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Melanoma and Merkel Cell Carcinomas

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Melanoma and Merkel Cell Carcinomas

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Melanoma

Melanoma originates in pigment producing cells of the epidermis called melanocytes. The pigment is called melanin and is responsible for our hair, skin, and eye color. In the US, over 90,000 new cases of invasive melanoma are diagnosed each year, accounting for less than 5% of all skin cancers. However, it causes most of the deaths from skin cancer.

Melanoma may be flat or raised with irregular borders. They may have one color or several colors including tan, brown, black, pink/red, blue, or white. They may be brand new lesions or arise from an existing mole that has changed in size, color, or shape. Melanomas may occur anywhere but are more common on the torso in men and on legs in women. In darker skin types, melanoma can also be found on hands and feet and even under nails.

In addition to the skin, melanomas can also occur in the uvea of the eye and mucosa that lines organs and body cavities.  See related eye cancers for more information.

Melanoma is curable when detected and treated early. However, once it spreads deeper into the skin or to other parts of the body, treatment becomes more difficult and may be deadly. Sentinel lymph node biopsy may be necessary to determine if melanoma has spread to the lymph nodes. Limb perfusion may be an option if melanoma has spread in the arm or leg. Radiation may be required after surgery to decrease risk of melanoma coming back. There are many new treatments for advanced melanomas including targeted therapies, immunotherapy, vaccines, cytokine therapies, and chemotherapy.

The team of experts that treat melanoma may include:

  • A dermatologist for a skin exam and biopsy to diagnose condition. If caught early, melanomas can be treated with surgery alone. Regular follow-up skin exams are necessary due to higher risk of developing another melanoma at a different site on the body and to monitor for recurrence.
  • Head and neck surgeon or surgical oncologist to assess lymph nodes and wider resection if more advanced melanoma.
  • A radiation oncologist for possible radiation therapy for aggressive cancers.
  • Oncologist if disease is extensive or has metastasized (spread elsewhere in body).

Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumor of the skin that originates from the Merkel cell that is involved with touch sensation. In the US, about 3,000 new cases are diagnosed each year. They usually arise in patients who are older or have a weakened immune system.

MCC tumors usually develop on sun exposed areas like face, head, or neck. They are flesh-colored, pink, or bluish-red bumps that tend to grow fast. Unfortunately, they commonly spread to other areas of the body and often comes back after treatment. Treatment requires a multidisciplinary team to remove the MCC, assess lymph nodes, and possible radiation or systemic therapy.

The team of experts that treat merkel cell carcinoma may include:

  • A dermatologist for a skin exam and biopsy to diagnose condition.
  • Head and neck surgeon or surgical oncologist to assess lymph nodes and resection.
  • Radiation oncologist for possible radiation therapy for aggressive cancers.
  • Oncologist if the disease is extensive or has metastasized (spread elsewhere in body).

Our team at Sylvester is involved in clinical trials when conventional or typical therapies are not effective.

Why Choose Sylvester Comprehensive Cancer Center?

Sylvester is an NCI-designated cancer center. The National Cancer Institute has reaffirmed us as South Florida’s only NCI-designated cancer center. We have been recognized for our scientific leadership, our commitment to training the next generation of cancer researchers and providers, as well as our engagement with the communities that we serve. For patients, this designation translates into greater access to leading-edge treatment options, including clinical trials that prioritize your specific cancer.

World-class melanoma surveillance and detection clinic. Earlier detection options and more accurate diagnoses helps us identify melanoma when it is most treatable.

Immunotherapy clinical trials. You’ll have access to the most advanced treatment options in South Florida.

One of the few institutions to offer reflectance confocal microscopy (RCM). RCM is able to differentiate between melanoma and other less serious or benign skin lesions to provide an accurate diagnosis. It gives high magnification images of the skin, enabling more accurate diagnosis of lesions that are not entirely defined on clinical examination and dermoscopy.

Advanced expertise in immunohistochemistry and tumor markers. Our expert pathologists make more accurate diagnoses. When pathologists can make the call on the aggressiveness of the tumor, treatment can be more appropriately recommended.

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Treatments

  • Surgery

    The most common treatment for melanomas (90 percent of cases) is surgery. We will determine the most appropriate surgical procedure and provide expert skin replacement for any skin damaged during cancer removal.

    • Wide Local Excision: The melanoma and some of the normal tissue around it are cut out in surgery. The size of the excision is based on the tumor thickness and how deep the melanoma invades into the skin layers. For some facial melanomas, a staged contoured excision may be recommended to plan for final plastic surgery reconstruction.

    • Lymph Node Sampling: Enlarged lymph nodes that can be felt by hand will be removed and biopsied to check for cancerous cells.

    • Sentinel Lymph Node Biopsy: The sentinel lymph node is the first lymph node to which cancer cells are likely to spread. It is identified, removed, and examined to determine cancer presence, the extent of the disease and a recommended treatment plan.

    • Lymphadenectomy: If cancer cells are found, the doctor will remove more lymph nodes and check tissue samples for signs of cancer. A regional lymphadenectomy involves just some of the lymph nodes being removed. A radical lymphadenectomy will remove most or all of the lymph nodes in the tumor area.

  • Chemotherapy

    Drugs administered intravenously, by oral pill, or by intra-arterial chemotherapy

    • Regional Chemotherapy ILI: If you have melanoma in an extremity that is not easy for surgery, or if you are not a candidate for surgery, we may offer isolated limb infusion (ILI). This delivers high local doses of chemotherapy for melanomas in the arms and legs and avoids damage to other tissue. You are hospitalized until the limb inflammation subsides.

    • Systemic Chemotherapy: Traditional chemotherapy delivered intravenously (by vein) or by mouth (pill form) that affects the entire body, in order to destroy cancer cells. Less frequently used for melanoma because of newer, more improved targeted therapies.

  • Immunotherapies

    Also called biologic therapies, these drugs boost the power of the body’s immune system to fight cancer. Biologic therapies under study for melanoma include:

    • Intra-tumor immunotherapy injections: A targeted drug or a combination of drugs or oncolytic virus are injected into tumors or lymph nodes that cannot be surgically removed due to too much tumor, its location, or because you cannot tolerate a surgical procedure.

    • Checkpoint Inhibitor Monoclonal Antibodies and Checkpoint Blockade Drugs: These treatments take advantage of immune T cells that are present in many tumors, but that have been shut off by cancer cells.

    • Interferon: This drug affects the division of cancer cells and can slow tumor growth.

    • Interleukin-2 or IL-2: This medicine enhances immune cells, especially lymphocytes, to kill cancer cells.

  • Targeted Therapy

    Targeted therapies are treatments using drugs or other substances to attack cancer cells, usually causing less harm to normal cells than chemotherapy or radiation therapy.

    • Signal Transduction Inhibitor Therapy: These drugs block signals that are passed from one molecule to another inside a cell. Different types (e.g., BRAF, MEK inhibitor therapies) are used to treat people with advanced melanoma or who have tumors that cannot be removed by surgery.

    • Oncolytic Virus Therapy: In this therapy, a virus is used to infect and break down cancer cells, but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells.

    • Angiogenesis Inhibitors: Drugs that block the growth of new blood vessels in tumors to starve them.

  • Radiation Therapy

    Radiation therapy is selectively used for some melanomas, such as tumors too large or located in difficult to treat areas. This may be the best option for patients with other medical complications. High-energy X-rays deliver a hefty daily dose of radiation over a period of two and a half weeks.

    • MRIdian System™ (also called ViewRay™):  We are one of few centers in the world equipped with this radiation delivery system that can acquire magnetic resonance imaging (MRI) images during treatment delivery. This tumor tracking tool better targets the tumor and spares more surrounding healthy tissue. It’s not used for superficial skin cancers, but is often indicated for tumors inside the brain, chest and abdomen or pelvis.

    • Stereotactic Body Radiation Therapy (SBRT): This radiation therapy comes from many different positions around the tumor. A high dose of radiation is directed at the cancer, but special care is taken to limit the exposure to healthy surrounding tissue.

  • Standard Treatments for Merkel Cell Skin Cancer

    For Merkel cell carcinoma, surgical excision, sometimes sentinel lymph node biopsy for certain size tumors, and clinical trials may be suggested.

    Radiation therapy is generally used to deliver a more conventional daily dose with each treatment over a period of five weeks as either the only treatment or as an adjunct to surgery to prevent local or regional relapse in the draining lymph node chain.

Tests


In addition to a complete medical history and physical examination, procedures for diagnosing melanoma include:

  • Skin Examination

    We will look and feel for any bumps or spots that look abnormal in color, size, shape, or texture. Any suspicious areas can have a tissue sample removed to be tested for cancer.

  • Skin Biopsy

    During this biopsy, a pathologist removes all or part of the abnormal-looking growth is cut from the skin to check for signs of cancer. Types of skin biopsies include.

    • Punch Biopsy: A circle of tissue is removed from the abnormal-looking growth.

    • Incisional Biopsy: Doctors use a scalpel to remove part of the growth.

    • Excisional Biopsy: The entire growth is removed, using a scalpel.

  • Dermoscopy

    Dermoscopy is an examination of the skin using a handheld magnifying device (skin surface microscopy). We evaluate pigmented (colored) lesions and identify any cancerous growths that are not just moles or non-cancerous marks.

  • Reflectance Confocal Microscopy (RCM)

    This additional high magnification testing helps identify lesions not totally defined by dermoscopy.

  • Lymph Node Mapping (Lymphoscintigraphy) and Sentinel Lymph Node Biopsy

    This technique is performed only when a primary melanoma is of a certain depth (thickness) or looks like a more aggressive tumor. The sentinel lymph node is the first lymph node to which cancer cells are likely to spread. It is identified, removed, and examined to determine cancer presence, extent of the disease and a recommended treatment plan.

  • Genetic Tests

    Roughly half of all melanomas have mutations in the BRAF gene that help the cells grow. Certain medicines help treat melanomas that have this change, but are not likely to successfully treat melanomas without this genetic change. Our pathologists are cellular experts who will test the cells and determine the best treatment approach.

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