Melanoma and Other Skin Cancers
The Johns Hopkins Melanoma Program coordinates multidisciplinary care for melanoma patients. Integrated care is provided by experts across a broad spectrum of specialties, and each patient is offered individualized treatment plans and a wide range of clinical trials opportunities.
Melanoma experts at Johns Hopkins are world leaders in the treatment and research of melanoma. Johns Hopkins melanoma experts lead clinical trials supported by national cooperative groups, federal research agencies, partnerships with biotechnology companies and developed through research pioneered at Johns Hopkins.
Melanoma is a cancer of the pigment-producing cells of the skin called "melanocytes." These are the cells that make dark skin dark, and allow fair skin to tan. Melanoma is an important cancer to know about, because if it is diagnosed and removed at an early stage, the cure rate is high. However, if it is diagnosed late, spread of the disease is likely to occur.
Melanoma can appear anywhere on the skin surface. In men, it is most common on the back or the head and neck, and in women, on the back or the back of the legs. Melanoma can develop in a pre-existing mole, or arise on normal-appearing skin. It is suspected when a "mole" looks uneven in terms of its border, shape, or color. Diagnosis is confirmed with a simple skin biopsy. Learn more about melanoma screening and prevention.
Melanoma is a type of skin cancer that can often be recognized by its appearance. Three features can help patients and physicians recognize melanoma:
- Asymmetry, or an irregular shape of a mole
- Borders that are irregular
- Color within the mole that is variable or very dark
A mole that increases in size, changes shape or color, itches or bleeds also is suspicious.
The diagnosis is confirmed by doing a biopsy of all or part of the mole. A biopsy is a simple outpatient surgical procedure where a piece of skin is removed and examined under the microscope. This microscopic examination is essential for the diagnosis of melanoma. The subsequent treatment is based on the thickness (depth) of the cancer, the location, and the presence or absence of melanoma elsewhere in the body.
A skin biopsy is done to make the diagnosis of melanoma. If the diagnosis of melanoma is confirmed, a second surgical procedure known as a wide local excision is required to control the disease in the area where it started. The purpose of the wide excision is to ensure that the melanoma has been excised completely and to decrease the chance of a local occurrence. Wide excisions are performed by surgical oncologists, plastic surgeons, head and neck surgeons or dermatologic surgeons, depending on the location and the size of the melanoma. A wide local excision is usually a very simple outpatient procedure. Occasionally, a skin graft may be needed.
If melanoma starts to spread, the first place it usually goes is to the nearby lymph nodes. In many patients with newly diagnosed invasive melanoma we investigate the nearby lymph nodes with a procedure called a sentinel node biopsy. This is an accurate way to find out if there has been any early spread of the melanoma. The result of the sentinel node biopsy helps physicians make treatment decisions.
Most patients diagnosed with melanoma today will do very well. However, there are some groups of patients, such as those with involved lymph nodes and those with very thick primary melanomas, who are at significant risk of recurrence of the disease. Alpha interferon is a treatment that works throughout the body. It can delay recurrences and possibly improve survival in patients who have involved lymph nodes or thick primary tumors. Interferon is a year long, difficult treatment, but is proven to delay recurrence and we offer it to high-risk patients.
If melanoma has spread beyond the regional lymph nodes, it becomes much more difficult to treat. Many different treatments, such as chemotherapy, immunotherapy, and combination therapies have been tried. Each of these has a small benefit, but none is routinely curative. Treatment plans require individualization and depend on many factors such as a patient's overall physical condition and the presence of other serious health problems.
New Treatment Approaches
Lymphatic mapping and sentinel lymph node biopsy is a useful tool for evaluating the regional lymph nodes in patients with newly diagnosed melanoma. Each area of the skin has lymphatic drainage that travels first to one or a small number of specific and identifiable lymph nodes in the nearby regional node basin. If this node is free of melanoma, the rest of the regional node basin will nearly always be free of melanoma as well. If the lymph node is free of disease, usually no further treatment is needed, and the patient is at relatively low risk of future recurrence. If the lymph node contains melanoma, additional surgery and systemic treatment will be recommended.
Sentinel lymph node biopsy should be considered for many patients with newly diagnosed invasive melanoma. It is offered to patients with melanoma greater than or equal to 1 mm in thickness, or to patients with thinner tumors with deeper Clark’s level or histologic ulceration. We selectively identify the first draining lymph node(s) and remove it for pathologic evaluation. Johns Hopkins surgeons have used the sentinel node technique for nearly a decade and for hundreds of patients, and use a simple and accurate technique to locate and remove the sentinel node.
Advanced Basal Cell Carcinoma
As part of the Bloomberg~Kimmel Institute for Cancer Immunotherapy’s Skin Cancer Program, our experts plan to study nivolumab for patients with advanced basal cell skin cancer as a first treatment, or for patients whose cancer comes back after treatment with standard therapy (hedgehog inhibitors). Basal cell carcinoma is the most common type of skin cancer and is usually cured with a simple procedure performed in a dermatologist’s office, but in a small number of patients, the cancer advances and/or spreads to other organs. Standard treatments for these advanced cases may have unpleasant side effects and generally don’t result in long-lasting responses. The response of basal cell carcinoma to anti-PD-1 will be studied in a new clinical trial conducted at Johns Hopkins.
Merkel Cell Cancer
Our skin cancer experts co-led a national trial and published the first study showing that a PD-1 checkpoint blocker worked in many cases of advanced Merkel cell cancer, a rare but very aggressive form of skin cancer. Before this study, it was considered an orphan disease lacking good treatment options. Our experts are building upon these initial findings, in a new study that combines nivolumab and the CTLA4 blocker ipilimumab (Yervoy) in an effort to get long-lasting responses for more patients. Research in other cancers found this combination worked well in some patients whose cancers did not respond to nivolumab alone.
Why melanoma and other advanced skin cancers respond to immunotherapy
Our unique collaboration between laboratory researchers and clinicians is key to our advances in immunotherapy—identifying treatments for each patient that will bring about long-lasting control of cancer.
Our research has uncovered two signs that identify a cancer that is likely to respond to immunotherapy:
- Cancer cells that contain many mutations in their DNA
- Cancer cells that express a protein called PD-L1
Generally, skin cancers have some of the highest number of DNA mutations among all cancers, which are caused by exposure to ultraviolet light (sunlight, or tanning beds). Many of these cancers express the PD-L1 protein. However, this is not the whole story. There are skin cancers that have lots of DNA mutations and express the PD-L1 protein but do not respond to immunotherapy. A better understanding of these two biomarkers and uncovering new ones is a major focus of ongoing research in the BKI. This will help our experts figure out how to make immunotherapy work effectively in more patients.
Our experts are exploring whether cancers that start in the skin, a highly immune organ that is the first line of defense against foreign invaders, are more easily recognized by the immune system than other types of cancers.