What are the other Names for this Condition? (Also known as/Synonyms)

• Cutaneous Superficial Spreading Melanoma
• Malignant Melanoma of Skin, Superficial Spreading Type
• SSM of Skin

What is Superficial Spreading Melanoma of Skin? (Definition/Background Information)

• A melanoma is a type of cancer that develops from cells called melanocytes. Melanocytes are cells that produce melanin, the pigment that gives skin its color
• Superficial Spreading Melanoma (SSM) of Skin is the most common subtype of cutaneous melanoma that usually arises from the non-exposed skin areas. However, skin on any part of the body may be affected
• SSM of Skin may initially start like a freckle on the skin that appears to be spreading, getting darker or lighter; it is capable of a rapid progression
• They are usually brown or black in color. Although these can occur anywhere on the body, common sites of occurrence include:
  • Chest and back in men
  • Legs in women
• Superficial Spreading Melanoma of Skin is diagnosed with the help of a biopsy. Once a definitive diagnosis has been made, it is surgically removed (excised)
• Depending on how far the disease has progressed, additional modes of therapy may be needed. The outcome of Superficial Spreading Melanoma of Skin is good when the diagnosis is made early and the condition is treated adequately

Who gets Superficial Spreading Melanoma of Skin? (Age and Sex Distribution)

• Superficial Spreading Melanoma of Skin can occur in young, as well as old individuals, and is one of the most common cancers in people younger than 30 years
• Both male and female genders have the same amount of risk for this condition
• Cutaneous melanomas occur more frequent in Caucasians, as compared to other races
• Almost 70% of all diagnosed melanomas are of this type; about 65% of all melanomas in fair-skinned individuals belong to this type

What are the Risk Factors for Superficial Spreading Melanoma of Skin? (Predisposing Factors)

The following factors may increase the risk for Superficial Spreading Malignant Melanoma of Skin:

• Severe exposure to ultra violet (UV) rays is a major risk factor, especially during one’s childhood (and to some extent during one’s adulthood). UV rays are present in sunlight and in tanning lamps and beds
• Nevus (medical term for mole) is a non-cancerous pigmented tumor. While most nevi never become cancerous (or malignant), a small number of atypical/dysplastic nevi (moles with abnormal shape/borders/color) may turn cancerous. When such dysplastic nevi run in families, the condition is called dysplastic nevus syndrome. Individuals with this condition have a 10% increased risk of developing melanoma. Despite the above and irrespective of the condition, whether the nevi are present since birth, or are normal, or atypical; more the number of moles, more is the risk
• Fair-skinned individuals are at a higher risk; more so those with freckles or those who develop sunburns easily
• Individuals with light or red hair color and those with blue eyes also have a higher risk
• Previous history of melanoma or a history of melanoma in parents/siblings; 6-14% of the individuals with melanoma are found to have someone with melanoma in their family
• An inherited condition called xeroderma pigmentosum, where the ability of the cells to repair sun-induced damage to genetic material is impaired
• Weakened immune system, as a result of infections (such as HIV), drugs (chemotherapy or immunosuppressants), and the presence of cancers (such as lymphoma)

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Superficial Spreading Melanoma of Skin? (Etiology)

The exact reason why some moles turn cancerous, and others do not, is still not known. However, the potential causes for Superficial Spreading Melanoma of Skin may include:

• Uncontrolled activity of oncogenes (rogue genes that promote cell growth and division) or depressed action of tumor suppressor genes (genes that normally keep a check on cell growth and division) is thought to play a role in the development of melanomas
• A majority of the cases involve mutations on the BRAF oncogene. Also, chromosomal abnormalities including chromosomal losses and gains have been noted
• UV-radiation induces damage to DNA (genetic material that determines all of our traits and functions), which in turn may turn-on oncogenes, or turn-off tumor suppressor genes
• In families with inherited melanomas, gene mutations that increase the risk of cancer are passed on from one generation to the next. About 1 in 5 individuals with a positive family history of melanoma, show mutations in the CDKN2A gene

What are the Signs and Symptoms of Superficial Spreading Melanoma of Skin?

Superficial Spreading Melanoma of Skin usually occurs in a previously benign mole. The signs and symptoms may include:

• All the signs of a cutaneous melanoma, including an irregularly shaped pigmented area on the skin that is changing, can be seen
• In females, the legs are the usual sites of SSM; while in males, the chest, back, and abdomen are mostly affected
• The growth of the skin lesion may exhibit a radial outward pattern. The thickness of the lesion may increase to become a papule, once the skin lesion stops increasing in size
• The pigmented lesion may be dark black in color, or shades of light/dark brown; some lesions may not show any color (called amelanotic melanoma)
• The papules show redness or present itching (due to inflammation). Such areas may also be scaly, or exhibit some oozing of fluid, or bleeding following ulceration
• If white to grey areas are seen, then it may indicate that the skin lesion is subsiding/regressing
• Some skin lesions may not have any signs and symptoms, until ulceration is noted

How is Superficial Spreading Melanoma of Skin Diagnosed?

A thorough history and a complete physical exam by a physician are crucial for the diagnosis of Superficial Spreading Melanoma of Skin. This is followed by some tests which include:

• Biopsy of skin: A sample of the skin, from any suspected area found on physical examination, is taken and examined under a microscope for signs of cancer by a pathologist. The types of biopsy performed include:
  • Excisional biopsy: After numbing the area with a local anesthetic, the entire mole is removed with a small border of surrounding skin. Where possible, this is the generally preferred method
  • Punch biopsy: After numbing the area with a local anesthetic, a circular blade is pressed into the skin around the suspicious area, and a round piece of skin removed. This type of biopsy is carried out, when the lesion (the suspicious area) is large in size
  • Incisional biopsy: After numbing the area with a local anesthetic, a portion of the tumor is removed using a surgical knife
  • Sentinel lymph node biopsy: Performed to determine if the melanoma has spread to nearby lymph nodes. A dye is injected into the area from where the melanoma is removed. The first lymph node that takes up the dye is biopsied and examined for cancer cells, under a microscope
  • The removed melanoma specimen can be tested for the presence of certain genes that if present increase the likelihood of metastasis. With some genetic profiles, more aggressive imaging and procedures might be considered
• Sometimes, biopsy of other large lymph nodes in the area near the melanoma may be performed using fine needle aspiration cytology (FNAC) technique. In this, a sample of cells is removed from the mass, using a syringe with a hollow needle and then examined under a microscope
• If the melanoma is suspected to have metastasized (spread) to internal organs, imaging tests, such as X-ray, CT scan or MRI of the affected areas, may be carried out
• In rare cases, biopsies of areas other than skin may have to be done, when the primary source/origin of the tumor cannot be determined 

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Superficial Spreading Melanoma of Skin?

Early stage melanomas include melanoma in situ (confined to just the upper skin layer called epidermis) or locally invasive melanomas that have spread to the deeper layers of the skin. The more advanced cases of Superficial Spreading Melanoma of Skin metastasize beyond the skin, to lymph nodes and other organs. Organs that are commonly involved in metastasis include:

• Lung
• Liver
• Brain
• Bone
• Gastrointestinal tract 

How is Superficial Spreading Melanoma of Skin Treated?

The choice of treatment for Superficial Spreading Melanoma of Skin depends on how far the cancer has progressed. This is estimated through staging of the tumor. Some of the factors taken into consideration during staging include:

• The thickness of the melanoma (also called Breslow’s measurement): Tumors can be thin, intermediate, or thick, depending on how deep into the skin they have penetrated. The thinner the tumor, the better the chances of a cure
• Presence of any ulceration (open sores) over the tumor.
• Spread of melanoma to lymph nodes or other internal organs

The melanoma is sorted into one of four stages depending on how far it has progressed, with I and II being early stages, III and IV being later stages, where melanoma has spread to sites beyond the skin. While early stage melanomas can be treated by surgery alone, the later stages of the disease often require a combination of treatment measures.

Treatment options for melanoma include:

Surgery:

• Simple excision of the tumor along with some normal, non-cancerous skin at the edges (called margin). The width of the margin is based on the thickness of the tumor; as the thickness of the melanoma increases, the margin required increases as well
• Slow Mohs Micrographic Surgery:
  • Used surgeons some Mohs as an alternative technique to standard excision of melanoma
  • A thin layer of skin is removed and checked for cancer. This process is the carried out continuously, until a cancer-free slice of skin is obtained
  • Because the slow process of histochemical testing required to detect melanoma cells, one stage of the surgery is completed each day. This surgery can almost always be done under local anesthetic 
• Lymph node dissection, in cases where the melanoma has spread to involve the nodes: Lymph nodes help in drainage of tissue fluid (lymph). However, removal of these nodes may therefore lead to a build-up of lymph causing swelling (lymphedema)

Chemotherapy:

• Drugs are used to kill the tumor cells, which may be given as oral pills, or injected into veins
• Side effects of chemotherapy may include nausea, vomiting, hair loss, loss of appetite, diarrhea, and fatigue, increased risk of infection, mouth sores, or easy bruising, depending on the drug used
• In cases, where the melanoma is advanced, but remains confined to an arm or leg; chemotherapy is only circulated through the affected the limb by a process called isolated limb perfusion

Immunotherapy:

• This therapy stimulates the immune system and involves the use of substances produced naturally by the body or such similar synthetics, made in a laboratory
• Drugs used include, synthetic immune proteins and proteins that boost the immune system, called cytokines- interferon alpha or interleukin-2
• Side effects of cytokines may include chills, fatigue, fever, headaches and muscle aches; while synthetic immune proteins may cause the immune system to start attacking other parts of the body

Targeted therapy:

• Involves the use of drugs tailored to target the differences in a melanoma cell, as compared to a normal cell
• Half of all melanomas involve a mutation in the BRAF gene. This is targeted by a drug vemurafenib
• Side effects may include nausea, joint pain, fatigue, rash, itching, hair loss, sensitivity to the sun, and rarely heart rhythm problems, liver problems, severe allergic reactions, and severe skin or eye problems

Radiation therapy:

• This uses high energy beams to kill cancer cells
• Generally, this method is not used to treat the original melanoma, but often to relieve symptoms, when the melanoma has spread to other organs; or following lymph node dissection, where many nodes were found to be cancerous
• The most common side effect is fatigue, but this resolves once treatment is complete

How can Superficial Spreading Melanoma of Skin be Prevented?

A few steps towards the prevention of Superficial Spreading Melanoma of Skin may include:

• Avoid direct exposure to UV rays and remain in the shade, as and when possible
• When heading out into the sun:
  • Slip on a shirt
  • Slop on some sunscreen. Sunscreens with SPF values higher than 30, and those offering broad spectrum protections (against UV-A and UV-B rays), are recommended. Apply an ounce to all exposed areas, 30 minutes before heading outdoors. Reapply every two hours, and also after excessive sweating
  • Slap on a hat
  • Wrap on sunglasses

This is encapsulated as the “Slip! Slop! Slap! Wrap” method for skin cancer prevention. (Source: The American Cancer Society, Atlanta)

• Avoid tanning beds and sun lamps
• Perform self-examination of your skin, from head to toe, once a month
• Get a professional skin exam from a healthcare provider, once a year
• All patients with melanoma should undergo skin examinations regularly even after treatment, at least once a year throughout their lives

What is the Prognosis of Superficial Spreading Melanoma of Skin? (Outcomes/Resolutions)

• The prognosis of Superficial Spreading Melanoma of Skin is nearly similar to other forms of cutaneous melanoma
• Individuals with early-stage Malignant Melanoma of Skin, Superficial Spreading Type have better outcomes compared to those with more advanced melanoma, where the cancer has spread to lymph nodes or other organs
• The prognosis depends upon a set of several factors, which include:
  • Stage of tumor: With lower-stage tumors, when the melanoma is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage cancers, such as those with metastasis, the prognosis is poor
  • Overall health of the individual: Individuals with overall excellent health have better prognosis compared with those with poor health
  • Age of the individual: Older individuals generally have poorer prognosis than younger individuals
  • The size of the melanoma: Individuals with small-sized melanomas fare better than those with large-sized ones
  • Individuals with bulky disease have a poorer prognosis
  • Involvement of vital organs may complicate the condition
  • The surgical resectability of melanoma of skin (meaning if the melanoma can be removed completely)
  • Whether the cancer is occurring for the first time or is recurrent. Recurrent cancers have worse prognosis compared to those that do not recur 
  • Response to treatment: Melanomas that respond well to treatment have better prognosis compared to melanomas that do not respond to treatment
  • Progression of the condition makes the outcome worse (progressive cutaneous melanoma)

Additional and Relevant Useful Information for Superficial Spreading Melanoma of Skin:

• Melanoma is the most common form of cancer in young adults, aged 25-29 years. 1 in 50 Americans, have a lifetime risk of developing melanoma
• The ‘Slip-Slop-Slap campaign’ was initially launched in Australia, by Cancer Council Victoria in the 1980s, to promote awareness about skin cancer and methods for its prevention. This was then adopted in New Zealand as the ‘Slip-Slop-Slap-Wrap campaign’ (Source: The Wikipedia)