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Melanoma in Richmond, VA

Skin cancer is on the rise, and melanoma is a life-threatening type of skin cancer that affects men and women of all ages. If you have an unusual growth on your skin or if you have been diagnosed with melanoma, our board-certified plastic surgeons are uniquely qualified to provide treatment. Richmond Plastic Surgeons offers melanoma treatment for the residents of Richmond, Midlothian and surrounding areas of Virginia. 

What is Melanoma?

Melanoma is the most dangerous common type of skin cancer.  The incidence of melanoma in most light-skinned populations has increased steadily through much of the twentieth century. The mortality has increased also, but not as much. Fortunately, melanomas are usually easy to recognize by skin examination. Currently, most patients present with early-stage disease, which may be cured with surgery alone. 

There are various ways to describe melanoma. “Histologic subtype” refers to the appearance of the melanoma under the microscope. The most common histologic subtype is Superficial Spreading Melanoma (SSM).  Others are Nodular, Acral Lentigenous, and Lentigo Maligna.  Melanomas are measured according to depth in millimeters from the surface of the skin (Breslow depth).  The level in the skin to which it has grown (Clark’s level) can also measure tumor invasion.  Other descriptive information includes ulceration, and mitotic index. This information is used by your doctor to predict prognosis and make treatment recommendations.

What Causes Melanoma?

The cause of melanoma is unclear. It is generally agreed that sunlight and ultraviolet light exposure can increase the risk of melanoma. Ultraviolet light may damage the DNA in cells. This can cause melanocyes, or pigment-producing cells, begin to grow and spread abnormally. Unfortunately, even a few severe sunburns early in life, may increase the risk of melanoma.  There is even some data that suggests that tanning beds may increase the risk of melanoma. Other risk factors for melanoma include:

  • Atypical or dysplastic nevi (moles)
  • Large congenital nevi
  • Fair skin, red or blonde hair, blue or green eyes
  • Difficulty tanning, with a tendency to get sunburn
  • Tendency to freckle
  • Personal or family history of melanoma
  • Immunosuppression
  • Xeroderma Pigmentosa (a rare skin disease)

About Diagnosing Melanoma

Most melanomas are diagnosed after a physical examination by a physician. The  “ABCDs of melanoma” can provide a quick way to remember the characteristics of a suspicious mole.  They are:

  • Asymmetry- Draw an imaginary line through the mole.  If the two halves are not similar, the mole is more suspicious.
  • Border- If the border of the mole is irregular, the mole is more suspicious
  • Color- If the several colors are present, the mole is more suspicious.
  • Diameter- If the diameter of the mole is more than 5 millimeters, the mole is more suspicious.

While these characteristics are helpful, it is most important to remember that any changing, growing, bleeding, itching or otherwise symptomatic lesion is suspicious and should be shown to your doctor as soon as possible. Your doctor may biopsy the lesion or recommend referral to a qualified plastic surgeon or dermatologist for biopsy and treatment.

A pathologist makes the diagnosis of melanoma after biopsy of suspicious lesions and interpretation of the tissue. This may take several days or weeks, depending on the lab which your insurance company requires we send the specimen. When the pathologist makes the diagnosis of melanoma, the thickness of the lesion is given. Other information may also be given such as the level (corresponds to the skin layers that are affected by the cancer). This information is used by your doctor to make treatment recommendations.

Why is it Important to Treat Melanoma Promptly?

If untreated, melanoma will spread (usually through the lymphatic system) to the vital organs (especially the lungs and liver) and may be fatal. Fortunately, the initial tumors usually occur on the skin and thus are recognizable from an early stage.  It appropriate treatment is provided early, very high rates of cure are possible. Tumor thickness is most important in predicting prognosis (chance of cure) and determining the treatment that is recommended. 

The accurate diagnosis and effective treatment of melanoma is important because of the potentially fatal nature of this disease. All changing, pigmented lesions should be considered melanoma until proven otherwise. Following diagnosis, treatment may involve dermatologists, pathologists, interventional radiologists, surgeons and oncologists. A board-certified plastic surgeon experienced in the treatment of melanoma is an essential member of the team and can provide complete surgical care for local and regional disease as well as reconstruction after removal of cancer. 

How is Melanoma Treated?

Proper treatment of melanoma may require attention to local, regional and systemic disease and reconstructive surgery to restore function and appearance.

  • Local Treatment of Melanoma – Local treatment of melanoma is always required after the disease is diagnosed. Local treatment refers to the complete removal of all melanoma cells present at the location where the melanoma was first found.  To ensure complete local treatment of the disease, the original lesion and a margin of normal-appearing tissue around it must be removed. Removal of this normal-appearing tissue surrounding the melanoma is intended to remove any melanoma cells not visible to the eye, and thus prevent local recurrence. In general, thicker lesions require wider margins be removed.  In some cases 3 or more centimeters of tissue must be removed.  In these cases a very large surgical wound may be left, and a plastic surgeon may be needed to provide the best reconstruction.
  • Regional Treatment of Melanoma – Regional treatment is only necessary in some cases of melanoma.  Regional treatment of melanoma refers to the treatment of the lymph nodes to which some melanoma cells may have spread.  An explanation of the lymphatic system is provided below.  Regional treatment may involve a Sentinel Node Biopsy (which is a diagnostic test intended to discover whether or not the melanoma as spread) and/or a Therapeutic Node Dissection (which is a treatment to remove lymph notes to which melanoma cells have spread).
  • Systemic Treatment of Melanoma – Systemic treatment is only necessary in some cases of melanoma.  Systemic treatment refers to the treatment of melanoma after it has spread beyond the initial tumor and lymph node drainage basin. In some cases, treatment is begun before blood tests or X-ray tests detect spread.  Common sites of spread are the liver or lungs.  An oncologist usually oversees this aspect of care.  Systemic treatment may involve vaccines, chemotherapy, interferon or other measures.
  • Reconstruction – The most important consideration in the treatment of melanoma is removal of the cancer.  This may require removal of large amounts of skin, creating a very large surgical wound.    In cases where the melanoma is found on the face or hand, for example, the removal may leave a disfiguring wound, or interfere with function. Wound closure may require skin grafting or the use of more sophisticated techniques to avoid disfigurement or restore function.  Plastic surgeons are skilled in a wide range of techniques to provide the best functional and cosmetic results and can often provide the most complete surgical treatment for melanoma.

At Richmond Plastic Surgeons our process for diagnosing and treating melanoma is as follows:

  1. Initial consultation and review of pathology or biopsy reports.
  2. Preoperative chest x-ray and blood tests
  3. Lymphoscintigraphy (done by a radiologist the morning of surgery)
  4. Surgery- Sentinel node biopsy, local treatment of the melanoma, and reconstruction of the surgical wound. This may be outpatient surgery, or involve an overnight hospital stay. 
  5. Review of the diagnostic test results- preoperative chest x-ray and blood tests, sentinel node biopsy results. This is generally done about a week after surgery.
  6. Therapeutic lymph node dissection (if necessary).
  7. Referral to an oncologist (if necessary).
  8. Lifelong skin examination by a dermatologist, including a schedule of periodic blood tests and x-rays.

Important Definitions and Concepts in Melanoma Treatment

  • Margin.  Melanomas, and other cancers, often extend beyond what is visible to the eye.  If your surgeon was to remove only what was visible on the surface, then some cancer cells may be left behind and the cancer would reappear at the original site (local recurrence).  For this reason some normal appearing tissue surrounding the melanoma must be removed. 
  • Lymphatic System. The Lymphatic System parallels the vascular system (arteries and veins) and contains lymph.  Lymph is a thin fluid with few blood cells.   The system includes lymphatic vessels and lymph nodes (these are usually in groups and are sometimes referred to as drainage basins).  It is now well understood that lymph travels in an orderly progression through lymphatic vessels, to sentinel lymph nodes (see below) to non-sentinel regional lymph nodes and beyond.  Lymph generally flows from the periphery of the body towards the heart, where it is returned to the vascular system.  The lymphatic system has several purposes including fighting infections and cancers.  The “swollen glands” which sometimes appear in your neck when you are sick are actually enlarged lymph nodes which are fighting infection and preventing bacteria from spreading around the body.
  • Sentinel Node.  The sentinel node is the first lymph node that receives lymph in a particular drainage basin.  It is important because it is representative of the rest of the nodes in the drainage basin.  Thus, if there are cancer cells in the sentinel node (the node is Positive), then there are probably cancer cells in the rest of the nodes of the drainage basin and these nodes should be removed (called a Therapeutic Lymph Node Dissection).  Conversely, if there are no cancer cells in the sentinel node (the node is Negative), then there are probably no cancer cells in the rest of the drainage basin and a therapeutic node dissection is not necessary.
  • Lymphoscintigraphy.   This is a diagnostic test used to find the sentinel node.  It is performed prior to surgery and is done in the radiology suite.  A short-acting (and very safe) radioactive material is injected by the radiologist around the melanoma biopsy site.  This travels through the lymph vessels to the lymph node drainage basin.  It concentrates in the sentinel node.  The patient is placed under a sensor.  An image is generated which identifies the lymph node drainage basin to which the melanoma drains, and the sentinel node.  The radiologist will identify and mark the approximate position of the sentinel node on the skin with gamma counter.  The procedure may take several hours to complete.
  • Blue Dye Injection.  A blue dye called Lymphazurin is injected around the melanoma at the beginning of surgery.  This will travel to the sentinel node and stain it blue.  Thus the surgeon will have a visual clue to assist in identification of the sentinel node.  This blue dye may cause the patient’s urine to turn blue or green for a few days.  This effect is harmless.
  • Sentinel Node Biopsy.  This is a diagnostic, minimally invasive, surgical procedure intended to determine whether or not melanoma cells have spread to the lymph nodes. This information is used by physicians to determine prognosis, and make recommendations for further treatment. The sentinel node is identified by the blue color imparted by the blue dye as well as the readings of a hand-held gamma probe used during the surgical procedure.  After removal the lymph node is sent to a pathologist where it is tested to determine whether or not melanoma cells are present.  This testing may take a week to complete.
  • Therapeutic Node Dissection.  This is a therapeutic surgical procedure in which all the lymph nodes in a drainage basin are removed.  This is done in an attempt to remove all the melanoma cells in the body and cure the disease.  Therapeutic node dissection is done in addition to local treatment of the melanoma.  Because this procedure may result in unintended consequences such as persistent swelling of a limb (lymphedema), lymph node dissections are usually only recommended when a sentinel node biopsy confirms the presence of melanoma.  Patients with firm, enlarged lymph nodes usually undergo biopsy of these nodes, and then therapeutic node dissection if melanoma is found.

FAQs About Melanoma

Q: What are my chances of survival now that I have been diagnoses with melanoma?

A: The chances of survival depend on the stage of the disease.  Overall survival is about 88% over 5 years, and the median survival for patients with early stage disease is 20 years

Q: How common is melanoma?

A: 44,000 new cases were diagnosed in 1999.  About 1 in 72 people born in 2000 will someday develop a melanoma

Q: How common is a second melanoma if I have been cured?

A: The overall recurrence rate is about 3-6%

Q: What are the risk factors for developing a melanoma?

A: The answer is given in the text above.

Q: How do I know I am cured?

A: The answer to this question is very difficult, since the disease can be very unpredictable and patients may develop recurrences decades after the first lesion treated.  Because of this unpredictability, lifelong surveillance is necessary.

Q: What is a sentinel node biopsy?   When is it necessary?

A:  The answer is given in the text above.

Q: If all my test are negative, when can I assume I am cured? 

A: The answer to this question is very difficult, since the disease can be very unpredictable and patients may develop recurrences decades after the first lesion treated.  Because of this unpredictability, lifelong surveillance is necessary.

Q: Do I need to see a medical oncologist after I am given the diagnosis of melanoma?

A: The answer is different for different patients.  We often encourage patients to see medical oncologists after treating them for melanoma.  

Q: Do I need a CT scan? 

A: It has been shown that sophisticated tests such as CT scans and radionucleotide scans are not helpful for early stage melanoma in asymptomatic patients. Such tests may cause unnecessary radiation exposure, additional expense and unnecessary inconvenience or anxiety.   False positive findings from these tests may lead to unnecessary, painful and expensive confirmatory tests.

Q: Why did my doctor send me to a Plastic Surgeon?

A:  The most important consideration in the treatment of melanoma is removal of the cancer.  This may require removal of large amounts of skin, creating a very large surgical wound.    In cases where the melanoma is found on the face or hand, for example, the removal may leave a disfiguring wound, or interfere with function. Wound closure may require skin grafting or the use of more sophisticated techniques to avoid disfigurement or restore function.  Plastic surgeons are skilled in a wide range of techniques to provide the best functional and cosmetic results and can often provide the most complete surgical treatment for melanoma.

Will I Have Scars After Getting Melanoma Treatment?

You will have a scar after your melanoma treatment.

When Will I See the Results?

You will see results immediately after the surgery to remove the melanoma.

What Are Possible Complications of Melanoma Treatment?

Bleeding, infection, scarring, and the possible complications.  Patients need long-term surveillance from their dermatologist to detect recurrences or new primary melanomas.

How Long Will the Results of Melanoma Treatment Last?

The melanoma is permanently removed from your skin, but once you are diagnosed with any type of skin cancer, your risk for future skin cancers increases. Your surgeon will suggest steps to take in changing your lifestyle to minimize the chances of developing skin cancer in the future.

How Much Does Melanoma Treatment Cost in Richmond?

Your melanoma treatment is usually covered by insurance. After your consultation, we will review your out-of-pocket costs. For your convenience, Richmond Plastic Surgeons accepts several forms of payment, including CareCredit® financing.

If you notice an unusual growth on your skin, contact us for a skin cancer and melanoma screening. Our board-certified plastic surgeons will diagnose and treat the condition.

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