Familial Malignant Melanoma

What is familial malignant melanoma?

Familial malignant melanoma is a term used in referring to families in which 2 or more first-degree relatives, such as a parent, sibling, and/or child, have a type of skin cancer called melanoma . Cancer begins when healthy cells begin to change and grow, out of control forming a mass called a tumor. Overall, about 8% of people newly diagnosed with melanoma have a first-degree relative with melanoma. A much smaller percentage of patients, about 1% to 2%, have 2 or more close relatives with melanoma.

Individuals in melanoma-prone families frequently have moles called dysplastic nevi. Dysplastic nevi are large, flat, irregular, asymmetric, variably pigmented moles. They occur primarily on sun-exposed skin, but they can also occur in areas that are not exposed to the sun. The moles must be monitored very carefully for any change in size, shape, and color to watch for cancer. In the United States, the average age when melanoma is diagnosed in people with familial melanoma is in the 30s; the average age when melanoma is diagnosed in the general population is in the 50s.

What causes familial melanoma?

Familial melanoma is a genetic or inherited condition. This means that the risk of melanoma can be passed from generation to generation in a family. To date, 2 genes have been primarily linked to familial melanoma, called CDKN2A and CDK4 . A mutation (alteration) in either of these genes gives a person an increased risk of melanoma. However, alterations in these 2 genes only account for a small percentage of familial melanoma.

CDKN2A is unusual because it affects 2 separate proteins that have different functions: one is called p16, and one is called p14ARF. Both CDKN2A and CDK4 play important roles in controlling when cells divide. Studies of families with mutations in CDKN2A from Europe, North America, and Australia have shown that the risk of melanoma varies by geographic area. The reasons for these differences are not fully understood. There may be differences in the amount of sun they receive, other individual or genetic differences, or a combination of these factors. In addition, there may also be an increased risk of pancreatic cancer .

Within melanoma-prone families with known genetic mutations, dysplastic nevi (moles) and sun exposure are independent risk factors for melanoma. Recently it has been discovered that variations in another gene, MC1R , alter the risk of melanoma, both in individuals with CDKN2A mutations and in individuals without CDKN2A mutations. MC1R is important in regulating pigment in the body; variations have been associated with freckling and red hair.

Other inherited genes are associated with an increased risk of melanoma. For instance, xeroderma pigmentosum (XP) is a rare disorder in which people have a mutation in a gene needed for repair of ultraviolet radiation (sunlight)-induced DNA damage. People with XP have an extremely high rate of skin cancer, including melanoma. A hereditary breast cancer gene called BRCA2 is associated with a slightly increased risk of melanoma. Scientists believe that there are other genes not yet identified that also increase the risk of melanoma. Learn more about the risk factors of melanoma . Research is ongoing to learn more about familial melanoma.

How is familial melanoma susceptibility inherited?

Normally, every cell has 2 copies of each gene: 1 inherited from the mother and 1 inherited from the father. Familial melanoma susceptibility follows an autosomal dominant inheritance pattern, in which case a mutation happens in only 1 copy of the gene. This means that a parent with a gene mutation may pass along a copy of their normal gene or a copy of the gene with the mutation. Therefore, a child who has a parent with a mutation has a 50% chance of inheriting that mutation. A brother, sister, or parent of a person who has a mutation also has a 50% chance of having the same mutation. However, if the parents test negative for the mutation (meaning each person’s test results found no mutation), the risk to the siblings significantly decreases but their risk may still be higher than an average risk.

Options exist for people interested in having a child when a prospective parent carries a gene mutation that increases the risk for this hereditary cancer syndrome. Preimplantation genetic diagnosis (PGD) is a medical procedure done in conjunction with in-vitro fertilization (IVF). It allows people who carry a specific known genetic mutation to reduce the likelihood that their children will inherit the condition. Eggs are removed and fertilized in a laboratory. When the embryos reach a certain size, 1 cell is removed and is tested for the hereditary condition in question. The parents can then choose to transfer embryos which do not have the mutation. PGD has been in use for over 2 decades, and it has been used for several hereditary cancer predisposition syndromes. However, this is a complex procedure with financial, physical, and emotional factors to consider before starting. For more information, talk with an assisted reproduction specialist at a fertility clinic.

How common is familial melanoma?

Most cases of melanoma are sporadic, meaning it occurs by chance. The number of people who have an inherited risk of melanoma is unknown, but the number is thought to be low. As explained above, it is estimated that about 8% of people with melanoma have a first-degree relative with melanoma, and about 1% to 2% of people with melanoma have 2 or more close relatives with melanoma.

How is familial melanoma diagnosed?

Familial melanoma is suspected when 2 or more close relatives have invasive melanomas, meaning the melanoma has spread to other parts of the body. In areas of higher sun exposure, like the southern United States or Australia, the frequency of sporadic melanoma is higher, so familial melanoma is not diagnosed unless 3 or more close relatives have invasive melanoma. Familial melanoma may also be suspected if a single family member has multiple melanomas.

Genetic testing for mutations in the CDKN2A gene is commercially available. However, genetic test results are unlikely to change screening recommendations or clinical care for people who have had melanoma or people who have a strong family history of melanoma. Most families with familial melanoma will not even have a genetic mutation identified. Other genes that may be involved can be found through an evaluation from a genetic counselor or physician.

What are the estimated cancer risks associated with familial melanoma?

A person with a hereditary risk of melanoma has a greatly increased risk of developing melanoma during their lifetime.

There is also an increased risk of pancreatic cancer in families with familial melanoma and CDKN2A mutations, but this is relatively rare. Brain tumors have also been reported in a few families. With XP, there is an increased risk of other skin cancers, such as squamous and basal cell carcinomas. With the BRCA2 mutation, there is an increased risk of breast cancer, ovarian cancer, prostate cancer, and pancreatic cancer.

What are the screening options for familial melanoma?

Anyone with a parent, sibling, or child who has had melanoma should be carefully monitored for melanoma themselves. In people that have had melanoma, thorough skin exams should initially be performed every 3 to 6 months by a dermatologist, which is a doctor who specializes in skin problems, a nurse specializing in dermatology, or another specially trained health care provider to monitor any pigmented lesions (mole or spot). It is important to watch moles closely for any signs of change in shape, size, or color . Dermatologists may take pictures of the skin and moles, known as mole mapping, or view moles with a hand-held device known as a dermatoscope. This may be helpful to show changes over time. Any suspicious moles or other skin changes should be removed by a doctor so the tissue can be analyzed under a microscope.

In families known or strongly suspected to have familial melanoma, children should begin screening by age 10. Family members should also perform regular self-examinations to look for skin changes. Due to the high risk of developing more than 1 melanoma, people with familial melanoma should avoid sun exposure and take steps to protect themselves when outdoors. Learn more about protecting your skin from the sun .

Screening recommendations may change over time as new technologies are developed, and more is learned about familial melanoma. It is important to talk with your doctor about appropriate screening tests.

Learn more about what to expect when having common tests, procedures, and scans .

Questions to ask the health care team

If you are concerned about your risk of cancer, talk with your health care team. It can be helpful to bring someone along to your appointments to take notes. Consider asking your health care team the following questions:

• What is my risk of melanoma?

• What can I do to reduce my risk of cancer?

• What are my options for cancer screening?

If you are concerned about your family history and think that you or other family members may have familial melanoma, consider asking the following questions:

• Does my family history increase my risk of melanoma?

• Does it suggest the need for a cancer risk assessment for me and my family?

• Will you refer me and my family to a genetic counselor or other genetics specialist?

• Should my family or I consider genetic testing ?

• What preventive measures do you recommend for me and my family to reduce the risk of skin cancer?

What preventive measures do you recommend for me and my family?