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Skin Cancer (Melanoma)

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What is melanoma skin cancer?

Melanoma is a cancer that starts in a certain type of skin cell. To understand melanoma, it helps to know about the normal structure and function of the skin.

 Image show the difference between Ordinary Mole and Melanoma:

Melanoma skin cancers

Melanoma is a cancer that begins in the melanocytes. Other names for this cancer include malignant melanoma andcutaneous melanoma. Because most melanoma cells still make melanin, melanoma tumors are usually brown or black. But some melanomas do not make melanin and can appear pink, tan, or even white.

Melanomas can occur anywhere on the skin, but they are more likely to start in certain locations. The trunk (chest and back) is the most common site in men. The legs are the most common site in women. The neck and face are other common sites.

Having darkly pigmented skin lowers your risk of melanoma at these more common sites, but anyone can develop this cancer on the palms of the hands, soles of the feet, and under the nails. 

Melanomas can also form in other parts of your body such as the eyes, mouth, and genitals, but these are much less common than melanoma of the skin. Melanomas in these organs are discussed in our other documents.

Melanoma is much less common than basal cell and squamous cell skin cancers, but it is far more dangerous. Like basal cell and squamous cell cancers, melanoma is almost always curable in its early stages. But it is much more likely than basal or squamous cell cancer to spread to other parts of the body if not caught early.

Other skin cancers

Skin cancers that are not melanomas are sometimes grouped as non-melanoma skin cancers because they develop from skin cells other than melanocytes. They tend to behave very differently from melanomas and are often treated in different ways.

Non-melanoma skin cancers include basal cell and squamous cell cancers. They are by far the most common skin cancers, and actually are more common than any other form of cancer. Because they rarely spread (metastasize) to other parts of the body, basal cell and squamous cell skin cancers are less worrisome and are treated differently from melanoma. Merkel cell carcinoma is an uncommon type of skin cancer that is sometimes harder to treat.

What are the risk factors for melanoma skin cancer?

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking and excess sun exposure, can be changed. Others, like a person's age or family history, can't be changed.

But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And some people who get the disease may have few or no known risk factors. Even if a person with melanoma has a risk factor, it is often very hard to know how much that risk factor might have contributed to the cancer.

Scientists have found several risk factors that could make a person more likely to develop melanoma.

Ultraviolet (UV) light exposure: Ultraviolet (UV) radiation is a major risk factor for most melanomas. Sunlight is the main source of UV rays. Tanning lamps and beds are also sources of UV rays. People who get a lot of exposure to light from these sources are at greater risk for skin cancer, including melanoma.

Ultraviolet radiation is divided into 3 wavelength ranges:

UVA rays cause cells to age and can cause some damage to cells' DNA. They are linked to long-term skin damage such as wrinkles, but are also thought to play a role in some skin cancers.

UVB rays can cause direct damage to the DNA, and are the main rays that cause sunburns. They are also thought to cause most skin cancers.

UVC rays don’t get through our atmosphere and therefore are not present in sunlight. They do not normally cause skin cancer.

While UVA and UVB rays make up only a very small portion of the sun’s rays, they are the main cause of the damaging effects of the sun on the skin. UV rays damage the DNA of skin cells. Skin cancers begin when this damage affects the DNA of genes that control skin cell growth. Both UVA and UVB rays damage skin and cause skin cancer. UVB rays are a more potent cause of at least some skin cancers, but based on what is known today, there are no safe UV rays.

The amount of UV exposure a person gets depends on the strength of the rays, the length of time the skin is exposed, and whether the skin is protected with clothing or sunscreen.

The nature of the UV exposure may play a role in melanoma development. Many studies have linked the development of melanoma on the trunk (chest and back) and legs to frequent sunburns (especially in childhood). The fact that these areas are not constantly exposed to UV light may also be important. Some experts think that melanomas in these areas are different from those on the face and neck, where the sun exposure is more constant. And different from either of these are melanomas that develop on the palms of the hands, soles of the feet, under the nails, or on internal surfaces such as the mouth and vagina, where there has been little or no sun exposure.

Moles: A nevus (the medical name for a mole) is a benign (non-cancerous) pigmented tumor. Moles are not usually present at birth but begin to appear in children and young adults. Most moles will never cause any problems, but a person who has many moles is more likely to develop melanoma.

Dysplastic nevi: Dysplastic nevi (nevi is the plural of nevus), also called atypical nevi, often look a little like normal moles but also look a little like melanoma. They are often larger than other moles and have an abnormal shape or color.  They can appear on skin that is exposed to the sun as well as skin that is usually covered, such as on the buttocks and scalp.

A small number of dysplastic nevi may develop into melanomas. But most dysplastic nevi never become cancerous, and many melanomas seem to arise without a pre-existing dysplastic nevus.

Lifetime melanoma risk may be higher than 10% for people with many dysplastic nevi (sometimes referred to asdysplastic nevus syndrome). Dysplastic nevi often run in families. Someone with many dysplastic nevi and with several close relatives who have had melanoma has a very high lifetime risk of developing melanoma.

People with this condition should have very thorough, regular skin exams by a dermatologist (a doctor who specializes in skin problems). In some cases, full body photographs are taken to help the doctor recognize which moles are changing and growing. Many doctors recommend that these patients be taught to do monthly skin self-exams as well.

Congenital melanocytic nevi: Moles present at birth are called congenital melanocytic nevi. The lifetime risk of getting melanoma for people with congenital melanocytic nevi has been estimated to be between 0 and 10%, depending on the size of the nevus. People with very large congenital nevi have a greater risk, while the risk is less for those with small nevi. For example, the risk for melanoma in congenital nevi smaller than the palm of your hand is very low, while those that cover large portions of back and buttocks (“bathing trunk nevi”) have significantly higher risks.

Congenital nevi are sometimes removed by surgery so that they do not have a chance to become cancerous. Whether doctors advise removing a congenital nevus depends on several factors including its size, location, and color. Many doctors recommend that congenital nevi that are not removed should be examined at regular intervals by a dermatologist and that the patient should be taught how to do monthly skin self-exams.

Again, the chance of any single mole turning into cancer is very low. However, anyone with lots of irregular or large moles has an increased risk for melanoma.

Fair skin, freckling, and light hair: The risk of melanoma is more than 10 times higher for whites than for African Americans. Whites with red or blond hair, blue or green eyes, or fair skin that freckles or burns easily are at increased risk.

Family history of melanoma: Your risk of melanoma is greater if 1 or more first-degree relatives (parent, brother, sister, or child) has had melanoma. Around 10% of all people with melanoma have a family history of the disease.

The increased risk might be because of a shared family lifestyle of frequent sun exposure, a family tendency to have fair skin, or a combination of factors. It may also be due to gene changes (mutations) that run in a family. Gene mutations have been found in anywhere from about 10% to 40% of families with a high rate of melanoma.

Most experts do not recommend that people with a family history of melanoma have genetic testing to look for mutations, as it is not yet clear how helpful this is. Rather, experts advise that they do the following:

Have regular skin exams by a dermatologist

Thoroughly examine your skin once a month

Be particularly careful about sun protection and avoid artificial UV rays (such as those from tanning booths)

Personal history of melanoma:A person who has already had melanoma has an increased risk of getting melanoma again. About 5% of people with melanoma will develop a second one at some point.

Immune suppression: People who have been treated with medicines that severely suppress the immune system, such as organ transplant patients, have an increased risk of melanoma.

Age: Although melanoma is more likely to occur in older people, this is a cancer that is also found in younger people. In fact, melanoma is one of the most common cancers in people younger than 30 (especially younger women). Melanoma that runs in families may occur at a younger age.

Gender: In the United States, men have a higher rate of melanoma than women overall, although this varies by age. Before age 40, the risk is higher for women; after age 40 the risk is higher in men.

Xeroderma pigmentosum: Xeroderma pigmentosum (XP) is a rare, inherited condition resulting from a defect in an enzyme that normally repairs damage to DNA. People with XP have a high risk for developing melanoma and other skin cancers at a young age. Because people with XP are less able to repair DNA damage caused by sunlight, they can develop many cancers on sun-exposed areas of their skin.

Do we know what causes melanoma skin cancer?

Although researchers have found some things that can raise a person’s risk of melanoma,  it’s not yet clear exactly how these factors cause melanoma.

For example, while most moles never turn into a melanoma, some do. Researchers have found some changes inside benign nevus (mole) cells that may cause them to become melanoma cells. But it is still not known exactly why some moles become cancerous or why having many moles or atypical (dysplastic) moles increases your risk of developing melanoma.

Researchers have learned a great deal in recent years about how certain changes in DNA can make normal cells become cancerous. DNA is the chemical in each of our cells that makes up our genes – the instructions for how our cells function. We usually look like our parents because they are the source of our DNA. But DNA affects more than just how we look.

Some genes contain instructions for controlling when our cells grow, divide into new cells, and die. Genes that help cells grow and divide are called oncogenes. Genes that slow down cell division or cause cells to die at the right time are called tumor suppressor genes. Cancers can be caused by DNA changes that turn on oncogenes or turn off tumor suppressor genes. Changes in several different genes are usually needed for a cell to become cancerous.

Ultraviolet (UV) radiation can damage DNA. Sometimes this damage affects certain genes that control how and when cells grow and divide. If these genes do not work properly, the affected cells may form a cancer.

Most UV radiation comes from sunlight, but some may come from man-made sources such as tanning booths. Usually it's not clear exactly when UV exposure causes DNA damage that might eventually lead to cancer. Some of the damage may take place in the few years before the start of the cancer. But much of it may be due to exposures that happened many years earlier. Children and young adults often get a lot of intense UV sun exposure that may not result in an actual cancer until many years or even decades later.

Scientists have found that the DNA of certain genes is often damaged in melanoma cells. Most of these DNA changes are not inherited. They are more likely the result of damage caused by sunlight. Some people’s cells do not seem to repair their damaged DNA as well as others. These people may be more likely to develop melanoma.

The knowledge of how certain DNA changes lead to melanoma is now being used to help treat this disease. For example, about half of all melanomas have a change (mutation) in the BRAF oncogene that helps drive their growth. This change is not inherited. It seems to occur during the development of the melanoma. Drugs that specifically target cells with this gene change are now being used to treat these melanomas. Other drugs that target similar genes such as MEK are being studied as well. 

In some families with inherited melanomas, gene mutations that greatly increase the risk of melanoma are passed from one generation to the next. Familial (inherited) melanomas most often have changes in tumor suppressor genes such as CDKN2A (also known as p16) and CDK4 that prevent them from doing their normal job of controlling the growth of the cell. Scientists reason that this leads to overgrowth and eventually cancer.

Many other gene changes have been found in melanoma cells as well. Some of these may prove to be good targets for drugs to help treat or even prevent this disease.

Can melanoma skin cancer be found early?

Melanoma can often be found early. Everyone can play an important role in finding skin cancer early, when it is most likely to be cured.

Self-exam: It's important to check your own skin, preferably once a month. You should know the pattern of moles, blemishes, freckles, and other marks on your skin so that you'll notice any new moles or changes in existing moles.

Self-exam is best done in a well-lit room in front of a full-length mirror. Use a hand-held mirror to help look at areas that are hard to see, such as the backs of your thighs. Examine all areas, including your palms and soles, scalp, ears, nails, and your back (in men, about 1 of every 3 melanomas occurs on the back). Friends and family members can also help you with these exams, especially for those hard-to-see areas, such as your scalp and back.

What to look for: Any unusual sore, lump, blemish, marking, or change in the way an area of the skin looks or feels may be a sign of skin cancer or a warning that it might occur.

Normal moles: A normal mole is usually an evenly colored brown, tan, or black spot on the skin. It can be either flat or raised. It can be round or oval. Moles are generally less than 6 millimeters (about ¼ inch) across (about the width of a pencil eraser). A mole can be present at birth, or it can appear during childhood or young adulthood. New moles that appear later in life should be checked by a doctor.

Once a mole has developed, it will usually stay the same size, shape, and color for many years. Some moles may eventually fade away.

Most people have moles, and almost all moles are harmless. But it is important to recognize changes in a mole – such as in its size, shape, or color – that can suggest a melanoma may be developing.

Possible signs and symptoms of melanoma: The most important warning sign for melanoma is a new spot on the skin or a spot that is changing in size, shape, or color. Another important sign is a spot that looks different from all of the other spots on your skin (known as the ugly duckling sign). If you have any of these warning signs, have your skin checked by a doctor.

The ABCDE rule is another guide to the usual signs of melanoma. Be on the lookout and tell your doctor about spots that have any of the following features:

A is for Asymmetry: One half of a mole or birthmark does not match the other.

B is for Border: The edges are irregular, ragged, notched, or blurred.

C is for Color: The color is not the same all over and may include shades of brown or black, or sometimes with patches of pink, red, white, or blue.

D is for Diameter: The spot is larger than 6 millimeters across (about ¼ inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this.

E is for Evolving: The mole is changing in size, shape, or color.

Some melanomas do not fit the rules described above. It is important to tell your doctor about any changes or new spots on the skin, or growths that look different from the rest of your moles.

Other warning signs are: A sore that does not heal, Spread of pigment from the border of a spot to surrounding skin, Redness or a new swelling beyond the border, Change in sensation – itchiness, tenderness, or pain, Change in the surface of a mole – scaliness, oozing, bleeding, or the appearance of a bump or nodule

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. It is sometimes hard to tell the difference between melanoma and an ordinary mole, even for doctors, so it is important to show your doctor any mole that you are unsure of.

Exam by a health care professional: Part of a routine cancer-related checkup should include a skin exam by a health care professional qualified to diagnose skin cancer. Your doctor should be willing to discuss any concerns you might have about this exam.

Any suspicious areas or unusual moles should be seen by your primary doctor or by a dermatologist, a doctor who specializes in skin problems. Many dermatologists use a technique called dermatoscopy (also known as dermoscopy,epiluminescence microscopy [ELM], or surface microscopy) to look at spots on the skin more clearly. A digital or photographic image of the spot may be taken. 

How is melanoma skin cancer diagnosed?

Most melanomas are brought to a doctor’s attention because of signs or symptoms a person is having.

If an abnormal area of skin raises the suspicion of skin cancer, your doctor will use certain medical exams and tests to find out if it is melanoma, non-melanoma skin cancer, or some other skin condition. If melanoma is found, other tests may be done to determine if it has spread to other areas of the body.

Medical history and physical exam: Usually the first step is for your doctor to take your medical history. The doctor probably will ask when the mark on the skin first appeared, if it has changed in size or appearance, and if it has caused any symptoms (pain, itching, bleeding, etc.). You may also be asked about exposures to known causes of skin cancer (including sunburns) and if anyone in your family has had skin cancer.

During the physical exam, your doctor will note the size, shape, color, and texture of the area(s) in question, and whether there is bleeding or scaling. The rest of your body may be checked for spots and moles that could be related to skin cancer.

The doctor may also feel the lymph nodes (small, bean shaped collections of immune cells) under the skin in the groin, underarm, or neck near the abnormal area. When melanoma spreads, it often goes to nearby lymph nodes first. Enlarged lymph nodes might suggest that any melanoma present may have spread there.

If you are being seen by your primary doctor and melanoma is suspected, you may be referred to a dermatologist (a doctor who specializes in skin diseases), who will look at the area more closely.

Along with a standard physical exam, many dermatologists use a technique called dermatoscopy (also known asdermoscopy, epiluminescence microscopy [ELM], or surface microscopy) to see spots on the skin more clearly. The doctor uses a dermatoscope, which is a special magnifying lens and light source held near the skin. Sometimes a thin layer of oil is used with this instrument. The doctor may take a digital photo of the spot.

When used by an experienced dermatologist, this test can improve the accuracy of finding skin cancers early. It can also often help reassure you that a spot on the skin is likely benign (non-cancerous) without the need for a biopsy.

Skin biopsy: If the doctor thinks a spot may be a melanoma, he or she will take a sample of skin from the suspicious area to be looked at under a microscope. This is called a skin biopsy.

Different methods can be used for a skin biopsy. The doctor will choose one based on the size of the affected area, where it is on your body, and other factors. Any biopsy is likely to leave at least a small scar. Different methods may result in different types of scars, so ask your doctor about scarring before the biopsy is done. No matter which type of biopsy is done, it should remove as much of the suspected area as possible so that an accurate diagnosis can be made.

Skin biopsies are done using a local anesthetic (numbing medicine), which is injected into the area with a very small needle. You will likely feel a small prick and a little stinging as the medicine is injected, but you should not feel any pain during the biopsy.

Shave biopsy: For this type of biopsy, the doctor first numbs the area with a local anesthetic. The doctor then shaves off the top layers of the skin with a small surgical blade. Usually just the epidermis and the outer part of the dermis are removed, although deeper layers can be taken as well if needed. Bleeding from the biopsy site is then stopped by applying an ointment or a small electrical current to cauterize the wound.

A shave biopsy is useful in diagnosing many types of skin diseases and in sampling moles when the risk of melanoma is very low. A superficial shave biopsy is not generally recommended if a melanoma is suspected unless the shave biopsy sample goes deep enough to get below the suspicious area. Otherwise, it may not be thick enough to measure how deeply a melanoma has invaded the skin.

Punch biopsy: A punch biopsy removes a deeper sample of skin. The doctor uses a tool that looks like a tiny round cookie cutter. Once the skin is numbed with a local anesthetic, the doctor rotates the punch biopsy tool on the surface of the skin until it cuts through all the layers of the skin, including the dermis, epidermis, and the upper parts of the subcutis. The edges of the biopsy site are then stitched together.

Incisional and excisional biopsies: To examine a tumor that may have grown into the deeper layers of the skin, the doctor may use an incisional or excisional biopsy. After numbing the area with a local anesthetic, a surgical knife is used to cut through the full thickness of skin. A wedge or sliver of skin is removed for examination, and the edges of the wound are stitched together.

An incisional biopsy removes only a portion of the tumor. An excisional biopsy removes the entire tumor, and is usually the preferred method of biopsy for suspected melanomas if it can be done. But it is not always possible, so other types of biopsies may be needed.

Biopsies of melanoma that may have spread: Biopsies of areas other than the skin may be needed in some cases. For example, if melanoma has already been diagnosed on the skin, nearby lymph nodes may be biopsied to see if the cancer has spread that far (or farther).

In rare cases, biopsies may be needed to figure out what type of cancer someone has. For example, some melanomas may spread so quickly that they reach the lymph nodes, lungs, brain, or other areas while the original skin melanoma is still small. Sometimes these tumors are found before the melanoma on the skin is discovered. In other cases they may be found long after a skin melanoma has been removed, so it's not clear that it might be the same cancer.

In still other cases, melanoma may be found somewhere in the body without ever finding a spot on the skin. This may be because some skin lesions go away on their own (without any treatment) after some of their cells have spread to other parts of the body. Melanoma can also start in internal organs, but this is very rare, and if melanoma has spread widely throughout the body, it may not be possible to tell which tumor was the first one.

When it has spread like this, the metastatic melanoma in certain organs might be confused with a cancer starting in that organ. For example, melanoma that has spread to the lung might be confused with a primary lung cancer (cancer that starts in the lung).

Special tests can be done on the biopsy samples that can tell whether it is a melanoma or some other kind of cancer. This is important because different types of cancer are treated differently.

These types of biopsies may be more involved than those used to sample the skin.

Fine needle aspiration biopsy: A fine needle aspiration (FNA) biopsy is not used on suspicious moles, but it may be used to biopsy large lymph nodes near a melanoma to find out if the melanoma has spread to them. For this type of biopsy, the doctor uses a syringe with a thin, hollow needle to remove very small tissue fragments from a tumor. The needle is smaller than the needle used for a blood test. A local anesthetic is sometimes used to numb the area first. This test rarely causes much discomfort and does not leave a scar.

If the lymph node is near the body surface, the doctor can often feel it well enough to guide the needle into it. For a suspicious lymph node deeper in the body or a tumor in an internal organ such as the lung or liver, ultrasound or a computed tomography (CT) scan (a special type of x-ray; see “Imaging tests” below) is often used to guide the needle into place.

FNA biopsies are not as invasive as some other types of biopsies, but they may not always provide enough of a sample to tell if melanoma is present. In these cases, a more invasive type of biopsy may be needed.

Surgical (excisional) lymph node biopsy: This procedure can be used to remove an enlarged lymph node through a small skin incision. A local anesthetic is generally used if the lymph node is near the surface of the body, but a person may need to be sedated or even asleep (using general anesthesia) if the lymph node is deeper in the body.

This type of biopsy is often done if a lymph node’s size suggests the melanoma has spread but an FNA biopsy of the node was not done or did not find any melanoma cells.

Sentinel lymph node biopsy: If melanoma has been diagnosed and has any concerning features (such as being at least a certain thickness), a sentinel lymph node biopsy is often done to determine if it has spread to nearby lymph nodes, which in turn might affect treatment options. This test can be used to find the lymph nodes that are likely to be the first place the melanoma would go if it has spread. That is why these lymph nodes are called sentinel nodes (they stand sentinel, or watch, over the tumor, so to speak).

To find the sentinel lymph node (or nodes), the doctor injects a small amount of a radioactive substance (and sometimes a blue dye) into the area of the melanoma. After an hour or so, the doctor checks various lymph node areas with a radioactivity detector (which works like a Geiger counter). A small incision is made in the identified lymph node area. The lymph nodes are then checked to find which one(s) turned blue or became radioactive. These sentinel nodes are removed and looked at under a microscope.

If the sentinel node does not contain melanoma cells, no more lymph node surgery is needed because it is very unlikely the melanoma would have spread beyond this point. If melanoma cells are found in the sentinel node, the remaining lymph nodes in this area are removed and looked at as well. This is known as a lymph node dissection.

If a lymph node near a melanoma is abnormally large, a sentinel node biopsy may not be needed. The enlarged node is simply biopsied.

Lab tests of biopsy samples: Samples from any biopsies you have will be sent to a lab, where a pathologist (a doctor who is specially trained to diagnose disease) will look at them under a microscope for melanoma cells. Often, skin samples are sent to a dermatopathologist, a doctor who has special training in making diagnoses from skin samples.

If the doctor can’t tell for sure if the sample contains melanoma cells just by looking at it, special tests may be done on the cells to try to confirm the diagnosis. These tests have names such as immunohistochemistry (IHC),fluorescence in situ hybridization (FISH), and comparative genomic hybridization (CGH).

If the samples do contain melanoma, the pathologist will look at certain important features such as the tumor thickness and mitotic rate (the portion of cells that are actively dividing). These features help determine the stage of the melanoma, which in turn affects treatment options and prognosis (outlook).

For people who have advanced melanoma, biopsy samples may be tested to see if the cells have mutations in theBRAF gene. About half of melanomas have BRAF mutations. Some newer drugs used to treat advanced melanomas are only likely to work if the cells have BRAF mutations 

Imaging tests: Imaging tests use x-rays, magnetic fields, or radioactive substances to create pictures of the inside of the body. They are used mainly to look for the possible spread of melanoma to lymph nodes or other organs in the body. They are not needed for people with very early-stage melanoma, which is very unlikely to have spread.

Imaging tests may also be done to help determine how well treatment is working or to look for possible signs of cancer recurrence after treatment.

Chest x-ray: This test may be done to help determine whether melanoma has spread to the lungs.

Computed tomography (CT) scan: The CT scan is a type of x-ray test that produces detailed, cross-sectional images of your body. Unlike a regular x-ray, CT scans can show the detail in soft tissues (such as internal organs). This test can help tell if any lymph nodes are enlarged or if organs such as the lungs or liver have suspicious spots, which might be due to the spread of melanoma. It can also help show spread to the lungs better than a standard chest x-ray.

Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into detailed images of the part of your body that is being studied.

Before the scan, you may be asked to drink a contrast solution and/or get an intravenous (IV) injection of a contrast dye that helps better outline abnormal areas in the body. You may need an IV line through which the contrast dye is injected. The injection can cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You need to lie still on a table while they are being done. During the test, the table slides in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring you have to lie in when the pictures are being taken. Spiral CT (also known as helical CT), which uses a faster machine that yields more detailed pictures, is now used in many medical centers.

CT-guided needle biopsy: CT scans can also be used to help guide a biopsy needle into a suspicious area within the body. For this procedure, you remain on the CT scanning table while a radiologist moves a biopsy needle through the skin and toward the suspicious area. CT scans are repeated until the needle is in the mass. A needle biopsy sample is then removed and looked at under a microscope.

Magnetic resonance imaging (MRI): Like CT scans, MRI scans give detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. A contrast material might be injected, just as with CT scans, but is used less often.

MRI scans are very helpful in looking at the brain and spinal cord.: MRI scans take longer than CT scans – often up to an hour. You may have to lie inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Newer, more open MRI machines can sometimes be used instead. The MRI machine also makes loud buzzing noises that you may find disturbing. Some places provide earplugs to help block this noise out.

Positron emission tomography (PET): For a PET scan, you receive an injection of a radioactive substance (usually a type of sugar related to glucose, known as FDG). The amount of radioactivity used is very low. Because cancer cells in the body are growing quickly, they absorb large amounts of the radioactive sugar. After about an hour, you are moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

This test can be useful to see if the cancer has spread to lymph nodes. PET scans can also help when your doctor thinks the cancer has spread but doesn't know where. Doctors find it most useful in people with advanced stages of melanoma. It is not very helpful in people with early-stage melanoma.

Some newer machines are able to do both a PET and CT scan at the same time. This lets the doctor compare areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.

Blood tests: Blood tests aren't used to diagnose melanoma, but some tests may be done before or during treatment, especially for more advanced melanomas.

Doctors often test for blood levels of a substance called lactate dehydrogenase (LDH) before treatment. If the melanoma has spread to distant parts of the body, a higher than normal level of LDH is a sign that the cancer may be harder to treat. This affects the stage of the cancer.

Other tests of blood cell counts and blood chemistry levels may be done in a person who has advanced melanoma to monitor the function of the bone marrow (where new blood cells are made), liver, and kidneys during treatment.

How is melanoma skin cancer staged?

The stage of a melanoma is a description of how widespread it is. This includes its thickness, whether it has spread to the lymph nodes or any other organs, and certain other factors. The stage is based on the results of the physical exam, imaging tests (CT or MRI scan, etc.), biopsies, and other tests.

A staging system is a standard way to sum up how far a cancer has spread. This helps members of the cancer care team determine a patient's prognosis (outlook) as well as the best treatment options.

There are 2 types of staging for melanoma:

Clinical staging is based on what is found on physical exam, biopsy/removal of the main melanoma, and any imaging tests that are done.

Pathologic staging uses all of this information, plus what is found during biopsies of lymph nodes or other organs if they are done.

The pathologic stage (determined after the node biopsy) may actually be higher than the clinical stage (determined before the node biopsy) if the biopsy finds cancer in new areas. Doctors use the pathologic stage if it is available, as it gives a more accurate picture of the extent of the cancer.

T categories: The T category is based on the thickness of the melanoma and other key factors seen in the skin biopsy.

Tumor thickness: The pathologist looking at the skin biopsy measures the thickness of the melanoma under the microscope. This is called the Breslow measurement. The thinner the melanoma, the better the prognosis. In general, melanomas less than 1 millimeter (mm) thick (about 1/25 of an inch) have a very small chance of spreading. As the melanoma becomes thicker, it has a greater chance of spreading.

Mitotic rate: Another important aspect for tumors is the mitotic rate. To measure this, the pathologist counts the number of cells in the process of dividing (mitosis) in a certain amount of melanoma tissue. A higher mitotic rate (having more cells that are dividing) means that the cancer is more likely to grow and spread. The mitotic rate is used to help stage thin melanomas (T1; see below).

Ulceration: Ulceration is a breakdown of the skin over the melanoma. Melanomas that are ulcerated tend to have a worse prognosis.

The possible values for T are:

TX: Primary tumor cannot be assessed.

T0: No evidence of primary tumor.

Tis: Melanoma in situ (The tumor remains in the epidermis, the outermost layer of skin).

T1a: The melanoma is less than or equal to 1.0 mm thick (1.0 mm = 1/25 of an inch), without ulceration and with a mitotic rate of less than 1/mm2.

T1b: The melanoma is less than or equal to 1.0 mm thick. It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2.

T2a: The melanoma is between 1.01 and 2.0 mm thick without ulceration.

T2b: The melanoma is between 1.01 and 2.0 mm thick with ulceration.

T3a: The melanoma is between 2.01 and 4.0 mm thick without ulceration.

T3b: The melanoma is between 2.01 and 4.0 mm thick with ulceration.

T4a: The melanoma is thicker than 4.0 mm without ulceration.

T4b: The melanoma is thicker than 4.0 mm with ulceration.

N categories: The possible values for N depend on whether or not a sentinel lymph node biopsy was done.

The clinical staging of the lymph nodes, which is done without the sentinel node biopsy, is listed below.

NX: Nearby (regional) lymph nodes cannot be assessed.

N0: No spread to nearby lymph nodes.

N1: Spread to 1 nearby lymph node.

N2: Spread to 2 or 3 nearby lymph nodes, OR spread of melanoma to nearby skin or toward a nearby lymph node area (without reaching the lymph nodes).

N3: Spread to 4 or more lymph nodes, OR spread to lymph nodes that are clumped together, OR spread of melanoma to nearby skin or toward a lymph node area and into the lymph node(s).

Following a lymph node biopsy, the pathologic stage can be determined, in which small letters may be added in some cases:

Any Na (N1a or N2a) means that the melanoma is in the lymph node(s), but it is so small that it is only seen under the microscope (also known as microscopic spread).

Any Nb (N1b or N2b) means that the melanoma is in the lymph node(s) and was large enough to be visible on imaging tests or felt by the doctor before it was removed (also known as macroscopic spread).

N2c means the melanoma has spread to very small areas of nearby skin (satellite tumors) or has spread to skin lymphatic channels around the tumor (without reaching the lymph nodes).

M categories; The M values are:

M0: No distant metastasis.

M1a: Metastasis to skin, subcutaneous (below the skin) tissue, or lymph nodes in distant parts of the body, with a normal blood LDH level.

M1b: Metastasis to the lungs, with a normal blood LDH level.

M1c: Metastasis to other organs, OR distant spread to any site along with an elevated blood LDH level.

Stage grouping: Once the T, N, and M groups have been determined, they are combined to give an overall stage, using Roman numerals I to IV (1 to 4) and sometimes subdivided using capital letters. This process is called stage grouping. In general, patients with lower stage cancers have a better outlook for a cure or long-term survival.

Stage 0: Tis, N0, M0: The melanoma is in situ, meaning that it is in the epidermis but has not spread to the dermis (lower layer).

Stage IA: T1a, N0, M0: The melanoma is less than 1.0 mm in thickness. It is not ulcerated and has a mitotic rate of less than 1/mm2. It has not been found in lymph nodes or distant organs.

Stage IB: T1b or T2a, N0, M0: The melanoma is less than 1.0 mm in thickness and is ulcerated or has a mitotic rate of at least 1/mm2, OR it is between 1.01 and 2.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.

Stage IIA: T2b or T3a, N0, M0: The melanoma is between 1.01 mm and 2.0 mm in thickness and is ulcerated, OR it is between 2.01 and 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.

Stage IIB: T3b or T4a, N0, M0: The melanoma is between 2.01 mm and 4.0 mm in thickness and is ulcerated, OR it is thicker than 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.

Stage IIC: T4b, N0, M0: The melanoma is thicker than 4.0 mm and is ulcerated. It has not been found in lymph nodes or distant organs.

Stage IIIA: T1a to T4a, N1a or N2a, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread.

Stage IIIB: One of the following applies:

T1b to T4b, N1a or N2a, M0: The melanoma can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread.

T1a to T4a, N1b or N2b, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.

T1a to T4a, N2c, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread.

Stage IIIC: One of the following applies:

T1b to T4b, N1b or N2b, M0: The melanoma can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.

T1b to T4b, N2c, M0: The melanoma can be of any thickness and is ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread.

Any T, N3, M0: The melanoma can be of any thickness and may or may not be ulcerated. It has spread to 4 or more nearby lymph nodes, OR to nearby lymph nodes that are clumped together, OR it has spread to nearby skin or lymphatic channels around the original tumor and to nearby lymph nodes. The nodes are enlarged because of the melanoma. There is no distant spread.

Stage IV: Any T, any N, M1(a, b, or c): The melanoma has spread beyond the original area of skin and nearby lymph nodes to other organs such as the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes. Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes.

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