Malignant melanoma is the most lethal form of skin cancer that can develop in several forms from melanocytes in the epidermis and dermis. Risk factors include fair skin, red/blond hair, family history, and sun exposure. Symptoms vary depending on the type but may appear as irregular colored lesions. Diagnosis involves biopsy and staging tests. Treatment options depend on invasion depth and may include surgery, chemotherapy, and immunotherapy. Nursing focuses on managing pain, reducing anxiety, educating on symptoms of metastasis, and supporting the patient.

1. CANCER OF THE SKIN
(MALIGNANT MELANOMA)

2. A malignant melanoma is a malignant
neoplasm in which atypical melanocytes
(pigment cells) are present in both the
epidermis and the dermis (and sometimes
the subcutaneous cells).
It is the most lethal of all skin cancers. It can
occur in one of several forms: superficial
spreading melanoma, lentigomaligna
melanoma, nodular melanoma, and acral-
lentiginous melanoma.

3. Most melanomas are derived from
cutaneous epidermal melanocytes; some
appear in preexisting nevi (moles) in the
skin or develop in the uveal tract of the
eye. Melanomas occasionally appear
simultaneously with cancer of other
organs.

4. Malignant melanoma can spread through
both the bloodstream and lymphatic
system and can metastasize to the bones,
liver, lungs, spleen, CNS, and lymph
nodes.

5. RISK FACTORSThe cause of malignant melanoma is unknown, but
ultraviolet rays are strongly suspected. Risk
factors include the following:
– Fair complexion, blue eyes, red or blond hair, and
freckles
– Celtic or Scandinavian origin
– Tendency to burn and not tan; significant history of
severe sunburn
– Older age; residence in the southwestern United
States
– Family or personal history of melanoma, the absence
of a gene on chromosome 9P, presence of giant
congenital nevi
– Dysplastic nevus syndrome

6. CLINICAL MANIFESTATIONS
A. Superficial Spreading Melanoma
Most common form; usually affects
middle-aged people, occurs most
frequently on trunk and lower
extremities
–Circular lesions with irregular outer
portions
–Margins of lesion flat or elevated and
palpable
–May appear in combination of colors,
with hues of tan, brown, and black
mixed with gray, bluish black, or white;

7. B. Lentigo-Maligna Melanoma
–Slowly evolving pigmented lesion
–Occurs on exposed skin areas; hand,
head, and neck in elderly people
–First appears as tan, flat lesion, which in
time undergoes changes in size and
color

8. C. Nodular Melanoma
–Spherical, blueberry-like nodule with
relatively smooth surface and uniform
blue-black color
–May be dome-shaped with a smooth
surface or have other shadings of red,
gray, or purple
–May appear as irregularly shaped
plaques
–May be described as a blood blister that
fails to resolve
–Invades directly into adjacent dermis
(vertical growth); poor prognosis

9. D. Acral-Lentiginous Melanoma
–Occurs in areas not excessively
exposed to sunlight and where hair
follicles are absent
–Found on the palms of the hands, soles,
in nail beds, and mucous membranes in
dark-skinned people
–Appears as an irregular pigmented
macule that develops nodules
–Becomes invasive early

10. ASSESSMENT AND
DIAGNOSTIC METHODS
• Excisional biopsy specimen; incisional
biopsy when the suspicious lesion is too
large to be removed safely without
extensive scarring.
• Chest x-ray, complete blood cell count,
liver function tests, and radionuclide or CT
scans are ordered for staging once
melanoma is confirmed.

11. MEDICAL MANAGEMENT
The therapeutic approach to malignant
melanoma depends on the level of
invasion and the depth of the lesion.
In addition to surgery, chemotherapy and
induced hyperthermia may be used to
enhance treatment. Investigators are
exploring the potential for the use of lipid-
lowering medications and vaccine therapy
to prevent melanoma

12. Surgical Management
• Surgical excision is the treatment of
choice for small superficial lesions.
• Deeper lesions require wide local
excision and skin graft.
• A regional lymph node dissection may
be performed to rule out metastasis,
although newer approaches call for
sentinel node biopsy to avoid problems
from extensive lymph node removal.
• Debulking the tumor or other palliative
procedures may be performed.

13. PLANNING AND GOALS
The major goals for the patient may
include relief of pain and discomfort,
reduced anxiety and depression,
increased knowledge of early signs of
melanoma, and absence of
complications.

14. NURSING INTERVENTIONS
• Relieving Pain and Discomfort
– Promote comfort and anticipate need for and
administer appropriate analgesic agents.
• Reducing Anxiety
– Give support, and allow patient to express
feelings (eg, anxiety, depression).
– Convey understanding of feelings.

15. –Answer questions and clarify information
during the diagnostic workup and
staging of the tumor.
–Point out resources, past effective
coping mechanisms, and support
systems to help the patient cope with
diagnosis and treatment.
–Include immediate family in all
discussions to clarify information and
provide emotional support.

16. MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Metastasis
• Educate patient about treatment and
deliver supportive care, provide and clarify
information about the therapy and the
rationale for its use, identify potential side
effects of therapy and ways to manage
them, and instruct the patient and family
about the expected outcomes of
treatment.

17. • Monitor and document symptoms that may
indicate metastasis: lung (eg, difficulty
breathing, shortness of breath, increasing
cough), bone (eg, pain, decreased mobility
and function, pathologic fractures), and
liver (eg, change in liver enzyme levels,
pain, jaundice).

18. • Encourage patient to have hope in the
therapy while being realistic.
• Provide time for patient to express fears
and concerns about the future.
• Offer information about support groups
and contact people.
• Arrange for hospice and palliative care
services.