Melanoma

with Gwenn Pavlovitz, M.D., Surgeon, Advanced Healthcare

Posted: March 1, 2005

In the early 1970s, melanoma, which is the deadliest form of skin cancer, affected fewer than 6 of every 100,000 people. Over the past 30 years, that number has nearly tripled, according to the American Cancer Society.

The main reason for the increase, said Dr. Gwenn Pavlovitz, a surgeon at Advanced Healthcare, is environmental. “It’s believed to be related to a loss of ozone in the upper atmosphere which allows more ionizing radiation to reach our skin,” she said.

If caught early, melanoma can often be cured. Steps can also be taken to prevent its development: Avoid sun exposure during peak burning hours and wear sunscreen of SPF 15 or higher on exposed skin.

Gwenn Pavlovitz, M.D., Surgeon, Advanced Healthcare "The best advice for reducing your chances of developing melanoma is to avoid sun exposure during the peak burning hours, from 10 a.m. to 3 p.m., and to wear sunscreen of SPF 15 or higher on exposed skin."

Other risk factors for the disease include the presence of congenital moles (ones you’re born with), the development a dysplastic (atypical or Clark’s) nevus, and a history of prior melanoma. Fair-skinned people, those who have had severe sunburns as children, people with more than 50 moles, and those with a family history of melanoma are at increased risk as well. Moles that develop in childhood, adolescence or later are not necessarily problematic.

What to watch for
Dr. Pavlovitz described a simple system, “ABCD,” to identify a mole (nevus) that should be evaluated by your doctor.
A = Asymmetrical
B = irregular Border
C = changes in Color (darker, two-tone or loss of color)
D = Diameter (larger than 6 millimeters – 1/4 inch)

“The general course of treatment is that a person with a suspicious mole would go to their primary care doctor or dermatologist, who does a shave or excisional biopsy, in which a tiny wedge of skin is removed and sent to a pathologist,” she said. If the biopsy is positive for melanoma, the patient is referred to a surgeon for further treatment. So by the time Dr. Pavlovitz sees a patient, he or she has already been diagnosed.

Determining treatment
Three important facts need to be considered in deciding treatment. One is the type of melanoma, another is its depth (or thickness into the skin) and the third is ulceration of the skin.

Two common types of melanoma are superficial spreading and nodular.

In quantifying the depth of the melanoma, two measures are used. “Breslow” measures in millimeters how thick or deep the melanoma is from top to bottom. “Clark” assigns a level from I (top layer of skin) to V (extending into the fat).

Dr. Pavlovitz also needs to know whether there is ulceration of the skin. “Given these three pieces of information (type, depth, ulceration),” she said, “melanomas are generally categorized as thin, intermediate or thick.”

Treatment plans
The categorization determines the type of treatment. For a thin melanoma, which is less than .76 millimeters, the treatment is wide local excision (WLE), with a 1-centimeter border around the lesion and into the fatty tissue underneath. The wound is then closed with sutures. For intermediate melanoma (0.76 to 4.0 millimeters), the treatment is WLE with a 2-centimeter margin, closure and a sentinel lymph node biopsy (SLNB).

SLNB uses two kinds of dye, a radioactive dye and a blue color dye, which are injected separately to identify the first lymph node that might contain melanoma cells if they had spread.

About two hours before surgery, the radioactive dye is injected into the skin around the melanoma. It then travels through the lymphatic channels and is trapped in the lymph node(s). At that point, the patient undergoes a scan to identify where the radioactive lymph node is located, and the skin overlying it is marked.

In the operating room, blue dye which is injected around the melanoma or scar travels to the lymph node and turns it bright blue. With a device called a Navigator, (a hand-held Geiger counter), the surgeon identifies the radioactive node and makes a small incision in the skin. The bright blue/radioactive lymph node is removed and sent to the pathologist. If cancer is found in that node, additional lymph nodes are removed; if not, the incision is closed.

Thick (greater than 4.0 millimeters) melanomas are generally treated with WLE alone.

“Common places where melanoma metastasizes (spreads) are the brain, lung and liver,” Dr. Pavlovitz said. Scans are also done to detect if or where melanoma has spread. A PET scan looks for metabolically overactive cells, and CAT scans look for abnormally enlarged areas in lymph nodes or organs, which may indicate cancer.

If the cancer has spread to lymph nodes or distant sites, immunotherapy may be the next step. “Interferon Alpha 2b can extend overall survival and disease-free survival rates,” Dr. Pavlovitz said.

Even patients who are cancer-free after surgery need to be examined every six months to a year for life to monitor for recurrence or the development of a second melanoma. Dr. Pavlovitz sees her post-op patients yearly for physical exams and blood tests or scans as appropriate.

Gwenn Pavlovitz, M.D.
262-375-3700
Advanced Healthcare – Cedar Creek Clinic
215 West Washington St.
Grafton, Wis.

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