Additional Evaluation After A Diagnosis Of Melanoma
After an initial diagnosis of melanoma, you will be referred to a specialist. The doctor will take a complete medical history, noting any symptoms or signs,
and perform a complete physical examination, including a total skin examination and lymph node examination. The focus of these examinations is to identify risk factors and signs or symptoms that may indicate melanoma has spread beyond the original site.
The extent of the initial evaluation is based on the primary melanomas risk of recurrence. For most people with thin melanoma , no further search for metastases or spread is generally necessary. For people with higher-risk melanoma, more extensive testing, such as imaging tests described below, may be considered, but this usually occurs after surgical management has been completed. Therefore, the extent of the initial evaluation for a person with newly diagnosed melanoma is based on the stage of melanoma and discussions with the team of doctors.
Depending on the results of the evaluation, including the pathology report of the primary melanoma tumor, further testing for high-risk or later-stage melanoma may include the following:
Lymphatic mapping and sentinel lymph node biopsy
Lymphatic mapping and SNB are usually recommended for people with a melanoma that is more than 1.0 mm thick or has ulceration.
This information is based on the ASCO guideline, Sentinel Lymph Node Biopsy for Melanoma. Please note that this link takes you to another ASCO website.
What Else Should I Know About Treatment For Advanced Melanoma
Thanks to research breakthroughs, more patients diagnosed with advanced melanoma are living longer some for years.
Because these breakthrough are relatively recent, its important to:
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Work with a team of melanoma specialists.
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Ask your melanoma specialists if any of the newer treatments are appropriate for you.
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Realize that no one treatment works for everyone, so you may need to try different treatments or combine treatments.
Researchers continue to study advanced melanoma, and next-generation treatments are now being studied in clinical trials. If you want to know whether you are a match for a trial, you can find out if there are any relevant trials at, Clinical Trial Finder.
Related AAD resources
ReferencesChukwueke U, Batchelor T, et al. Management of brain metastases in patients with melanoma. J Oncol Pract. 2016 12:536-42.
Emory Medical Center. A year in the life: Jimmy Carter shares his cancer experience. Posted July 11, 2016. Last accessed March 26, 2018.
Podlipnik S, Carrera C, et al. Performance of diagnostic tests in an intensive follow-up protocol for patients with American Joint Committee on Cancer stage IIB, IIC, and III localized primary melanoma: A prospective cohort study. J Am Acad Dermatol. 2016 75:516-24.
Nordmann N, Hubbard M, et al. Effect of gamma knife radiosurgery and programmed cell death 1 receptor antagonists on metastatic melanoma. Cureus. 2017 9: e1943.
What Is Meant By A Sentinel Lymph Node Biopsy For Melanoma
Melanomas are rapidly spreading tumors. The first lymph node that a melanoma travels to is called the sentinel lymph node. A sentinel lymph node biopsy is a type of surgery in which a few lymph nodes nearest to the melanoma are removed and examined for the presence of melanoma cells. It is a minimally invasive surgery with a low risk of side effects. Sentinel lymph node biopsy or SLNB helps the doctor know about the stage of melanoma to plan appropriate treatment for the patient. It also helps the doctor to know the patients chances of recovery .
During a sentinel lymph node biopsy:
- A dye or a tracer material is injected into the site of the tumor or mass that help stain the sentinel nodes during the procedure.
- The stained path from the tumor to the sentinel lymph nodes is mapped using an instrument that detects the tracer.
- The surgeon removes the sentinel lymph nodes and sends them for lab examination.
If the sentinel lymph node biopsy detects cancer cells, the surgeon removes all local lymph nodes or destroys them with radiation therapy or do both, the surgery as well as radiation therapy.
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Understanding Your Stage Of Squamous Cell Skin Cancer
The stage is based on the size of the tumor, how deeply into the skin it has grown, and whether cancer has spread beyond the tumor to the lymph nodes. Your doctor will look at the results of the biopsy to determine the stage. If you have squamous cell skin cancer, your doctor may also recommend imaging such as CT or PET-CT scan, or testing lymph nodes near the tumor to see if the cancer has spread beyond the skin.
Most non-melanoma skin cancers are Stage 0 or Stage 1. Stage 3 and 4 are relatively rare. Based on the type of cancer, the stage of cancer, your overall health, and other factors, your doctor works with you to develop a treatment plan.
What Is Skin Cancer
Cancer can start any place in the body. Skin cancer starts when cells in the skin grow out of control.
Skin cancer cells can sometimes spread to other parts of the body, but this is not common. When cancer cells do this, its called metastasis. To doctors, the cancer cells in the new place look just like the ones from the skin.
Cancer is always named based on the place where it starts. So if skin cancer spreads to another part of the body, its still called skin cancer.
The skin
Ask your doctor to use this picture to show you where your cancer is
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Taking Care Of Yourself
Hearing that your cancer has spread is scary, but a lot of research is underway to find new treatments. And there are treatments available to try to stop the disease from spreading, so you can live longer.
It’s important to have support and to talk about your fears and feelings, too. Your doctor can help you find a cancer support group.
These tips may help you feel better during melanoma treatment:
- If you lose your appetite, eat small amounts of food every 2 to 3 hours instead of bigger meals. A dietitian can give you other tips on nutrition and eating during your cancer treatment. Ask your doctor for a referral.
- Exercise can help you feel better overall and fight fatigue. But listen to your body, and balance rest and activity.
- Get the kind of emotional support that’s right for you. It could be from family, friends, your cancer support group, or a religious group.
Spreading To The Organs
After the cancer has spread to the lymph nodes, the lymph nodes and/or blood vessels help the cancer move to other areas of the body, like the organs. Which organ it will spread to first, varies depending on where the cancer started, the type and the person, but the liver, lungs, and brain are common sites for metastases.
Once its in the organs, it is known as stage four melanoma.
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Biological Therapies And Melanoma
Biological therapies are treatments using substances made naturally by the body. Some of these treatments are called immunotherapy because they help the immune system fight the cancer, or they occur naturally as part of the immune system. There are many biological therapies being researched and trialled, which in the future may help treat people with melanoma. They include monoclonal antibodies and vaccine therapy.
Benign Tumors That Start In Melanocytes
A mole is a benign skin tumor that develops from melanocytes. Almost everyone has some moles. Nearly all moles are harmless, but having some types can raise your risk of melanoma. See Risk Factors for Melanoma Skin Cancer for more information about moles.
A Spitz nevus is a kind of mole that sometimes looks like melanoma. Its more common in children and teens, but it can also be seen in adults. These tumors are typically benign and dont spread. But sometimes doctors have trouble telling Spitz nevi from true melanomas, even when looking at them under a microscope. Therefore, they are often removed, just to be safe.
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The 4 Stages Of Melanoma
Two main things determine the stage of melanoma: The thickness or depth of the tumor and how far it has spread when its diagnosed, explains David Polsky, M.D., dermatologist at NYU Langone Medical Center in New York City. In stages 0, 1, and 2, the melanoma is limited to the skin. In stage 3, its spread to the lymph nodes, small structures throughout your body that help filter fluids and fight infection. In the most advanced stage, stage 4, melanoma cells have broken away from the original tumor, traveled through the body and formed a new tumor somewhere else.
Early Detection Prevents Melanoma From Spreading
While there are still many mysteries when it comes to why and how melanoma develops, it is certain that the sooner melanoma is discovered, the lower the chances of it spreading and becoming deadly. Thats why its essential to perform regular skin checks and know the symptoms of melanoma so you can catch it early.
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Melanoma Of The Head And Neck Treatment
Surgical resection with wide margins and often sentinel lymph node biopsy is required for melanoma that has not spread. Thin tumors, up to 1 millimeter thick, can be resected with 1-centimeter margins around the tumor. The greater the depth of invasion, the larger the margin required, up to 2 centimeters. Mohs surgery is not suitable for melanoma because the diagnosis often requires special pathologic staining that is not part of the Mohs technique.
To obtain a sentinel lymph node biopsy, a preoperative sentinel node localization study is performed: A radionuclide tracer is injected in the melanoma, then a radionuclide uptake SPECT or SPECT-CT scan shows which nodes the tracer spreads to first. These sentinel nodes may or may not contain melanoma: They are the nodes that a melanoma that has spread would first encounter, and contain melanoma cells when melanoma has spread to lymph nodes. Because there are hundreds of lymph nodes in the head and neck, your surgeon will use a gamma probe at surgery to identify and confirm that the nodes selected for removal are the sentinel nodes.
When enlarged lymph nodes are present, a neck dissection is performed at the time of surgery. If distant spread is detected during the workup that is, melanoma has spread to other organs immunotherapy and sometimes radiation therapy are used for treatment.
Johns Hopkins Head and Neck Cancer Surgery
What Increases The Risk Of Melanoma
Unusual moles, exposure to sunlight, and health history can affect the risk of developing melanoma.
Anything that increases your risk of getting a disease is called a risk factor. Risk factors for melanoma include the following:
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How Is Metastasis Detected
If your doctor suspects that your melanoma may have spread, there are several tools available to verify the diagnosis. These include a blood test for lactate dehydrogenase , which increases when melanoma metastasizes, and imaging studies, such as chest X-ray, computed tomography , magnetic resonance imaging , positron emission tomography and ultrasound.
The doctor may also need to take a sample of your lymph nodes, using a procedure called “sentinel lymph node mapping.” If confirmed, there are many treatments available, including chemotherapy, immunotherapy, radiation therapy and surgery.
How Does The Doctor Know I Have Melanoma
A new spot on your skin or a spot thats changing in size, shape, or color may be a warning sign of melanoma. If you have any of these changes, have your skin checked by a doctor.
The doctor will ask you questions about when the spot on your skin first showed up and if it has changed in size or the way it looks. The rest of your skin will be checked. During the exam your doctor will check the size, shape, color and texture of any skin changes. If signs are pointing to melanoma, more tests will be done.
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Tests That May Be Done
The doctor will ask you questions about when the spot on your skin first showed up and if it has changed in size or the way it looks or feels. The rest of your skin will be checked. During the exam your doctor will check the size, shape, color and texture of any skin changes. If signs are pointing to skin cancer, more tests will be done.
Skin biopsy
In a biopsy, the doctor takes out a small piece of tissue to check it for cancer cells. A biopsy is the only way to tell for sure if you have skin cancer and what kind it is.
There are many types of skin biopsies. Ask your doctor what kind you will need. Each type has pros and cons. The choice of which type to use depends on your own case.
In rare cases basal and squamous cell skin cancer can spread to the nearby lymph nodes Ask your doctor if your lymph nodes will be tested.
Basal and squamous cell cancers don’t often spread to other parts of the body. But if your doctor thinks your skin cancer might spread, you might need imaging tests, such as MRI or CT scans.
Common Places For Melanoma To Spread
Melanoma can spread from the original site on your skin and form a tumor in any organ or body tissue, but its most likely to metastasize to the lymph nodes, liver, brain, lungs, and less commonly, the bones. Melanoma really likes the brain and the liver, says Lisa Zaba, M.D., dermatologic oncologist at Stanford Medical Center in San Jose, CA. If you notice any of the following red flags, it might mean your melanoma has spread and warrants a call to your doctor right away.
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Keeping Health Insurance And Copies Of Your Medical Records
Even after treatment, its very important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.
At some point after your cancer treatment, you might find yourself seeing a new doctor who doesnt know about your medical history. Its important to keep copies of your medical records to give your new doctor the details of your diagnosis and treatment. Learn more in Keeping Copies of Important Medical Records.
Complementary And Alternative Treatments
It’s common for people with cancer to seek out complementary or alternative treatments. When used alongside your conventional cancer treatment, some of these therapies can make you feel better and improve your quality of life. Others may not be so helpful and in some cases may be harmful. It is important to tell all your healthcare professionals about any complementary medicines you are taking. Never stop taking your conventional treatment without consulting your doctor first.All treatments can have side effects. These days, new treatments are available that can help to make many side effects much less severe than they were in the past.
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How Do You Treat Stage 4 Melanoma
The good news is that even stage 4 melanoma can be treated. The sooner the cancer is found, the sooner it can be removed and the higher your chances are for recovery. Stage 4 melanoma also has the most treatment options, but these options depend on:
- where the cancer is
- how advanced the cancer has become
- your age and overall health
How you respond to treatment also affects your treatment options. The five standard treatments for melanoma are:
- surgery: to remove the primary tumor and affected lymph nodes
- chemotherapy: a drug treatment to stop growth of cancer cells
- radiation therapy: the application of high-energy X-rays to inhibit growth and cancer cells
- immunotherapy: treatment to boost your immune system
- targeted therapy: the use of drugs or other substances to attack cancer drugs
Other treatments may also depend on where the cancer has spread to. Your doctor will discuss your options with you to help map out a treatment plan.
How Can Melanoma Spread To The Brain
While melanoma normally begins in the skin, cancer cells sometimes grow and break away from the place where the cancer began. The cells that break away often travel to nearby:
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Blood vessels
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Lymph nodes
Once in the blood or lymph , the melanoma cells often travel to the lungs, liver, spleen, or brain.
Cancer cells growing bigger than normal cells
Cancer cells can grow, break off, and spread.
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Subtypes Of Melanoma Defined By Gene Mutations
Melanoma cells are usually classified by histologic types , which are based on how the cells appear under a microscope. Recent information has shown that melanoma can also be classified into molecular subtypes. These molecular subtypes are based on the specific genetic changes in the melanoma cells, called mutations. These genetic changes include:
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BRAF mutations. The most common genetic change in melanoma is found in the BRAF gene, which is mutated in about 50% of cutaneous melanomas.
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NRAS mutations. NRAS is mutated in the tumors of around 20% of people with melanoma.
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NF-1 mutations. NF-1 mutations are present in the tumors of around 10% to 15% of people with melanoma.
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KIT mutations. These mutations occur more commonly in melanomas that develop from mucus membranes, melanomas on the hands or feet, or melanomas that occur in chronically sun-damaged skin, such as lentigo maligna melanoma.
Some melanomas do not have mutations in the BRAF, NRAS, NF-1, or KIT genes. These tumors have other genetic changes that cause them to grow. Researchers are trying to target other mutations found in these tumors in clinical trials.
The classification of melanoma into different subtypes based on genetic changes can have a major effect on the types of treatment used for advanced melanoma. Targeting specific mutated genes is an important way of treating invasive melanoma, called targeted therapy. Learn more about targeted therapy in the Types of Treatment and Latest Research sections.