Moles to Melanoma: Recognizing the ABCDE Features by the National Cancer Institute
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The focus of our post this week is preventable cancer. Therefore, we are sharing this article from the National Cancer Institute (NCI) concerning a multi-year study of skin lesions and moles which resulted in melanoma.
Skin cancer is the most common form of cancer in the United States, and melanoma is responsible for the most skin cancer deaths with over 9,000 each year. An individual dying from melanoma loses an average of 20.4 years of potential life. Total melanoma treatment costs are about $3.3 billion annually in the United States. Melanoma is the fifth most common cancer for men, and is the seventh most common cancer for women. More than 90% of melanoma cases in the United States are attributed to skin cell damage from ultraviolet (UV) radiation exposure.
The National Cancer Institute has collected photographs of 29 different pigmented skin lesions, presented as case studies, to help patients and other individuals recognize common moles, dysplastic nevi (DN), and melanomas that started from DN. Each case series shows changes in an individual pigmented lesion (mole) over time and across the various mole changes typically seen in individuals from U.S. melanoma-prone families.
What are moles, dysplastic nevi and melanoma?
- Common Moles – A non-cancerous growth on the skin that is formed by a cluster of melanocytes (cells that make a substance called melanin, which gives color to skin and eyes). A mole may be dark or flesh-colored and may be raised from the skin.
- Dysplastic Nevi (DN) – A type of mole that may develop into a type of skin cancer called malignant melanoma. They look different from common moles. A DN is often larger with borders that are not easy to see. Its color is usually uneven and can range from pink to dark brown. Parts of the mole may be raised above the skin surface.
- Melanoma – A form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines.
Who is the intended audience?
- The pictures used in this article were taken over more than a 35-year period. They show moles and melanomas from participants enrolled in the NCI Familial Melanoma Study.
- The pictures show examples of the variability in pigmented lesions in U.S. melanoma-prone families.
- Because most of the study participants are Caucasian, the nevi and melanomas shown are not representative of those found in individuals with darker skin.
- Melanomas and lesions suspicious for melanoma vary widely in appearance; these pictures should not be used to diagnose melanoma.
- NCI does not provide medical advice to users of its website.
- Consult with a qualified health care provider if you have concerns about your skin.
About the photos
- The photographs have variations in color due to differences in photography equipment, lighting, and skin color of the individual (e.g. sunburned or suntanned).
- Photographs are standardized to ease viewing.
- Rulers show size of the moles and melanomas in millimeters.
This study only includes individuals in U.S. melanoma-prone families who are at high-risk of developing this form of skin cancer. As shown in Figure 1, Caucasians are at the highest risk of developing melanoma. To date, this study has not identified or enrolled any non-Caucasian families. Therefore, this tool does not provide images representative of other ethnicities.
Figure 1: Melanoma incidence by race/ethnicity in the U.S. Surveillance, Epidemiology and End Results Program 1975-2012
Reference: Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2012, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2012/ , based on November 2014 SEER data submission, posted to the SEER web site, April 2015
Data points are not included for clarity of presentation, but may be found at https://seer.cancer.gov/csr/1975_2012/sections.html Figure 16.2.
Where can I find information on Skin Cancer in other Ethnicities?
- National Cancer Insititure – “Anyone Can Get Skin Cancer”, includes images of skin cancer in people with darker skin
- Skin Cancer Foundation – “Skin Cancer and Skin of Color”
Where can I find information about Non-Melanoma Skin Cancer?
This collection does not include any pictures of non-melanoma types of skin cancer (e.g. basal cell or squamous cell), since they arise from different cell types in the skin they look very different from melanoma. For information on those types of skin cancer, visit the following websites: https://www.cancer.gov/types/skin & https://www.cancer.org/cancer/cancercauses/sunanduvexposure/skin-cancer-facts.
What information does this resource provide?
This resource provides information about and examples of: common moles, dysplastic nevi (atypical moles) and melanoma. This collection does not include any pictures of non-melanoma types of skin cancer (e.g. basal cell or squamous cell). Since they arise from different cell types in the skin, they look very different from melanoma. Additional information, including resources for other types of non-melanoma skin cancer, can be found in the Intended Audience section.
The “ABCDE” rule describes the features of early melanoma. These features are:
Asymmetry – The shape of one half does not match the other half.
Border that is irregular – The edges are often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.
Color that is uneven – Shades of black, brown, and tan may be present. Areas of white, gray, red, pink, or blue may also be seen.
Diameter – There is a change in size, usually an increase. Melanomas can be tiny, but most are larger than 6 millimeters wide (about 1/4 inch wide).
Evolving – The mole has changed over the past few weeks or months.
A common mole is a non-cancerous growth on the skin that is formed by a cluster of melanocytes (cells that make a substance called melanin, which gives color to skin and eyes). A mole may be dark or flesh-colored and may be raised from the skin. Most adults have between 10 and 40 common moles. These growths are usually found above the waist on areas exposed to the sun. Common moles are seldom found on the scalp, breast, or buttocks.
- Common moles are growths on the skin that develop when pigment cells (melanocytes) grow in clusters; also called “common nevi” or “common acquired nevi”.
- Appearance (using ABCDE rules)
- Asymmetry: Usually symmetrical, round or oval.
- Border: Usually have a distinct edge that separates it from the rest of the skin.
- Shape: Usually round or oval.
- Color: Usually have an even color; may be pink, tan, brown, black (in deeply pigmented individuals), or a color that is very close to a person’s normal skin tone.
- Diameter: Usually less than 5 millimeters or about ¼ inch (smaller than a pencil eraser).
- Evolving: Moles go through a life-cycle. Often they start as small freckle-like spots; gradually round up and form a bump; may lighten, become flesh-colored; become less elevated, flatten and eventually disappear. Life-cycle is a gradual process typically over many years. Some moles do not go through the entire life-cycle. Vast majority are stable and then disappear; rarely develop into melanoma (or cancer).
Mole Case 1: Stable normal mole
Over thirty years, this common mole remained the same size (about 6 millimeters), color, shape, and elevation (height) above the skin.
- Asymmetry none
- Border no irregularity
- Color even
- Diameter 6 millimeters
- Evolving not changing
Clinical Diagnosis Common acquired nevus
This picture shows a large mole which is slightly bigger than a pencil eraser. The mole is a smooth light tan and pink bump with normal skin markings (lines) present on the entire surface. Unlike most moles, there are some hairs growing from the center and edges of the mole. All of the features of this mole are normal.
Recognizing the ABCDE Features
Dysplastic Nevi (DN)
A dysplastic nevus (DN) is a mole that may develop into malignant melanoma, a skin cancer starting in pigment cells. DN look different from common moles. DN are often larger than common moles (more than 5 millimeters) and have borders that are not easy to see. Their color is usually uneven and can range from pink to dark brown. Similar to common moles, parts of the DN may be raised above the skin surface. Some doctors use the term “atypical mole” to refer to DN.
- The word “dysplastic” in its name refers to the look and pattern of cells in the nevi as they appear under a microscope.
- Appearance (according to ABCDE rules)
- Asymmetry: irregular shape
- Border: indistinct (blurry) borders
- Color: mixture of colors (tan, brown, and red or pink shades)
- Diameter: greater than 5 millimeters or ¼ inch and have a flat part
- Evolving: Majority are stable and then disappear; typically start to show these features when small and show all features by the time they reach the size of most moles; become larger than most moles and eventually disappear.
- The “ABCDE” rules were made for identifying early melanoma, but can also be used to describe DN.
- Clinicians use the number of DN to identify some individuals who are at increased risk of developing melanoma.
- DN most likely found on sun-exposed areas, especially intermittently exposed, such as the back, but are also frequent on chest, arms and legs.
- Approximately 10% of adult populations of northern European descent have at least one DN.
- DN are frequently found in melanoma-prone families in North America, Europe, and Australia.
- Melanomas may develop from DN.
- Risk of melanoma is high for people who have a large number of DN; especially high for people with a family history of both DN and melanoma.
Stable and Fading
Evolving Toward Melanoma
Over five years, this dysplastic nevus more than doubled in size, increasing from 3 millimeters to 10 millimeters wide. The color lightened from dark brown to very light in the center and reddened around the edges. The shape became more irregular and the borders became more indistinct. The mole was mostly flat but slightly raised in the center, and then became flatter. The mole was removed because it continued to change in color and the patient reported that it had been itching.
Over seventeen years, this DN increased in size to 8 millimeters and then decreased to 4 millimeters. The nevus went from reddish brown, partially flat with an irregular outline and indistinct borders to light tan and barely visible. The large papule (bump) in the center flattened.
Over twenty-six years, this DN grew from 14 millimeters wide to about 17 millimeters, and then decreased to 14 millimeters. The mole contained shades of tan to dark brown, red and pink, but as the mole became smaller it faded considerably to light pink. The lighter area in the right lower portion became a flesh-colored almost flat bump that was barely visible. The irregular scalloped-shaped outline filled in as the nevus grew into a more irregular shape. Later the mole started fading and became less irregular.
Over twenty-two years, these two mostly flat DN with irregular and indistinct outlines were stable and then regressed (faded). Both nevi were approximately 5 millimeters wide, and after several years, decreased to about 4 millimeters. Both nevi had slight mixtures of tan, brown, and red shades which became more uniform. Both nevi faded; the “B” nevus became flat and barely visible.
Over eight years, this DN increased in diameter from 4 millimeters to 7 millimeters. The mixture of tan to dark brown colors lightened and then darkened. The partially flat mole with indistinct borders had a slightly irregular outline which became more irregular. The mole was removed because it was getting darker (after having lightened) and was growing slightly larger.
Over four and a half years, this DN increased in diameter from 8 millimeters to 9 millimeters. The mole is partially flat and has an irregular shape and indistinct border. It contains a mixture of tan to dark brown colors which lightened and then darkened. The upper central and right side lightened considerably with an arc of very light color across the central portion. The shape became more irregular as the pigment receded (color faded). Then, much of the nevus darkened considerably and a new area of very dark brown color developed that extends inwardly at the 4 o’clock to 5 o’clock position. The mole was removed because it had changed in color over the past year.
Melanoma is a form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but infrequently can also begin in other pigmented tissues, such as in the eye or the intestines. Melanoma is potentially dangerous because it can spread to nearby tissues and other parts of the body, such as the lung, liver, bone, or brain. The earlier that melanoma is detected and removed, the more likely that treatment will be successful.
- A type of skin cancer that begins in melanocytes (cells that make the pigment melanin).
- Early, thin melanomas are curable by minimal surgery alone.
- Advanced melanomas may spread to others parts of the body; treatments such as additional surgery, chemotherapy, radiation therapy, immunotherapy and/or new types of treatment being tested in clinical trials may be used.
- Appearance of early melanoma (according to ABCDE rules)
- Asymmetry: Often irregular and asymmetrical (the shape of one half does not match the other half).
- Border: Usually irregular. Edges often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.
- Color: Usually uneven in color. Shades of black, brown, and tan may be present. May also have areas of white, gray, red, pink, or blue.
- Diameter: Change in size, usually an increase. Melanomas can be tiny, but most are larger than 6 millimeters wide (about ¼ inch wide). The surface may appear scaly.
- Evolving: The mole has changed in size, shape, and/or color over the past few weeks or months. Development of a new mole that has any of the ABCDE features in an area of previously normal skin.
- Melanomas can vary greatly in how they look. Many show all of the “ABCDE” features; however, some may show only one or two of those features.
Guidelines for Individuals at Increased Risk of Melanoma
A new and unusual mole developed on the arch of the foot in an area of skin that was previously normal. The mole steadily increased in size and irregularity. It was 10 millimeters in diameter, and larger and more irregular than any of the moles nearby. The mole was mostly flat with an irregular darker border, and a mixture of light brown to very dark brown with some lighter color in the center. It was removed because it displayed several of the warning signs for melanoma (changes in size, color, and shape).
Over two years, this DN changed in size, color, shape and surface. It was predominantly flat with some tiny bumps in the center, and uniformly tan with a triangular shape and indistinct borders. The nevus then enlarged slightly to 6 millimeters by 5 millimeters and developed a new black slightly raised area and a fine scale on the surface. The mole was removed because it was changing in ways highly suspicious for melanoma.
Two relatively small nevi were on the left abdomen at about 4 o’clock from the navel. Two years later, the mole closer to the navel had become very prominent and was circled as #60. (The smaller, more distant mole did not change.) The nevus was 8 millimeters in diameter. It had very indistinct borders, an irregular outline, and an asymmetric shape. The color varied from reddish dark brown to a very dark brown in the center portion. The lesion was removed because it was changing in ways very suspicious for melanoma (rapid growth, dark coloration, and asymmetric shape).
The patient reported that the mole was new and had grown much larger during the previous six months. The mole is large (7 millimeters in diameter), and contains a mixture of reds and browns. The area of very dark brown color in the right central part is especially concerning in a patient with very fair skin. The borders are indistinct and quite irregular. The mole is larger, darker, and more irregular than any of the moles nearby. The mole was removed because it was new, and had changed in size, color, and shape during a very short period of time.
The DN of interest (marked with an arrow and then circled as #30) was stable and appeared mainly unchanged for many years. The DN was partially flat and had an irregular outline and indistinct borders. It contained multiple shades of tan and brown. After a long period of relative stability, over two years, it increased in size to about 8 millimeters in diameter and darkened when most other moles had faded. The mole was removed five months after the picture shown in image 5 because it continued to darken over a short period of time.
Over two and a half years, the small tan mole of interest developed into a DN which changed in size, color, shape and surface. It grew to about 8 millimeters in diameter. A very dark brown portion developed at top of the mole. Then most of the rest of the mole darkened considerably while the central area lightened greatly. It was darker than all of the other moles and quite irregular in shape. The mole was removed because it was changing in ways suspicious for melanoma.
While cancer of the skin is the most common form of cancer, it is also the most preventable. One can reduce one’s risk of skin damage and skin cancer by seeking shade under an umbrella, tree, or other shelter before you need relief from the sun. Your best practice to protect your skin is to use sunscreen or wear protective clothing when you’re outside—even when you’re in the shade. Prevention practices, regular self-exams and having one’s doctor exam any mole changes are the keys to living a skin cancer free life.
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