How scared should we be?

August 25, 2006 1:44 PM

If a biopsied spot turns out to be melanoma, what's likely to happen and what's not? Is there only a remote chance of needing chemo, radiation, or other terrifying stuff, or more than a remote chance? (Percentages, anyone?) I have some related questions, too.

Three or so months ago, my husband had an ink-black spot under his toenail, or maybe on it -- we couldn't tell which. It looked as if he bumped his toe. After about a month, on a day spent tromping around in the water and hiking, it disappeared. But, the exact same place started going from very light gray to darker gray -- again, we can't tell if it's on the skin or the nail. A dermatologist he saw today said she sees some brown, and she's having him get a biopsy a week from Tuesday. She didn't find any more spots. My husband grew up in a beach town, with lots of sunburns, and his father's father had skin cancer on his face.

My husband thinks the spot might be moving along with the nail as the nail grows, though. Would that be inconsistent with melanoma, and what would it be consistent with?

If it is melanoma, how worried should we be, and about what possibilities? My ideal answer would be facts like, "x% of this kind of melanoma leads to y happening." (Well, my ideal answer would actually be, "What you describe doesn't sound like melanoma because...," but I'll take what I can get.)

Also, they've told him his foot will be encased in a boot after the biopsy. How bad will the biopsy be, and for how long afterwards?

I'd also be interested in recommendations for other discussion boards that would intelligently address this topic.

posted by daisyace to health (20 comments total)

(A request for clarification)

Not all skin cancers are melanomas; carcinomas are actually more common. Are you asking about melanomas because they're scarier, and you want to be prepared for that possibilty, or are you wondering about skin cancers in general?

I've had a biopsy on a mole, and it wasn't bad at all. Local anesthetic, about a week of low-key healing under a bandage, a pink scar that's completely faded now. Your husband's sounds as if it may be complicated by the toenail, however.
posted by redfoxtail at 2:00 PM on August 25, 2006

redfoxtail, I was asking about melanomas because I was too ignorant to know that it wasn't a synonym for skin cancer. So my real question is: if it is skin cancer, how worried should we be, and about what possibilities?

(And I'm glad your biopsy sounds like it was ok and without further consequence.)
posted by daisyace at 2:14 PM on August 25, 2006

I'd imagine they'll have to violate the integrity of his toenail somehow... which sounds painful. It's my understanding that most common skin cancers are benign (basal carcinoma), but those those that are serious (melanoma) are extremely dangerous.
posted by phrontist at 2:16 PM on August 25, 2006

We've had experience with both types in my family-- my mother gets carcinomas, which are not particularly dangerous and are essentially "burned" off your skin by the doctor. Annoying, but not deadly.

My father died of melanoma 10 years ago-- it spread pretty quickly through his body, he was gone within a year after the diagnosis. At the time is was pretty much untreatable, hopefully that has changed.

This is not a good place for you to get this information-- go to someplace like WebMD where you can get up to date information that's been looked at by real doctors.
posted by InfidelZombie at 2:47 PM on August 25, 2006

It seems to me that it would be very unusual for your husband to have a skin cancer under his toenail. It also wouldn't move with the toenail. That would indicate to me that it's probably not skin cancer.

If it is skin cancer, though, they'll want to remove it as quickly as possible, which may mean removing the nail with it. If it turns out to be a melanoma, or some other virulent cancer, they're going to do other tests. If those tests (checking the lymph nodes), come back positive, then further treatment will be warranted.

But it's probably not cancer. It's probably just a pinched toenail.

Important: I am not a doctor.
posted by bshort at 2:52 PM on August 25, 2006

The medical term you want to google for more info is "subungual melanoma" (ie. melanoma under the nail).

Then google "Breslow depth" which is currently how melanomas are staged in the US.

Here is a link about current staging.
posted by i_am_a_Jedi at 3:45 PM on August 25, 2006

MedlinePlus is a good place to find out medical information. It should link you to plenty of articles on skin cancers, as well as any reputable organizations related to that. I've found it very helpful for other medical problems.
posted by Margalo Epps at 3:46 PM on August 25, 2006

As hard as it is, try not to worry or spend much time on this until after the testing. Melanoma is a very uncommon type of cancer. Getting it checked out now (a couple months after first seeing it) is the best thing you could have done.
posted by sevenless at 4:07 PM on August 25, 2006

I've just had a look at the nail, and at the sites and searches suggested by phrontist, I_am_a_Jedi, and Margalo Epps, and sites branching out from those. Thanks for those links, and for the other thoughts so far. I'm already somewhat relieved to report that I don't see much of a match between melanoma (which starts as a brown or black streak running up the nail) and my husband's toe, which looks like it could have some brown or black under it, but is graphite gray across part of the top surface of the nail, as if rubbed with a pencil.

I also found an article about ordinary dermatologists calling for unnecessarily painful nail bed biopsies, in cases where more expert dermatologists might suggest a painless nail plate biopsy first. So, given the appearance that's not typical of melanoma, the fact that it looks to involve the nail plate, the fact that the toenail involvement could make the biopsy painful, and this article, we're hoping a second opinion might make even the nail bed biopsy unnecessary. But, I don't think the odds are great for that, simply because we don't know how to connect to the right dermatologist who'd make that call. Maybe we'll get additional help from the question I posted on WebMD -- thanks for that one, InfidelZombie.
posted by daisyace at 4:58 PM on August 25, 2006

I'm totally not a doctor, but, anecdotally, skin biopsies are extremely common, so having a biopsy ordered doesn't mean there's something wrong.

From an article in The Baltimore Sun on July 14 (it's no longer available for free online, so let me know if you want me to e-mail it to you from lexis nexis):
"To be sure, skin cancer is not among the 10 leading causes of cancer deaths, according to 2006 projections by the American Cancer Society. But melanoma will be diagnosed in 62,190 people this year and kill 7,910. It would kill many more if it weren't caught and treated early. The incidence is rising, though more slowly than in the past.

"This year there will be more than 1 million cases of basal and squamous cell cancers, which often occur in sun-exposed areas of skin, such as the face, neck and hands. Most of these are curable because they, too, are usually caught early. But removing cancers, especially from the face, can be disfiguring."

Also, melanoma is apparently not for-sure linked to sun exposure (from the same article:

"In a combined analysis of three large studies published in the Journal of Clinical Oncology last year, Harvard researchers listed the risks for melanoma in the following order: Older age, male, family history of melanoma, high number of moles, history of severe sunburn and light-colored hair. In other words, sun is one factor among many."
posted by Airhen at 5:06 PM on August 25, 2006

I've had moles biopsied and subsequently removed because the biopsies revealed cancerous characteristics or potential. As mentioned above, there are many different types of skin cancer, some more dangerous than others.

Point being, don't freak out if you hear the word "cancer" from the doctor, because many forms are easily and successfully treated by removal of the mole/spot on the skin.
posted by lalex at 5:45 PM on August 25, 2006

IIANAD.

I do have first-hand experience with melanoma.

I had a mole removed from the back of my arm when I was 19 that turned out to be a bona-fide melanoma. Fortunately, it was caught early, so a biopsy of the surrounding skin (removing about an inch in diameter) was the end of it. The skin around it was fine, and I've had no recurrence since then. (Eight years and counting.) I do have an inch-long scar.

Three months is not a long time to have any kind of spot, so I wouldn't jump immediately to panic and metastasis. However, keep in mind that melanoma — unlike basal- or squamous-cell carcinomas — is characteristically very dark — black or deep maroon/brown — because it's a malfunctioning melanocyte (the kind of cell that makes pigment in the skin).

Never, ever ignore a new, dark spot on your body, even if it shows up in a strange place, like the sole of a foot or between fingers. Sun exposure is not a reliable predictor for where melanoma shows up.

Mine was only diagnosed because I happened to be at the dermatologist because I had acne, and had a weird feeling about the black spot on the back of my arm.
posted by bisesi at 8:49 PM on August 25, 2006

I don't want to ask an obvious question, but why aren't you talking to your husband's dermatologist about this? It would seem that s/he is closest to this case and can answer your question much better than random people on the internet. If, on the off chance you have talked to this, s/he doesn't welcome your questions, that's a sign you need to find a new doctor.
posted by MeetMegan at 9:17 PM on August 25, 2006

Talk to the dermatologist or surgeon that is doing the biopsy. I have plenty of experience with skin cancers (personal plus I work in surgery and see them all the time). Not all melanomas are dark, Melanoma insitu comes to mind. Squamous can also spread, basal usually takes quite awhile.

As far as the toe, if it is a melanoma he should be referred to a surgeon. Lymph nodes may be biopsied to see what the chances are that it has spread. I would never let a dermatologist do anything other than a biopsy, (they are NOT surgeons).

IANAD. YMMV. Usual disclaimers apply.
posted by 6:1 at 9:57 PM on August 25, 2006

A reasonable percentage of melanomas show up on parts of the body that get little UV exposure (genitals, soles of the feet, oral cavity, nail beds, and within the eye). So if you ever go in to your doc for a skin exam, they should strip you down to nothing and look you over like your getting checked for a shiv on Oz.

Daisyace, from what you have said, assuming it's true that the dark spot genuinely vanished, it's unlikely this is a melanoma. However, the difference between survival and certain death with melanoma is simple timing so this isn't a situation where one would look for reasons to avoid a biopsy. If the biopsy shows melanoma, then it's likely the next step is a sentinel node biopsy. The presence or absence of malignant cells in the sentinel node will determine lot about prognosis.

Good luck.
posted by docpops at 9:58 PM on August 25, 2006

An incredible amount of the information here is wrong.

Melanoma is rare, invasive melanoma is rarer still, metastatic even rarer (though utterly deadly), and lastly that's an incredibly uncommon spot. Past that, though, it has nothing (or very, very little) to do with sun exposure or the darkness/diameter/elevation of the lesion, or a history of regression; nor will it *likely* require invasive surgery past a full excision with clean borders (SNBs are viewed as informational but not useful wrt. survival rates). Small pink spots can be invasive and spread, while large raised nasty looking moles (I've got my share) may be just this side of atypia.

It's not a well understood disease. Even skin cancer specialists propagate similar misinformation. You did the right thing to have it biopsied since a changing (or new) spot is by far (~20X) the best indicator of a serious condition. If you're white, you've got a 1-50 to 1-100 shot at having melanoma in your lifetime. It's uncommon, but it's possible, so rest easy unless you ever receive bad news.. not before. :)

Just stay off the Internet when it comes to researching possible diseases and afflictions. You'll find nothing but horror stories, misinformation, and worryworts posting on "survivors' forums," so in most cases your physician - while not perfect - is your best friend. Ask questions until you're satisified and if you can't get to that point, find another.

Interestingly, a study showed decreased rates of reoccurance in patients that had higher rates of sun exposure after a primary melanoma. For sure there is little causation between the two, but it's interesting.

So, after all those big scary words and blather, there's absolutely no reason to be scared whatsoever. Honestly. It's probably 1 in 100 skin cancer, and then even if it is you've got maybe a 10% chance of it being melanoma, then another 10% there of the melanoma being invasive, and then another 10% chance of it being metstatic (and that's where you pretty much die). I made those numbers up, but people like numbers, and they're probably roughly order-of-magnitude correct at least. On the bright side, if it's a bad melanoma, you're not going to have to deal with (traditional) chemo and radiation since it doesn't work on the little fuckers. :)
posted by kcm at 11:14 PM on August 25, 2006

(When I say information here is wrong, I don't mean to put anyone down or reject it outright, but there's a lot of well-meaning but misleading statements with varying amounts of truth.. as I know it anyway.)
posted by kcm at 11:20 PM on August 25, 2006

kcm - at OHSU in Portland, one of the meccas for surgical treatment of melanoma, sentinel node biopsy is nearly all they do to predict staging and prognosis.

As for 'rare', the incience of melanoma in the world population is doubling almost every five years. It's the most common cancer in men between ages 25 and 54, and the second most common in women of the same age range. It outpaces by a mile the rise of any other malignancy.
posted by docpops at 3:36 PM on August 26, 2006

I have worked at some *major* cancer facilities, I agree with docpops. Sentinel node biopsies are very important to predict if the melanoma has spread, (sentinel nodes are lymph nodes).
posted by 6:1 at 3:45 PM on August 26, 2006

In case anyone ever checks back here, a second opinion concluded no biopsy was needed, and a fungal infection was diagnosed. Thanks again for the help!
posted by daisyace at 10:51 AM on September 23, 2006