What Is Metastatic Melanoma
Melanoma is a cancer that begins in the melanocytes . Metastatic melanoma is considered to be a late form of stage IV of melanoma cancer and occurs when cancerous melanoma cells in the epidermis metastasize and progress to other organs of the body that are located far from the original site to internal organs, most often the lung, followed in descending order of frequency by the liver, brain, bone and gastrointestinal tract 1). The two main factors in determining how advanced the melanoma is into Stage IV are the site of the distant metastases and whether or not the serum lactate dehydrogenase level is elevated. LDH , an enzyme found in your blood and almost every other cell of your body, turns sugar into energy, and the more you have in your blood or other body fluid, the more damage has been done to your bodys tissues.
It is crucial to diagnose melanoma in its early stages before it metastasizes, as once it has spread, it is difficult to locate its origin and so treatment and patients survival rate tends to be hindered 2).
An estimated 178,560 cases of melanoma will be diagnosed in the U.S. in 2018 3). Of those, 87,290 cases will be in situ , confined to the epidermis , and 91,270 cases will be invasive, penetrating the epidermis into the skins second layer 4).
Melanomas can develop anywhere on the skin, but they are more likely to start on the trunk in men and on the legs in women. The neck and face are other common sites.
New Hope For Beating Skin Cancers Deadliest Form
It starts as a tiny dark spot on your calf or the crook of your neck or your back. Its probably blotchy, like a Rorschach test, and if a doctor notices it, she is likely to take a second look. Id like to examine this one more closely, she might say about the mark on your skin that youd perhaps never even noticed. And its often good news to hear a doctor say that, because if you catch this little mass of dark, feisty cells before they spread, the inkblot cant seep into your body and stain your liver or bones or brain with cancer.
While relatively rare, with 21 new cases per 100,000 people in the United States each year, melanomas are the most dangerous form of skin cancer that humans develop. They begin when melanocytes, cells that produce and contain the pigment melanin and dictate the tone of a persons skin, mutate and start dividing too quickly, forming these telltale blotches. But once a melanoma has advanced from being an isolated group of cells on the skin and has sent scouts to other parts of the body, its notoriously hard to treat, despite its small size.
Gram for gram, melanoma is the most deadly form of skin cancer, says Stanford dermatologist and melanoma program director Susan Swetter, MD. Differences in survival drop dramatically with only a few millimeters of increased tumor thickness on the skin.
Metastatic Melanoma Life Expectancy
The 5-year survival rate for a metastatic melanoma is about 15% to 20% 7). The 10-year survival is about 10% to 15% 8). The outlook is better if the spread is only to distant parts of the skin or distant lymph nodes rather than to other organs, and if the blood level of lactate dehydrogenase is normal.
- The survival differences among M categories will be useful for clinical trial stratification however, the overall prognosis of all patients with stage IV melanoma remains poor, even among patients with M1a. For this reason, the Melanoma Staging Committee recommended no stage groupings for stage IV.
Table 2. American Joint Committee on Cancer TNM system for Stage 4 Melanoma
- A sore that doesnt heal
- Spread of pigment from the border of a spot into surrounding skin
- Redness or a new swelling beyond the border of the mole
- Change in sensation, such as itchiness, tenderness, or pain
- Change in the surface of a mole scaliness, oozing, bleeding, or the appearance of a lump or bump
Be sure to show your doctor any areas that concern you and ask your doctor to look at areas that may be hard for you to see. Its sometimes hard to tell the difference between melanoma and an ordinary mole, even for doctors, so its important to show your doctor any mole that you are unsure of.
Metastatic melanoma in the brain
Figure 2. Metastatic melanoma in the brain
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Your May Experience Side Effects
The vast majority of patients who receive immunotherapy will have little to no side effects, says Dr. Betof Warner. Its a huge change from the days when patients were on chemotherapy and were profoundly nauseous, vomiting, and had suppressed immune systems. Still, side effects can occur, including flu-like fever, aches, fatigue, and nausea. The risk of side effects with targeted therapy is a bit higher, but Dr. Betof Warner says they tend to disappear faster. These can include rashes, headaches, joint pain. And more seriously, kidney failure, bleeding, and heart and liver problems.
Recognizing The Signs And Symptoms
The most noticeable sign of melanoma is the appearance of a new mole or a change in an existing mole or birthmark. People should be aware of any pigmented areas on the skin that appear abnormal in color, shape, size, or texture.
People with stage 4 melanoma may also have ulcerated skin , which is skin with tiny breaks on the surface. These ulcerations can bleed.
Another sign is swollen or hard lymph nodes, which a doctor can confirm by carrying out a physical examination. Other tests include blood tests and imaging scans to confirm the presence of cancer and check how much it has spread.
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Stage : Melanoma In Situ
The earliest stage of melanoma is stage 0, also known as melanoma in situ or carcinoma in situ. In situ is a Latin phrase that means in position, and this diagnosis means that the cancer cells are present only in the epidermisthe bodys most superficial layer of skinand nowhere else.
This diagnosis has a very good prognosis, Noelani González, MD, an instructor of dermatology at the Mount Sinai Icahn School of Medicine in New York City, tells Health. People with localized melanomas who are treated quickly have a 5-year survival rate of 97%meaning they are, on average, about 97% as likely to still be alive in five years as people who dont have these cancers.
Treatment for this stage cancer involves a wide excision surgery, where the affected skin is cut away and the wound is stitched and bandaged. The skin will be removed with margins, explains Dr. González. That means that some normal skin will also be removed around the edges to make sure there arent any cancer cells left over.
The removed skin is then looked at under a microscope to ensure that all of the cancer was removed with clean margins, says Dr. González. Because stage 0 cancer has not spread to any other tissues or organs, no further treatment is required.
If Youve Been Diagnosed With Stage Iv Or Even Stage Iii Melanoma Youll Likely Be Wondering If Youll Be Alive 30 Years From Now If Youre Middle Age Or Younger
In general, survival rate statistics for melanoma are generally calculated at five years and 10 years after initial diagnosis, says Kara Shah, MD, an adult and pediatric dermatologist and founder of Kenwood Dermatology in Cincinnati, OH.
The five-year survival rate for metastatic melanoma is only four percent, according to the National Cancer Institute Surveillance, Epidemiology and End Results Program.
Stage IV melanoma involves distant metastasis to other body organs or to distant areas of skin, says Dr. Shah.
For local disease the five-year survival is 84 percent.
While melanoma is unlikely to recur after more than 10 years since diagnosis, it does recur in a small minority of patients , says Dr. Shah.
The Braf Gene Mutation And Melanoma
Roughly half of all documented melanoma cases present with mutations in the BRAF gene. The melanoma cells that have these changes create a BRAF protein, which aids them in their growth. If a person with the BRAF gene mutation has melanoma, knowing about the mutation is of great benefit for treatment because healthcare providers can use targeted therapy to inhibit the BRAF gene mutation from aiding in the growth of the cancer.
If a diagnosis of melanoma is already established, the healthcare provider will look at two factors to determine how advanced a stage 4 melanoma has become: the location of the distant tumors and an elevated level of serum lactate dehydrogenase , which is an enzyme responsible for turning sugar into energy. The higher the LDH level in body fluids, the more damage the cancer has done.
Treatments For Stage Iv Metastatic Melanoma
In order to treat stage IV melanoma, the primary tumor and any enlarged lymph nodes to which the cancer has spread may be surgically removed or treated with radiation.
Cancer that has metastasized to internal organs may also be surgically removed, depending on whether the tumors are causing symptoms, where the tumors are located, and how many tumors have formed. For metastases that cannot be removed, treatment options include radiation therapy, chemotherapy, immunotherapy, or targeted therapies.
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What Do Stage 4 Tumors Look Like
A change to an existing mole or normal skin can be the first sign that the cancer has spread. But the physical symptoms of stage 4 melanoma arent the same for everyone. A doctor will diagnose stage 4 melanoma by looking at the primary tumor, the spread to nearby lymph nodes, and whether the tumor has spread to different organs. While your doctor wont base their diagnosis only on what your tumor looks like, part of their diagnosis involves looking at the primary tumor.
Final Point To Consider
Current survival statistics are based on previous populations going back at least five years, and do not apples-to-apples reflect the next five, let alone 10, years of newly diagnosed cases of melanoma.
Dr. Shah is triple board certified: general dermatology, pediatric dermatology and general pediatrics. Her special interests include melanocytic nevi , melanoma, psoriasis, acne, atopic dermatitis/eczema, hair and nail disorders, birthmarks and genetic skin diseases.
Lorra Garrick is a former personal trainer certified by the American Council on Exercise. At Bally Total Fitness she trained clients of all ages for fat loss, muscle building, fitness and improved health.
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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.
What Are The Prognosis And Survival Rates For Metastatic Melanoma
The prognosis for thin melanomas completely removed by surgery remains quite good although patients require long-term monitoring to watch for both new melanomas as well as evidence of late recurrence and previously undiagnosed metastasis of the original one. Survival rates for melanoma, especially for metastatic melanoma, vary widely according to many factors, including the patient’s age, overall health, location of the tumor, particular findings on the examination of the biopsy, and the depth and stage. Survival statistics are generally based on five-year survival. Much of the success reported for the targeted therapies focus on “disease free” time because, in many cases, the actual five-year survival is not affected. It is hoped that combination therapy with two or more agents targeting different stages of the melanoma cell cycle will change that.
- For stage 1 , five-year survival is near 100%.
- For stage 2 , five-year survival is 80%-90%.
- For stage 3 , five-year survival is around 50%.
- For stage 4 , five-year survival is 10%-25% depending upon sex and other demographic factors.
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Clinical Characteristics Of The Patients With Brain Metastasis
A total of 79 patients were identified for this analysis. The demographic and baseline characteristics of the patients are described in Table . The median time from primary melanoma diagnosis to brain metastasis was 3.2 years , and the median time from stage IV diagnosis to brain metastasis was 2 months . Forty patients had prior extracranial metastasis at the time of initial brain metastasis 28 had concurrent extracranial metastasis at the time of brain metastasis and 5 patients developed extracranial metastasis subsequently, defined as at least 1 month after initial diagnosis of brain metastasis. Six patients had brain metastasis as the only site of distant metastasis until death or at the time of the analysis.
Table 1 Patient characteristics and treatment
The cerebrum was the most common site of brain metastasis , and 21.5% and 8.9% patients had metastasis to the cerebellum and pons, respectively. Thirty-nine had a solitary brain metastasis at the initial brain metastasis diagnosis, and the largest size of the initial brain metastasis was 10 mm or less in 31.7%. Thirty-six patients had neurological symptoms associated with brain metastasis. Forty-nine of the 79 patients had received systemic therapy prior to or at the time of brain metastasis, including checkpoint inhibitors, targeted drugs, cytotoxic chemotherapy and/or cytokine therapy.
Survival Rate For Stage 4 Cancer Depends On Factors Like The Cancer Types Treatments Patient’s Health Condition Etc Work With Your Doctor For Best Results
When one is diagnosed to have Stage IV cancer, the immediate concern is if the person will be able to survive the disease. This concern, also medically known as the prognosis, depends on many factors, including availability of treatment and one’s general health condition. Knowing what stage one’s cancer is mostly determines his probability of surviving based on research. Cancer staging therefore helps the doctor to advise the patient about his condition and what forms of treatment are suitable, and to predict his survival rate in the next few years.
Cancer survival rate refers to the percentage of patients afflicted with a certain form of cancer who survive the disease for a specified amount of time. Statistics often refer to a five-year period where scientific surveys on these patients are based, although these data do not specify whether the patients are still undergoing treatment or are completely cancer-free after five years. An over-all five-year survival rate of 80% would mean that for every 100 patients with the disease, 80 would probably live for at least another five years, and 20 would probably not survive this period of time.
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Central Nervous System Changes
Patients dying of stage IV melanoma may exhibit changes in their mentation.Their activity decreases and they may sleep quite a bit. The Hospice Foundation notes that patients may not respond to conversation or questions 2. Patients with brain metastasis from the melanoma may lapse into a coma, a deep state of unconsciousness from which they cannot be aroused. Hospice states that even though patients are in a coma they may still hear what is said and feel pain. One of the last senses to go before death is hearing. As patients near death, they may experience sensory changes and hallucinate or hear things that are not there.
- Patients dying of stage IV melanoma may exhibit changes in their mentation.
- As patients near death, they may experience sensory changes and hallucinate or hear things that are not there.
What To Ask Your Doctor About Stage Iv Melanoma
When your doctor tells you that you have Stage IV melanoma, it can be frightening and overwhelming. But it is important to use the time with all of your doctors to learn as much about your cancer as you can. Your doctors will provide you important information about your diagnosis, prognosis, and treatment options.
It is often helpful to bring a friend or family member with you to your doctor appointments. This person can lend moral support, ask questions, and take notes.
The following questions are those you may want to ask your doctors. Some of the questions are for your medical oncologist, some are for your surgical oncologist, and some for your dermatologist. Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something s/he has said so that you can better understand it. You may find it helpful to print out these questions and bring them with you to your next appointment.
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Diagnosis Of Metastatic Melanoma
Your care team may use several tests to diagnose metastatic melanoma.
If theres evidence of a primary tumor, a biopsy may be taken. For this, a small section of suspected cancerous skin is removed with a razor, scalpel or small punch tool. The removed tissue is examined under a microscope to determine whether its melanoma.
Additional tests are needed to determine whether the cancer is metastatic melanoma, or if theres no visible primary tumor. To test for metastatic melanoma, or melanoma that has spread to lymph nodes or distant parts of the body, your care team may perform the following tests.
- Lymph node mapping and sentinel lymph node biopsy : Your doctor may perform a physical exam of your lymph nodes and check for swelling or physical masses. If no tumors are found , an SLNB may be done. For an SLNB, a radioactive dye is injected to locate the primary tumor. Then, the doctor will remove the lymph nodes that the dye traveled to and check them for melanoma.
- Computed tomography scan, positron emission tomography scan, magnetic resonance imaging scan or ultrasound exam: Each of these scans is a noninvasive way to look inside your body and check for tumors.
- Blood chemistry studies: Cancer may cause elevated or abnormal levels of certain substances in your blood. A laboratory test can identify if your blood chemistry shows signs of a cancerous tumor.