Stages of Melanoma

When a biopsy shows that melanoma is present, the first thing doctors will need to determine is the “stage” of the cancer. There are five stages, Stage 0 and Stages I through IV (one through four). Determining your stage is very important because your stage will help determine your treatment options and prognosis.

 

Overview of Stages O-IV

Stages are labeled using 0 and Stages I through IV (one through four).

  • A lower number, like one (I), means the melanoma has not spread far.
  • The higher the number, the farther it has spread and the more serious the cancer.

 

How Stage 0 is Diagnosed

 

Step 1: Physical Examination

The patient should get a physical examination of the entire skin area and the lymph node areas near the suspected melanoma.

Step 2: Biopsy

In a skin biopsy, a portion of the lesion or the whole lesion is removed, along with an area of surrounding normal skin.  If the whole lesion isn’t removed, then the thickest part of the lesion is removed, including the full depth of the lesion. This is usually done in the doctor’s office.

The tissue sample from the biopsy is sent to a pathologist, a doctor specially trained in the microscopic examination and diagnosis of tumor samples. The pathologist will do the following:

  • Determine whether the lesion is benign or malignant
  • Measure the thickness of the lesion (using the Breslow Depth)
  • Note how deeply it grows into the underlying normal tissue (Clark Level)
  • Check whether the lesion is ulcerated. In ulceration, the epidermis (outer layer of the skin) that covers a portion of the lesion is not intact
  • Check the mitotic count to see how many cells are actively dividing
  • Look for cancer at the edges of the biopsy

Step 3: Tests to Make Certain

Usually for Stage 0 disease, additional screening testing is not performed. Some doctors will screen with a chest x-ray and a blood test, but, because the chances of finding distant disease is very low, more invasive tests that have some degree of risk are not typically done.

  • X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs
  • Blood tests. Blood may be tested to help determine if the cancer has spread

 

Stage 0 Melanoma (in situ)

In Stage 0 melanoma, the malignant tumor is still confined to the upper layers of the skin (epidermis). This means that the cancer cells are only in the outer layer of the skin and have not grown any deeper. The term for this is in situ, which means “in place” in Latin. In Stage 0 melanoma there is no evidence the cancer has spread to the lymph nodes or to distant sites (metastasis).

Tis (tumor in situ)

Stage 0 (in situ)

Tis (tumor in situ)

Tumor is limited to the epidermis

No invasion of surrounding tissues or lymph nodes or distant sites

Risk: Very low

Stage 0 is defined as TisN0M0: 

  • Tis (Tumorin situ): cancer cells are found only in the outer layer of skin (epidermis) and have not grown into any other layers. The cancer cells have not shown signs of spreading
  • NO: means no evidence cancer has spread to the lymph nodes
  • MO: means melanoma has not spread to distant sites (metastasized)

Risk: Patients with Stage 0 melanoma are considered at very low risk for local recurrence or for regional and distant metastases. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

 

Treatment Options for Stage 0 Melanoma

The standard of treatment for Stage 0 melanoma (in situ) is re-excision of the original site with a surrounding area of normal-looking skin being taken. The standard amount of normal skin is 0.5 centimeters in every direction around the original cancer. This procedure may be done in a doctor’s office under local anesthetic.

Surgery

The purpose of surgery is to remove any cancer remaining after the biopsy. This procedure is called a wide excision.

The surgeon removes the rest of the tumor including the biopsy site, the surgical margin (a surrounding area of normal-appearing skin), and the underlying subcutaneous tissue, to make certain the whole tumor has been removed.

The width of the margin taken depends upon the thickness of the primary tumor. Most surgeons follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program: at least 0.5 centimeter margins in all directions (less than 0.25 inch).

The surgery typically results in a scar at least 4-5 cm (about 2 inches) in length, but it may be longer depending on the location on the skin and the size and orientation of the biopsy site. Skin grafting may sometimes be required to cover the wound, especially if it is on the face, the fingers, or toes.

 

What to Ask Your Doctor About Stage 0 Melanoma

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information about your diagnosis. It is often helpful to bring a friend or family member with you. Friends and family can lend morale support, help you by asking questions, and help you understand what your doctor has said.

The following questions can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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.

 

Diagnosis Questions Your Notes
What is the difference between in-situ melanoma and invasive melanoma?
Should I get a second opinion to confirm my diagnosis?
What is my prognosis?
What type of follow-up will I need?

Treatment Questions Your Notes
Do I need additional treatment?
Have you looked at all my other moles and my lymph nodes?

You Should Also Ask Your Notes
How often should I go for a skin exam?
What are the chances of my melanoma recurring?
What are my chances of developing a new melanoma?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?

Stage 0 Follow-Up

After treatment, all patients with Stage 0 melanoma should receive a skin examination, using the following schedule:

Type of Follow-up Description of Follow-up
Skin Examination Annually by healthcare provider Monthly self-examination.
Imaging Tests Possibly to check for specific symptoms.

All patients with Stage 0 melanoma should have a skin examination at least once a year for the rest of their life. Imaging tests are performed if specific signs of cancer appear.

Good news!

When melanoma is found and treated early, the chances for long-term, disease-free survival are excellent. With treatment, patients with Stage 0 melanoma have a 5 and 10 year overall survival rate of 99%-100%.1

Large scale studies have shown the following probabilities of disease-free survival. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

 

 

Stage I Melanoma

Stage I melanoma is defined as a melanoma that is up to 2 mm thick. A Stage I melanoma may or may not have ulceration. There is no evidence the cancer has spread to lymph nodes or distant sites (metastasis). There are two subclasses of Stage I melanoma: 1A, 1B.

 

Stage 1: Melanoma „localized tumor“

 

Subclasses 1A, 1B

Differentiated by tumor thickness (Breslow Depth)

It hasn’t spread to nearby lymph nodes or distant sites

Risk: Low

 

Stage I Melanomas Are Defined by 3 Primary Characteristics:

  • Tumor thickness (Breslow Depth): how deeply the tumor has penetrated the skin. Thickness is measured in millimeters (mm). For example:
    • 1 mm = .04 inch, or less than 1/16 inch (about equal to the edge of a penny)
    • 2 mm = between 1/16 and 1/8 inch (about equal to the edge of a nickel)
    • 4 mm = between 1/8 and 1/4 inch (about equal to the edges of two nickels)
  • Ulceration: when the epidermis (or top layer of skin)  that covers a portion of the primary melanoma is not intact. Ulceration can only be seen under a microscope, not by the naked eye.
  • Mitotic Count (Rate): describes how quickly the tumor cells are dividing. Mitotic count is calculated by a pathologist who counts the average number of actively dividing cells in the biopsy sample.

There Are 2 Subclasses of Stage I Melanoma

Stage 1A (T1aNOMO)

T1a: Tumor is no more than 1.0mm thick, no ulceration, and mitotic count is less than 1/mm.2
NO: No spread to nearby lymph nodes.
MO: No evidence of metastasis to distant sites.

Stage 1B (T1bNOMO or T2aNOMO)

T1b: Tumor is no more than 1.0mm thick, with ulceration, or a mitotic count equal or greater than 1/mm.2
T2a: Tumor is 1.01-2.0mm thick with no ulceration.
NO: No spread to nearby lymph nodes.
MO: No evidence of metastasis to distant sites.

Risk: Patients with Stage I melanoma are considered low risk for local recurrence or for regional and distant metastases. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

 

How Stage I is Diagnosed

 

Step 1: Physical Examination

The patient should get a physical examination of the entire skin and lymph node area near the suspected melanoma.

Step 2: Biopsy

In a skin biopsy, a portion of the lesion or the whole lesion is removed, along with an area of surrounding normal skin. If the whole lesion is not removed, then the thickest part of the lesion is removed, including the full depth of the lesion. This is usually done in the doctor’s office.

The tissue sample from the biopsy is sent to a pathologist (a doctor specially trained in the microscopic examination and diagnosis of tumor and lymph node tissue samples). The pathologist will do the following:

  • Determine whether the lesion is benign or malignant
  • Measure the thickness of the lesion (Breslow Depth)
  • Estimate how rapidly the cells in the specimen are dividing using a measure known as the mitotic count (rate)
  • Check whether the lesion is ulcerated. In ulceration, the epidermis (the outer layer of the skin) that covers a portion of the lesion is not intact.
  • Look for cancer at the edges of the biopsy

Step 3: Tests to Make Certain

If the results of the pathology show a very superficial melanoma the doctor may not need to order additional tests, as the possibility that the melanoma has spread beyond the original site is very, very low. If the biopsy report suggests that the primary melanoma is deep enough that it might have spread, the doctor will order other tests that may include the following:

  • Sentinel lymph node biopsy. This is a surgical procedure and is used to determine if cancer cells have spread to the lymph nodes in the area of the melanoma. See Sentinel Lymph Node Biopsy.
  • X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
  • Blood tests. Blood levels of LDH may be tested to help determine if the cancer has spread.

Step 4: Additional Tests

Sometimes the following special scanning tests (similar to x-rays in that they provide special images of the inside of the body and require no surgery) may also be performed. These are usually performed on melanomas that have a high probability of having spread to other parts of the body.

  • Ultrasound. An ultrasound uses sound waves to create pictures of the internal parts of the body, including collections of lymph nodes (called basins) and soft tissue.
  • Computed tomography (CT or CAT) scan. A CT scan creates a 3-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed view that shows any abnormalities or tumors.
  • Magnetic resonance imaging (MRI). An MRI is done with a special scanning machine that uses magnetic fields, not x-rays, to produce detailed images of the body.
  • Positron emission tomography (PET) scan. In a PET scan, a special fluid made of sugar is injected into the body, which can be seen by a special scanner. Cancer cells usually absorb sugar more quickly than normal cells, so they may light up on the PET scan. PET scans are often used in addition to a CT scan, MRI, and physical examination.

 

Treatment Options for Stage I Melanoma

The standard of treatment for Stage I melanoma is surgery and sometimes sentinel lymph node biopsy, based upon your stage of melanoma and your doctor’s assessment.

Surgery for Stage I Melanoma

The purpose of surgery is to remove any cancer remaining after the biopsy. This procedure is called a wide excision.

The surgeon removes the rest of the tumor including the biopsy site, the surgical margin (a surrounding area of normal-appearing skin), and the underlying subcutaneous tissue, to make certain the whole tumor has been removed.

The width of the margin taken depends upon the thickness of the primary tumor. Most surgeons follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program which call for a 1cm margin in all directions. This typically results in a scar at least 6cm (about 2 inches) in length, but it may be longer depending on the location on the skin and the size and orientation of the biopsy site. Skin grafting may sometimes be required to cover the wound, especially if it is on the face, the fingers, or toes.

Sentinel Lymph Node Biopsy (SLNB)

Sentinel lymph node biopsy is most accurate when the lymph channels around the primary melanoma have not been disturbed by a prior wide excision. Therefore, in general, the sentinel node biopsy and wide excision are done during the same surgery, with the sentinel node biopsy being done first.

Recommended For Patients With:

  • Stage I tumors equal to or greater than than 1.0mm
  • Ulcerated tumors of any thickness
  • Positive biopsy margins
  • Lymphovascular invasion (seeing cancer cells In the lymphatic channels or blood vessels
  • Young adults with the presence of mitosis (rate at which cells divide)

Purpose

  • Determine whether any cancer cells have spread to the sentinel node, the first lymph node to receive drainage from the primary tumor, and the site where melanomas commonly spread to first.
  • Further treatment will depend on whether the lymph node biopsy is positive.

 

What to Ask Your Doctor about Stage I Melanoma

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information about your diagnosis. It is often helpful to bring a friend or family member with you. Friends and family can lend morale support, help you by asking questions, and help you understand what your doctor has said.

The following questions can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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.

Diagnosis Questions Your Notes
How was it determined that I had Stage I melanoma?
Were there concerning features on the biopsy such as ulceration or a high mitotic rate?
Should I get a second opinion to confirm the diagnosis?

Treatment Questions Your Notes
Do you recommend I have a sentinel lymph node biopsy (SLNB)? Why or why not?
If I need a SLNB, how much experience does the surgeon you are recommending have doing this procedure?
What treatment plan do you recommend? Why?
Have you looked at all my other moles and lymph nodes?
What is my prognosis?
What type of follow-up will I need?

You Should Also Ask Your Notes
How often should I go for a skin exam?
What are the chances of my melanoma recurring?
What are the chances of my developing a new melanoma?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?

Stage I Follow-Up

After treatment, all patients with Stage I melanoma should receive a physical examination, including a skin examination, using the following schedule:

Type Description
Skin Examination Annually by healthcare provider
Monthly self-examination
Physical
Examination
Years 1-5: every 3-12 months
After Year 5: annually as needed
Monthly self-examination of lymph nodes
Imaging Tests Possibly to check for specific symptoms

All patients with Stage I melanoma should have a skin examination once a year. A physical examination should be performed every 3-12 months for the first 5 years, then once a year as needed. The frequency of the physical examinations depend on the perceived level of risk for new primary melanomas and for the recurrence of the previous tumor. Imaging tests are performed for specific symptoms.

 

Survival Rates

Good News!

With the right surgery, patients with Stage I melanoma are considered at low risk for local recurrence or for regional and distant metastases. Therefore early detection of melanoma through skin self-examination and physical examination continues to be of utmost importance.

Large scale studies have shown the following probabilities of disease-free survival. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

5 years after treatment1 10 years after treatment1
Stage IA: 97% Stage IA: 95%
Stage IB: 92% Stage IB: 86%

Stage II Melanoma

Stage II melanoma is defined by tumor thickness and ulceration. There is no evidence the cancer has spread to nearby lymph nodes or to distant sites (metastasis).

 

Stage 1 & 2 Melanoma

Ulceration = the skin that covers a part of the primary melanoma is broken. Not seen by the naked eye, only through the microscope by a pathologist.

 

Stage II: Melanoma „localized tumor“

Subclasses IIA, IIB, IIC

Differentiated by tumor thickness [Breslow Depth]

It hasn’t spread to nearby lymph nodes or distant sites

Risk: intermediate for occurring again in the same spot or spreading to distant sites.

 

Stage II Melanomas are Defined by 2 Primary Characteristics:

  • Tumor thickness (Breslow Depth): how deeply the tumor has penetrated the skin. Thickness is measured in millimeters (mm). For example:
    • 1 mm = .04 inch, or less than 1/16 inch (about equal to the edge of a penny)
    • 2 mm = between 1/16 and 1/8 inch (about equal to the edge of a nickel)
    • 4 mm = between 1/8 and 1/4 inch (about equal to the edges of two nickels)

     

  • Ulceration: when the epidermis (or top layer of skin) that covers a portion of the primary melanoma is not intact. Ulceration can only be seen under a microscope, not by the naked eye.

 

There Are 3 Subclasses of Stage II Melanoma:

 

Stage IIA (T2bN0M0 or T3aN0M0)

T2b:  tumor is 1.01 – 2.0mm thick, with ulceration
T3a:  tumor is 2.01 – 4.0mm thick, with no ulceration
N0: no spread to nearby lymph nodes
M0: no evidence of metastasis to distant sites

 

Stage IIB (T3N0M0 or T4aN0M0)

T3b: tumor is 2.01 – 4.0mm thick, with ulceration
T4a: tumor is greater than 4.0mm thick, with no ulceration
N0: No spread to nearby lymph nodes
M0: No evidence of metastasis to distant sites

 

Stage IIC (T4bN0M0)

T4b: tumor is greater than 4.0mm thick, with ulceration
N0: no spread to nearby lymph nodes
M0: no evidence of metastasis to distant sites

Risk: With treatment, Stage II melanoma is considered intermediate to high risk for local recurrence or distant metastasis. Keep in mind that the statistics shown for survival are only averages; everyone’s cancer and survival rates is based on many factors and determined on an individual basis.

 

How Stage II is Diagnosed

 

Step 1: Physical Examination

The patient should get a physical examination of the entire skin area and lymph node area near the suspected melanoma.

Learn more about the doctor’s examination

 

Step 2: Biopsies

First a skin biopsy is done. In a skin biopsy, a portion of the lesion or the whole lesion is removed, along with an area of surrounding normal skin. If the whole lesion is not removed, then the thickest part of the lesion is removed, including the full depth of the lesion. This is usually done in the doctor’s office.

Once Stage II is determined, then a sentinel lymph node biopsy (SLNB), which is recommended for all patients with Stage II melanoma should be done. This is a surgical procedure and is used to determine if cancer cells have spread to the lymph nodes nearest the area of the melanoma.

The tissue samples from the biopsies are sent to a pathologist (a doctor specially trained in the microscopic examination and diagnosis of tumor and lymph node tissue samples) who will examine the specimen. The pathologist will do the following:

  • Determine whether the lesion is benign or malignant
  • Measure the thickness of the lesion (Breslow Depth)
  • Check whether the lesion is ulcerated. In ulceration, the epidermis (outer layer of the skin) that covers a portion of the lesion is not intact
  • Look for cancer at the edges of the biopsy
  • Determine if cancer cells have spread to the lymph nodes nearest the area of the melanoma

Learn about the skin biopsy

Learn more about the Sentinel Lymph Node Biopsy

 

Step 3: Tests to Make Certain

The doctor may order other various tests to confirm a diagnosis of melanoma and/or determine if or where the disease has spread:

  • X-ray: An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
  • Blood tests: Blood levels of LDH may be tested to help determine if the cancer has spread.

 

Step 4: Additional Tests

Sometimes the following special scanning tests (similar to X-rays in that they provide special images of the inside of the body and require no surgery) may also be performed.

  • Ultrasound: An ultrasound uses sound waves to create pictures of the internal parts of the body, including collections of lymph nodes (called basins) and soft tissue.
  • Computed tomography (CT or CAT) scan: A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed view that shows any abnormalities or tumors.
  • Magnetic resonance imaging (MRI): An MRI is done with a special scanning machine that uses magnetic fields, not x-rays, to produce detailed images of the body.
  • Positron emission tomography (PET) scan: In a PET scan, a special fluid made of sugar is injected into the body, that can be seen in a special scanner. Cancer cells usually absorb sugar more quickly than normal cells, so they may light up on the PET scan. PET scans are often used in addition to a CT scan, MRI, and physical examination.

 

Treatment Options for Stage II Melanoma

After your stage of melanoma has been identified, your doctor will discuss a plan of treatment with you. Treatment of Stage II melanoma can include surgery, sentinel lymph node biopsy, immunotherapy, and clinical trials.

Surgery

The purpose of surgery is to remove any cancer remaining after the biopsy. The procedure is called wide local excision. Surgery is the main treatment for Stage II melanoma. The surgeon removes the rest of the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin), and underlying subcutaneous tissue to make sure the whole tumor has been removed. The width of the margin taken depends upon the thickness of the primary tumor. Most surgeons follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program:

  • Stage IIA & IIB – 2 cm margin – about .75 inch – for tumors between 1.1 mm and 3.99 mm in depth (Breslow Depth)
  • Stage IIC – 2-4 cm margin – about .75 inch to 1.5 inch – for tumors greater than 4 mm; 2 cm margin – about .75 inch – for tumors between 1.1 mm and 3.99 mm in depth (Breslow depth)

Recent advances in surgery allow surgeons to take narrower margins than before, so a much greater amount of normal skin is preserved.

Sentinel Lymph Node Biopsy (SLNB)

Sentinel lymph node biopsy is recommended for all Stage II tumors regardless of size. Sentinel node biopsy is most accurate when it is performed before wide local excision, the surgery to remove the tumor and the surrounding skin.

Purpose:

  • Determine whether any cancer cells have spread to the sentinel node, the first lymph node to receive drainage from the primary tumor, and the site where melanomas commonly spread to first.
  • Further treatment will depend on whether the lymph node biopsy is positive.

Adjuvant therapy

Systemic treatment, given after surgery to remove all the melanoma may be recommended for patients with Stage IIB or IIC melanoma. These systemic therapies go in the bloodstream in an effort to reach and destroy any remaining cancer cells throughout the body.

  • Interferon is a protein produced by normal cells to fight viral infections and disease and is used in large doses to treat melanoma as an immunotherapy.

Purpose:

  • Interferon therapies have been shown to help the body’s immune system fight certain diseases more effectively.
  • Several studies indicate that high dose interferon alfa-2b, a manufactured form of interferon, consistently delays relapse/recurrence of melanoma in patients with Stage IIB/C. However, studies have not consistently shown that interferon can extend overall survival.

Clinical Trials

Clinical trials are research studies to evaluate new therapies and improve cancer care. These studies are responsible for most of the advances in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial. Several treatments for Stage IV melanoma are currently being tested in clinical trials for Stage II:

  • Yervoy (ipilimumab), Keytruda (pembrolizumab), Opdivo (nivolumab), and other therapies designed to boost the immune system to fight the return of melanoma
  • Targeted therapies and targeted therapy combinations that work by blocking the function of the  mutated BRAF protein
  • Vaccines that may improve the specific immune response to melanoma

What to Ask Your Doctor about Stage II Melanoma

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information your diagnosis. It is often helpful to bring a friend or family member with you. Friends can lend morale support and help you by asking questions, and help you understand what your doctor has said.

The following questions can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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 doctor’s visit.

Diagnosis Questions Your Notes
How was it determined that I have Stage II melanoma?
Were there concerning features on the biopsy such as ulceration or a high mitotic rate?
Should I get a second opinion to confirm the diagnosis?

Treatment Questions Your Notes
How much experience does the surgeon you are recommending have doing a sentinel lymph node biopsy (SLNB)?
What treatment plan do you recommend? Why?
Should I consider adjuvant treatment? What are the side effects of these treatments?
What is my prognosis?
What type of follow-up will I need?
Do you recommend I see a medical oncologist? Why or why not?

Clinical Trial Questions Your Notes
What are clinical trials?
Should I consider enrolling in a clinical trial? Why or why not?

You Should Also Ask Your Notes
How often should I go for a skin exam?
What are the chances of my melanoma recurring?
What are my chances of developing a new melanoma?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?

Stage II Follow-Up

After treatment, all patients with Stage II melanoma should receive a physical examination, including a skin examination, using the following schedule. Other scans and tests may be recommended.

Type of Follow-up Description
Skin Examination Annually by healthcare provider
Monthly self-examination
Physical
Examination
For Stage IIA patients:
Years 1-5: every 3-12 months
After Year 5: annually as needed
Monthly self-examination of lymph nodesFor Stage IIB and Stage IIC patients:
Years 1-2: every 3-6 months
Years 3-5: every 3-12 months
After Year 5: annually as needed
Monthly self-examination of lymph nodes
Imaging Tests For Stage IIA patients:
Only to check for specific symptomsFor Stage IIB and IIC patients:
Possibly every 3-12 months to check for recurrence.
Brain MRI For Stage IIA patients: None

For Stage IIB and IIC patients: Possibly annually

All patients with Stage IIA melanoma should have a skin examination once a year. A physical examination should be performed every 3-12 months for the first 5 years, then once a year as needed. The frequency of a physical examinations depends on the perceived level of risk for new primary melanomas and for the recurrence of the previous tumor. Imaging tests are performed only for specific symptoms.

All patients with Stage IIB and IIC melanoma should have a skin examination once a year. Patients should have a physical examination every 3-6 months for years 1-2, every 3-12 months for years 3-5, and then once a year as needed Imaging tests are recommended if specific signs of cancer appear. You may also receive imaging tests every 3-12 months to check for cancer recurrence that isn’t causing symptoms. Possible tests for screening include a chest x-ray, CT scan, and a PET/CT scan; and a brain MRI every year. These tests may be done for up to 5 years after treatment has ended. Imaging tests are not recommended after 5 years if there has been no recurrence and you don’t have any symptoms. If follow-up tests show that the cancer has come back, treatment options will depend on the type of recurrence.

Survival Rates

With treatment, Stage II melanoma is considered intermediate- to high-risk for local recurrence or distant metastasis. Therefore, early detection of melanoma through skin self-examination and medical examination continues to be of the utmost importance

Large-scale studies have shown the following probabilities of disease-free survival. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

5 years after treatment1 10 years after treatment1
Stage IIA: 81% Stage IIA: 67%
Stage IIB: 70% Stage IIB: 57%
Stage IIC: 53% Stage IIC: 40%

Stage III Melanoma

Stage III melanomas are tumors that have spread to regional lymph nodes. There may also be in-transit or satellite involvement.  In Stage III melanoma, the depth of the melanoma no longer matters. There is no evidence of distant metastasis.

Microscoptically = seen by pathologist after biopsy or dissection
Macroscoptically = seen by naked eye or felt by hand

Stage III: Melanoma ‘regional spread’

Subclasses IIIA, IIIB, IIIC

Defined by number of lymph nodes to which it has spread

It can, but it need not have ulceration

Different whether the spread to the lymph nodes, can be detected microscoptically or macroscoptically

Risk: Intermediate to high for occurring again in the same spot or spreading to distant sites

Stage III Melanomas Are Defined By 3 Primary Characteristics:

  •  Number of lymph nodes to which the tumor has spread
  •  Whether the tumor spread to the lymph node is microscopic or macroscopic:
    • Micrometastases are tiny tumors not visible to the naked eye. They can be detected only by microscopic evaluation after sentinel lymph node biopsy or elective lymph node dissection.
    • Macrometastases can be felt during physical examination or seen with the naked eye when inspected by a surgeon or pathologist. Their presence is confirmed by lymph node dissection or when the tumor is seen to extend beyond the lymph node capsule.
  • Ulceration: when the epidermis (or top layer of skin) that covers a portion of the primary melanoma is not intact. Ulceration can only be seen under a microscope, not by the naked eye.

There Are 3 Subclasses of Stage III Melanoma

Stage IIIA

T1-T4aN1aM0 or T1-T4aN2aM0

  • T1-T4a: tumor of any thickness with no ulceration
  • N1a: micrometastasis to 1 nearby lymph node
  • N2a: micrometastasis to 2-3 nearby lymph nodes
  • M0: no evidence of metastasis to distant sites

Stage IIIB

T1-T4bN1aM0, T1-T4bN2aM0, T1-T4aN1bM0, T1-T4a/bN2bMO, or T1-T4a/bN2cMO

  • T1-T4a: tumor of any thickness, with no ulceration
  • T1-T4b: tumor of any thickness with ulceration
  • N1a: macrometastasis to 1 nearby lymph node
  • N2a: macrometastasis to 2-3 nearby lymph nodes
  • N1b: macrometastasis to 1 nearby lymph node
  • N2b: macrometastasis to 2-3 nearby lymph nodes
  • N2c: presence of in-transit metastasis or satellite metastasis
  • M0: no evidence of metastasis to distant sites

Stage IIIC

T1b-4bN1bM0, T1-T4bN2bM0, T1-T4a/bN3M0

  • T1-T4a: tumor of any thickness with no ulceration
  • T1-T4b: tumor of any thickness with ulceration
  • N1b: macrometastasis to 1 nearby lymph node
  • N2b: macrometastasis to 2-3 nearby lymph nodes
  • N3: metastais in 4 or more lymph nodes, the presence of matted lymph nodes or the combination of in-transit/satellite metastases and metastic lymph nodes
  • M0: no evidence of metastasis to distant sites

Risk: With treatment, Stage III disease has an intermediate to high risk for local recurrence or distant metastasis. Even within Stage III, the earlier the melanoma is found and treated, the better the outcome. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

 

How Stage III is Diagnosed

 

Step 1: Physical Examination

The patient should get a physical examination of the entire skin, the lymph node areas, and organs.

Step 2: Skin Biopsy

First a skin biopsy is done. In a skin biopsy, a portion of the lesion, or the whole lesion is removed, along with an area of surrounding normal skin. If the whole lesion, is not removed, then the thickest part of the lesion is removed, including the full depth of the lesion. This is usually done in the doctor’s office.

The tissue sample from the biopsy is sent to a pathologist (a doctor specially trained in the microscopic examination and diagnosis of tumor and lymph node tissue samples) who will examine the specimen. He/she will do the following:

  • Determine whether the lesion is benign or malignant.
  • Measure the thickness of the lesion (Breslow Depth).
  • Check whether the lesion has ulcerated. In ulceration the epidermis (the outer layer of the skin) that covers a portion of the lesion is not intact.
  • Look for cancer at the edges of the biopsy.

Step 3: Lymph Node Biopsy

During the physical examination, if the lymph nodes nearest the melanoma site are found to be abnormally hard or large a needle biopsy (Fine Needle Aspiration) is performed with local anesthetic. A slender needle is placed through the skin and into the suspicious lymph node. A small tissue sample is removed when the needle is withdrawn.

If the node is found to contain melanoma all of the lymph nodes should be removed. This procedure is called a therapeutic lymph node fissection (TLND). A sentinel lymph node biopsy is not recommended.

If the lymph nodes are not abnormally large or hard there are  circumstances where the doctor will recommend that a sentinel lymph node biopsy (SLNB), be done. These include the melanoma being equal or greater than 1mm thick, any ulcerated tumor, and a high mitotic rate.

This is a surgical procedure and is used to determine if cancer cells have spread to the lymph nodes nearest the area of the melanoma. Once it has been determined that the melanoma has spread to the lymph nodes all of the remaining lymph nodes should be removed. This procedure is called a complete lymph node dissection (CLND).

Step 4: Tests to Make Certain

The doctor may order other various tests to confirm a diagnosis of melanoma and/or determine if or where the disease has spread:

  • X-ray: An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
  • Blood tests: Blood levels of LDH may be tested to help determine if the cancer has spread.

Step 5: Additional Tests

Often the following special scanning tests (similar to x-rays in that they provide special images of the inside of the body and require no surgery) are performed.

  • Ultrasound: An ultrasound uses sound waves to create pictures of the internal parts of the body, including collections of lymph nodes (called basins) and soft tissue.
  • Computed tomography (CT or CAT) scan: A CT scan creates a 3-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed view that shows any abnormalities or tumors.
  • Magnetic resonance imaging (MRI): An MRI is done with a special scanning machine that uses magnetic fields, not x-rays, to produce detailed images of the body.
  • Positron emission tomography (PET) scan: In a PET scan, a special fluid made of sugar is injected into the body, which can be seen by a special scanner. Cancer cells usually absorb sugar more quickly than normal cells, so they may light up on the PET scan. PET scans are often used in addition to a CT scan, MRI, and physical examination.

 

Treatment Options for Stage III Melanoma

After your stage of melanoma has been identified, your doctor will discuss a plan of treatment with you. It is important to know whether all of your Stage III melanoma has been completely removed with surgery (known as “resected Stage III”) or if it was not possible to remove all of the melanoma (know as “unresectable Stage III”). These two types of Stage III melanoma are treated very differently. Unresectable Stage III patients are treated similarly to Stage IV melanoma patients.

Surgery

The purpose of the surgery is to remove any cancer remaining after the biopsy of the primary melanoma. This procedure is called a wide local excision. Wide local excision is recommended for small, easily removable recurrent tumors and for patients with a limited number of in-transit tumors.

The surgeon removes the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin), and underlying subcutaneous tissue. Most surgeons follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program.

  • The recommended margins for wide local excision of the primary melanoma ranges from 1-2cm and is determined by the thickness of the primary melanoma.

Learn more about surgery

Lymph Node Dissection

When cancerous lymph nodes are found and there is evidence that the melanoma has spread to nearby lymph nodes, an additional surgery to remove the remaining lymph nodes from the area is usually recommended. If your melanoma was found by sentinel lymph node biopsy this is called a complete lymph node dissection (CLND). If your melanoma was found because your lymph nodes were enlarged, this is called a therapeutic lymph node dissection (TLND).

The goal of the surgery is to prevent further spread of the disease through the body by way of the lymphatic system. Current studies are underway to determine whether CLND and TLND may also prolong survival.

CLND and TLND also play an important role in controlling the pain often caused by untreated lymph node disease.

Sentinel Lymph Node Biopsy (SLNB)

If a patient has already been diagnosed with Stage III melanoma, a SLNB is typically recommended only when it is suspected there might be melanoma in another lymph node basin.

The results of the biopsy will guide the course of treatment.

Learn more about SLNB

Adjuvant Therapy

Systemic treatment, given after surgery to remove all the melanoma, is often recommended for Stage III melanoma. These systemic therapies go in the bloodstream in an effort to reach and destroy any remaining cancer cells throughout the body.

Immunotherapies

Clinical Trials

Clinical trials are research studies to evaluate new therapies and improve cancer care. These studies are responsible for most of the advances in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial.

Several treatments for Stage IV melanoma are currently being tested in clinical trials for Stage III.

  • Yervoy (ipilimumab), Keytruda (pembrolizumab), Opdivo (nivolumab), and other therapies designed to boost the immune system to fight the return of melanoma
  • Targeted therapies and targeted therapy combinations that work by blocking the function of the  mutated BRAF protein
  • Vaccines that may improve the specific immune response to melanoma

Stage III Unresectable Treatments

Unresectable melanoma means that it was not possible to remove all of your melanoma. Stage III unresectable patients are treated similarly to Stage IV melanoma patients.

Surgery

See Stage III above.

Lymph Node Dissection

See Stage III above.

Sentinel Lymph Node  Biopsy (SLNB)

See Stage III above.

Adjuvant Therapy

  • Immunotherapies

Targeted Therapies

  • COTELLIC (cobimetinib) and ZELBORAF (vemurafenib) Combination
  • MEKINIST (trametinib) and TAFINLAR (dabrafenib) Combo
  • MEKINIST (trametinib)
  • TAFINLAR (dabrafenib)
  • ZELBORAF (vemurafenib)

Radiation Therapy

Radiation therapy in the adjuvant setting has been shown to improve local control (in the lymph node basin) but has not been proven to improve overall survival (living longer) in randomized, controlled studies.

Clinical Trials

Clinical trials are research studies to evaluate new therapies and improve cancer care. These studies are responsible for most of the advances in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial.

 

What to Ask Your Doctor about Stage III Melanoma

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information about your diagnosis. It is often helpful to bring a friend or family member with you. Friends can lend moral support and help you by asking questions, and help you understand what your doctor has said.

The following questions relate to some of the most important aspects of a melanoma diagnosis and can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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 doctor’s visit.

Diagnosis Questions Your Notes
How was it determined that I have Stage III melanoma?
How many of my lymph nodes have melanoma?
Do I have in-transit metastases?
Were they able to completely resect (remove) all of my melanoma?

Treatment Questions Your Notes
Do you recommend a complete lymph node dissection (CLND)?
How much experience do you or the surgeon you are recommending have treating melanoma and doing a CLND?
What treatment plan do you recommend? Why?
Should I consider adjuvant immunotherapy or targeted therapy? What are the side effects of these treatments?
What is my prognosis?
What type of follow-up will I need?
Should I get a second opinion?

Clinical Trial Questions Your Notes
What are clinical trials?
Should I consider enrolling in a clinical trial?
Do you participate in clinical trials?
Should I be referred to a center that has clinical trials?
You Should Also Ask Your Notes
Do I need regular scans? Do I need a brain scan?
How often should I go for a skin exam?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?

Stage III Follow-Up

After treatment, all patients with Stage III melanoma should receive a physical examination, including a skin examination, using the following schedule. Regular chest x-rays, CT scans of the trunk and pelvis, and brain MRI may also be recommended.

Type of Follow-up Description
Skin Examination Annually by healthcare provider
Monthly self-examination
Physical Examination Years 1-2: every 3-6 months
Years 3-5: every 3-12 months
After Year 5: annually as needed
Monthly self-examination of lymph nodes
Imaging Tests Possibly every 3-12 months to check for recurrence
Brain MRI Possibly each year

All patients with Stage III melanoma should have a skin examination once a year for life. Patients should have a physical examination every 3-6 months for years 1-2, every 3-12 months for years 3-5, and then once a year as needed.

Imaging tests are recommended if specific signs of cancer appear. You may also receive imaging tests every 3-12 months to check for cancer recurrence that isn’t causing symptoms. Possible tests for screening include a chest x-ray, CT scan, PET/CT scan, and brain MRI. These tests may be done for up to 5 years after treatment has ended. Imaging tests are not recommended after 5 years if there has been no recurrence and no symptoms.

Survival Rates

With treatment, Stage III melanoma is considered intermediate- to high-risk for local recurrence or distant metastasis.

Therefore, early detection of melanoma through skin self-examination and medical examination continues to be of utmost importance.

Large-scale studies have shown the following probabilities of disease-free survival. Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis.

5 years after treatment 1 10 years after treatment1
Stage IIIA: 78% Stage IIIA: 68%
Stage IIIB: 59% Stage IIIB: 43%
Stage IIIC: 40% Stage IIIC: 24%

 

Stage IV Melanoma

In Stage IV, the melanoma has traveled beyond the regional lymph nodes to more distant areas of the body. The most common sites of metastasis are to vital organs (lungs, abdominal organs, brain, and bone) and soft tissues (skin, subcutaneous tissues, and distant lymph nodes).

Stage IV: Melanoma ‘metastasis beyond regional lymph nodes’

Subclasses M1a, M1b, M1c

Characterized by:
Location of different metastases
Number and size of tumors
Elevated LDH

M1a: spread to distant skin, the subcutaneous layer or to distant lymph nodes. LDH is normal
M1b: the tumor has metastasized to the lung. LDH is normal
M1c: tumor has metastasized to vital organs other than the lungs, and serum LDH is normal
or
There are any distant metastases with elevated LDH

Stage IV Melanoma Primary Characteristics Include:

  • Location of distant metastases
  • Number and size of tumors
  • Elevated LDH levels usually indicate that the tumor has spread to internal organs

There Are 3 Subclasses of Stage IV Melanoma:

The subclasses are based on where the metastases are located and the level of LDH. It does not include any T or N classification.

  • M1a: the tumor has metastasized to distant skin, the subcutaneous layer or to distant lymph nodes. LDH is normal
  • M1b: the tumor has metastasized to the lungs. LDH is normal
  • M1c:
    • the tumor has metastasized to organs other than the lungs, and LDH is normal, OR
    • there are any distant metastases with elevated LDH

Why the Location of Metastases Is Important

Large-scale studies indicate that the respective 1, 2, and 5 year survival rates for Stage IV melanoma are1:

  • Distant skin, soft tissue, and/or lymph nodes – 62%, 43%, 28%
  • Lung – 53%, 31%, 15%,
  • Visceral – 33%, 18%, 9%

Why Brain Metastases Are Different

While brain metastases are part of Stage IV, the risk factors, diagnosis, and treatment, are different than other types of metastases.

Why LDH Levels Are Important

Compared with the survival of patients with normal LDH levels, patients with high LDH levels have significantly worse overall survival. The respective 1, 2, and 5 year survival rates were2:

  • Abnormal LDH – 33%, 18%, 10%
  • Normal LDH – 61%, 33%, 18%

How Stage IV is Diagnosed

Step 1: Physical Examination

The patient should get a physical examination of the entire skin, lymph node areas, and organs.

Step 2: Tests to Make Certain

The doctor may order various other tests to confirm a diagnosis of melanoma and/or determine if or where the disease has spread:

  • X-ray: An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
  • Blood tests: Blood levels of LDH may be tested to help determine if the cancer has spread.

Step 3: Additional Tests

Often following special scanning tests (similar to x-rays in that they provide special images of the inside of the body and require no surgery) are performed:

  • Ultrasound: An ultrasound uses sound waves to create pictures of the internal parts of the body, including collections of lymph nodes (called basins) and soft tissue.
  • Computed tomography (CT or CAT) scan: A CT scan creates a 3-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed view that shows any abnormalities or tumors.
  • Magnetic resonance imaging (MRI): An MRI is done with a special scanning machine that uses magnetic fields, not x-rays, to produce detailed images of the body.
  • Positron emission tomography (PET) scan: In a PET scan, a special fluid made of sugar is injected into the body, which can be seen by a special scanner. Cancer cells usually absorb sugar more quickly than normal cells, so they may light up on the PET scan. PET scans are often used in addition to a CT scan, MRI, and physical examination.

 

Treatment Options for Stage IV Melanoma

Once your stage of melanoma has been determined, your doctor will discuss a treatment plan with you. Several new drugs have been approved by the FDA, and have shown improvements in survival. Many experimental treatments are also under investigation and may be available by enrolling in a clinical trial.

Surgery

The purpose of the surgery is to remove the cancerous tumors or lymph nodes that have metastasized or spread to other areas of the body, if they are few in number and/or are causing symptoms.

Treatment Options

Treatment given in addition to a primary cancer treatment (such as surgery) is recommended for Stage IV melanoma. These are systemic therapies that go through the bloodstream to reach and affect cancer cells throughout the body. The goal of systemic treatment is to try and control the melanoma and treat symptoms. Treatments can be divided into immunotherapies, targeted therapies, and chemotherapy.

Immunotherapies

Targeted Therapies

Chemotherapy

Radiation Therapy

Radiation is used in some situations to slow tumor growth or shrink a tumor in organs where surgery is not possible or is not recommended. It is also used to relieve symptoms caused by tumors, such as in the brain or bone.

Clinical Trials

Clinical trials are research studies to evaluate new therapies and improve cancer care. These studies are responsible for most of the advances in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial.

Several experimental treatments are currently being tested in clinical trials.

  • Immunotherapies: designed to boost the body’s immune response to tumors. Ongoing clinical trials include anti-CTLA-4, PD1, and PD-L1, as well as other immunotherapies.
  • Targeted Therapies: designed to inhibit mutations and pathways that promote the growth and survival of tumor cells. Some clinical trials are designed for patients with specific mutations in their tumors (for example, BRAF), and thus require testing to determine if patients are appropriate for a given therapy.
  • Vaccines
  • Adoptive Cell Transfer [ACT]: the transfer of immune cells that have been selected or engineered to attack tumors, particularly with tumor infiltrating lymphocytes [TIL].
  • Chemotherapy
  • Combinations: trials to combine different systemic treatments, as well as trials to test whether combining systemic treatments with surgery, radiation, and other therapies can improve outcomes in patients.

In addition to performing clinical trials to test the safety and effectiveness of new treatments, many investigators are also working to determine why therapies work in some patients but not in others, as well as why they sometimes stop working after initial success.  This research depends on the participation of patients in clinical trials, and sometimes in parallel studies that allow researchers to analyze samples of blood, tumor tissue, or other materials.  Some studies have the potential to help patients who currently have melanoma, but also to help melanoma patients in the future.

 

What to Ask Your Doctor about Stage IV Melanoma

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information about your diagnosis. It is often helpful to bring a friend or family member with you. Friends can lend morale support and help you by asking questions, and help you understand what your doctor has said.

The following questions relate to some of the most important aspects of a melanoma diagnosis and can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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 doctor’s visit.

Diagnosis Questions Your Notes
How was it determined that I have Stage IV melanoma?
Where has my melanoma spread?
Is my brain involved?
Will I need additional tests or procedures to confirm the stage of my disease?

Treatment Questions Your Notes
Was I tested for the BRAF mutation? Should I be tested for the NRAS or C-KIT mutation?
What treatment plan do you recommend? Why?
Should I consider immunotherapy, targeted therapy, or chemotherapy to treat my melanoma? Why?
What are the possible side effects of these treatments?
Will the treatments affect my ability to work?
Do I need radiation therapy?
Can I use complementary or alternative therapies? Why or why not?
What is my prognosis?
What type of follow-up will I need?
Do I need regular scans? Do I need a brain scan?
Should I get a second opinion?

Clinical Trial Questions Your Notes
What are clinical trials?
Should I consider enrolling in a clinical trial? Why or why not?
Do you participate in any clinical trials?
Should I be referred to a center that has clinical trials?

You Should Also Ask Your Notes
How often should I go for a skin exam?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?

 

Stage IV Follow-Up

After treatment, all patients with Stage IV melanoma should receive a physical examination, including a skin examination, using the following schedule. Depending upon the circumstances, follow-up for patients may be required monthly or even weekly. Regular chest x-rays, CT scans of the trunk and pelvis, and brain MRI may also be recommended.

Type of Follow-up Description
Skin Examination Annually by healthcare provider
Monthly self-examination
Physical Examination Years 1-2: every 3-6 months
Years 3-5: every 3-12 months
After Years 5: annually as needed
Monthly self-examination of lymph nodes
Imaging Tests Possibly every 3-12 months to check for recurrence
Brain MRI Possibly annually

Stage IV melanoma that has been completely removed (NED = no evidence of disease) is usually followed closely in the clinic with physical exams, blood work, and scans on an every 3-6 month basis for at least the first two years, and then spaced out over time. These patients are followed at least annually after year 5.

Imaging tests are recommended if specific signs of cancer appear.  You may also receive imaging tests every 3-12 months to check for cancer recurrence that isn’t causing symptoms. Possible tests for screening include a chest x-ray, CT scan, PET/CT scan, and brain MRI every year. These tests may be done for up to 5 years after treatment has ended.  Imaging tests are not recommended after 5 years if there has been no recurrence and no symptoms.

Survival Rates

The 5-year survival rate is about 15% to 20%. The 10-year survival is about 10% to 15%.

Keep in mind that the statistics shown for survival are averages; everyone’s cancer and survival rate is based on many factors and determined on an individual basis. There are patients who survive melanoma long-term. The survival prognosis is better if the melanoma has spread to only distant parts of the skin or distant lymph nodes rather than to other organs, and if the LDH level is normal.

The following factors may provide a relatively more favorable prognosis and help guide decisions about what treatments and therapies are recommended:

  • A limited number of sites of melanoma metastases
  • The disease is limited to soft tissues and lymph nodes rather than bone and vital organs
  • Stage IV melanoma does not develop until more than 1 year after treatment of earlier-stage melanoma
  • A normal lactate dehydrogenase level (blood test)
  • The occurrence of an observable and favorable response to treatment

Additional favorable patient factors include:

  • A normal appetite
  • Absence of nausea, vomiting, or fever;
  • The ability to conduct daily activities unimpaired
  • Being female.

 

 

Brain Metastases

Brain metastases, a specific form of Stage IV melanoma, are one of the most common and difficult-to-treat complications of melanoma.  They differ from all other metastases in terms of risk factors, diagnosis, and treatment.

Who Is At Risk?

More than 60% of all Stage IV melanoma patients will develop brain metastases at some point but certain factors can increase that risk: 1,2

  • The primary tumor was on the head, neck, trunk, or abdomen
  • The primary tumor was ulcerated or deep or invasive
  • The melanoma was unresectable Stage III or Stage IV when diagnosed
  • The melanoma has spread to the internal organs
  • The LDH is high

Why Are Brain Metastases So Difficult To Treat?

Brain metastases are difficult to treat. There are several potential reasons.

  • There is growing evidence that brain tumors are very different from tumors in other parts of the body and need to be treated differently.
  • The brain looks familiar. Melanocytes arise from the same part of the early embryo as the brain, so the brain might be a very natural environment for melanoma tumors to grow in.
  • Often, by the time the patient first exhibits symptoms, they already have multiple lesions.
  • Brain metastases tend to be very aggressive.
  • The brain has many defenses to reduce the penetration of harmful substances. This is called the blood-brain-barrier and it prevents many medications from entering the brain.
  • Treatment options may damage surrounding normal tissue and have significant impact on the quality of life.

What Determines the Treatment Options and Prognosis For Patients With Brain Metastases?

  • Certain characteristics of both the patient and the cancer will affect the patients’ prognosis as well as their eligibility for treatment.  The following factors are associated with better outcomes: 3,4,5
  • Younger age: <60
  • Fewer vs. more brain metastases: <3 lesions
  • No extracranial disease: extracranial is the presence of disease outside the cranium
  • LDH is normal
  • High Karnofsky Performance Status (KPS) score (>70)

Risk

Until recently, melanoma brain metastases carried a poor prognosis, with a median overall survival of about 4-5 months. However, improvements in radiation and systemic therapies are offering promise for this challenging complication, and some patients are curable.

 

Diagnosis and Treatment Options for Brain Metastases

Tests

Several types of brain scans can be used to diagnose melanoma brain metastases, including CT scans, MRI, or PET scans.

Learn more about imaging studies

 

Symptoms to Watch For

Specific neurologic signs and symptoms might indicate brain metastases. These include headache, muscle weakness, and behavioral changes such as changes in judgment and reasoning.  Physical problems can include vision changes, hearing loss, dizziness, nausea or vomiting, language disturbances, difficulty walking, and seizures.

If you have been diagnosed with melanoma and have any of these symptoms, you should contact your medical oncologist as soon as possible.

Treatments Options

Your doctor will discuss a treatment plan with you. The treatment options for brain metastases are determined by the number of metastases, their size and location, the presence of extracranial metastases (melanoma outside of the brain and spinal cord), and the performance status of the patient.

Treatment Options

 

What to Ask Your Doctor about Brain Metastases

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important to use the time when you are with your doctor to learn as much about your cancer as you can.

Your doctor will provide you some important information about your diagnosis. It is often helpful to bring a friend or family member with you. Friends can lend moral support and help you by asking questions, and help you understand what your doctor has said.

The following questions relate to some of the most important aspects of a melanoma diagnosis and can serve as a guide to help you focus on what questions to ask your doctor.

Remember, it is ALWAYS okay to ask your doctor to repeat or clarify something they have 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 doctor’s visit.

Diagnosis Questions Your Notes
How many brain tumors do I have?
Do I have active disease in my brain?
Is the disease outside of my brain controlled?

Treatment Questions Your Notes
What treatment plan do you recommend? Why?
Am I a candidate for stereotactic radiosurgery (SRS)? Why or why not?
Am I a candidate for surgery?
Should I consider immunotherapy or targeted therapy? Why?
What is my prognosis?
What type of follow-up will I need?
Should I get a second opinion?

Clinical Trial Questions Your Notes
What are clinical trials?
Should I consider enrolling in a clinical trial? Why or why not?
Do you participate in any clinical trials?
Should I be referred to a center that has clinical trials?