctor gets biopsy and microstaging (if needed) information from the pathologist, your melanoma can be clinically staged and treated. Up-to-date staging details can be found at the AJCC (America Joint Commission on Cancer). Depending on the stage of your melanoma, your doctor may recommend excision alone, excision and SLNBx (sentinel lymph node biopsy), more invasive surgery, targeted systematic therapy or immune therapy based on NCCN (Comprehensive Cancer Network National) guidelines.