What is melanoma?
In the simplest terms, melanoma is a cancer of melanocytes, which are cells whose primary function is to make pigment. These are the same cells that make birthmarks and freckles; however in those cases the cells are not cancerous. Although most melanomas are dark or "pigmented", some melanomas are not. These are called "amelanotic melanomas" and with the exception of not having pigment, behave similarly to pigmented lesions. Melanocytes are also found in the eye and in mucosal surfaces such as the mouth and bowel which is why patients can develop melanoma there as well as on the skin.

Who is at risk for melanoma?
Caucasians have a risk of melanoma that is about ten times that of other racial and ethnic groups, but everyone has some risk. Risk is highest in people who have a high number of moles (more than 20-30 in an adult), who have strong family history of melanoma, and who tend to sunburn easily. If you are concerned about your risk discuss this with your primary care provider or dermatologist. In some cases it may be appropriate to visit the dermatologists at Emory as part of your care, but you should start with your own primary care provider or dermatologist.

What can I do to prevent melanoma?
Practicing sun-safe behavior is the most important preventive. This includes frequent use of sunscreen with SPF of 15 or higher and avoidance of unnecessary exposure to the sun. Above all do not get sunburned. This is especially important for children and adolescents.

What can I do to detect melanoma early?
The most important thing is examination of the skin by yourself or a loved one about once a month. This should include the scalp and the palms and soles. Moles that look asymmetric, have irregular borders, have more than one color, and/or are larger in diameter than a pencil eraser may be suspicious, but it should be emphasized that by no means all of these are melanomas. The most important thing to look for is change in a mole or any skin lesion, even if it does not look dark. Any suspicious lesions should be shown to your primary care provider or dermatologist. It is also helpful to ask your primary care provider to do a skin examination as part of any routine medical care that you receive.

Dermatologists at the Winship Cancer Institute follow patients with large numbers of nevi, or moles, who are at especially high risk of developing melanoma over time using total body digital photography (mole mapping). This enables them to detect the earliest changes in nevi which may be at risk for progressing to melanoma. These lesions can then be selectively removed (biopsied). This modality appears to be effective at sparing patients from unnecessary biopsies, while increasing the likelihood of catching early melanoma.

How is melanoma diagnosed?
A biopsy of a suspicious lesion is needed to establish a diagnosis and to guide further treatment. Most patients referred here have already had a biopsy done.

How do we determine prognosis with melanoma?
As with all cancers, how far advanced (also known as the "stage", see below) a melanoma is when it is diagnosed determines the overall prognosis for a patient. The most important factor with a primary melanoma (the initial melanoma on the skin) is how thick it is, in millimeters, when measured under the microscope by a pathologist. Melanomas can be classified as: "thin" (1 millimeter or thinner), "intermediate" (1-4 millimeters) or "thick" (greater than 4 millimeters). For most patients referred to Emory, the approximate thickness will have already been determined by an outside pathologist. This will be confirmed by one of Emory's dermatopathologists along with the determination of several other characteristics which will aid your doctor in tailoring your treatment to your specific situation.

What is a cancer "stage"?
Stages allow doctors to offer patients some statistical probability of the likelihood of certain events such as disease recurrence after treatment and survival with treatment. The American Joint Commission on Cancer in conjunction with it's international counterpart periodically convenes a group of world experts on each tumor type to determine how best to group cancers into "stages." It is important to note that these are percentages based on a population and so there is variation among individuals.

Many patients who come to Winship have had an opportunity to investigate their disease on the internet. While learning as much as possible about your disease is important, it is also important not to confuse a pathologic descriptor of melanoma, "Clark's level," with "stage." Many patients will have a Clark level IV melanoma. This is not to be confused with stage IV, which has a poor prognosis and is defined by metastatic spread. In contrast, Clark level IV does not have any real bearing on stage at all, and is frequently present in even those lesions that are Stage I with excellent overall prognoses.

What are the specific stages of melanoma?
Although the specific stage of melanoma will be discussed with each patient individually by his/her doctor, melanoma can be separated in simple terms by a few characteristics:

• Most patients who have been diagnosed with melanoma from a biopsy of a mole or birthmark will have stage I or stage II disease.
• This is defined by melanoma that has not spread to the lymph nodes.
• By definition, melanoma that has spread to the lymph nodes is at least stage III disease.
• If melanoma has spread to internal organs or to other distant parts of the body it is classified as stage IV.

This is a simplification of the staging system for melanoma but is intended to provide patients with an overview of the way the doctors treating patients with melanoma break things down.

What are the characteristics of melanoma that help define how it gets treated?
Melanoma is one of the few cancers which can spread or "recur" in any of three ways.

• Melanoma can return in the area where it grows or was originally found, known as a "local" recurrence.
• It can spread to the lymph nodes.
• It can spread via the bloodstream to the internal organs such as the lung or liver, among others, or to distant sites on the skin.

Because melanoma can spread in any of these ways, your surgeon will plan your treatment so as to minimize the chance that any of these can occur. What follows explains each of the three methods of spread and how they can be addressed during the course of your treatment.

How do we minimize the chance of "local" recurrence?
As with all cancers, the way we treat the area where your melanoma has arisen is by removing the entire melanoma or it's scar (some patients will have already had the entire melanoma removed before they are referred to Emory Winship) with an area of normal tissue around it. The amount of normal tissue (or "margin") around the melanoma which needs to be removed is defined by how thick the melanoma actually is. A number of studies have been performed to determine the narrowest margin acceptable to minimize the chance of a melanoma returning in the area where it originally grew. This is called a "wide-local excision" and your doctor will demonstrate exactly what this will mean for you.