The Stitch

Mole or melanoma?

That is the question.
Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous cancer
Or to get skin checks and biopsies by dermatology
And by pathology know the true diagnosis.

If you recognize a loose adaption of Shakespeare’s famous “To Be or Not To Be” soliloquy from Hamlet, good for you. But more important than your literary smarts, is knowing that melanoma –   considered the most aggressive skin cancer – can be effectively treated with surgery if caught early, before it spreads to lymph nodes or other organs. Let’s review some basics.

White or fair-skinned individuals have 20 times the melanoma of African Americans and five times that of Hispanics. Other risk factors are freckles, multiple (50 or more) moles (AKA nevi), family history of melanoma, and tanning bed treatments or lots of sun exposure (i.e., ultra-violet radiation), or 10 or more bad sunburns. Some of these factors we can’t control but reducing exposure and protecting skin from the sun with lotions and sprays are good habits.


Another good habit is routinely checking your skin check and getting skin exams by dermatologists. Though doctors have more education and experience, we can apply the formula of the experts – the ABCDE’s of melanoma – by observing changes in the following:

A: Asymmetry of skin lesions
B: Border irregularity of skin lesions
C: Color variation of skin lesions
D: Diameter – skin lesions greater than six millimeters
E: Evolution of skin lesions (e.g., those that start to ulcerate or bleed)

Dermatologists can also perform biopsies. They numb an area of a suspicious skin lesion that could be melanoma or other skin cancer and cut a piece free to send to pathologists in a lab to examine the cells under a microscope. The best biopsy for melanomas is done with a “skin punch” tool that looks like a miniature, open, tin can attached to a plastic handle. The open part of the tin can is a sharp, circular edge that cuts through the skin with a twisting movement to obtain adequate thickness.

If a biopsy comes back as melanoma, the pathology report provides other useful information to doctors – the most important being thickness, which is the distance from the skin surface to where the tumor extends below the surface. This is called “Breslow’s thickness,” named after the pathologist who showed that thickness of a melanoma is a reliable predictor for survival from the disease.

Thicker melanomas are more likely to have spread (metastasized) to nearby lymph, so surgeons often cut out nodes to also help determine stage of the disease.

Melanomas are found in “hard-to-discover places” like under the fingers and toenails, the eye retina, or the mucosa covering our rectum. Melanomas spread to unusual places like the heart and adrenal glands, in addition to typically distant sites like the brain, bones, liver, and lungs.  When cancer reaches stage IV, surgery doesn’t really help, but recently discovered immunotherapies have provided new hope and promise for stage IV patients.

Don’t end up like Hamlet. Pay attention to your skin.

Learn more about melanoma and treatment options at Baylor Medicine.

-By Brian Lassinger, instructor of surgery in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine

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