Masonic Cancer Center, University of Minnesota

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Masonic Cancer Center of the University of Minnesota

Melanoma Treatment

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General Information About Melanoma

Melanoma is a disease in which malignant (cancer) cells form in the skin cells called melanocytes (cells that color the skin).

Melanocytes are found throughout the lower part of the epidermis. They make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to tan, or darken. Anatomy of the skin with melanocytes; drawing shows normal skin anatomy, including the epidermis, dermis, hair follicles, sweat glands, hair shafts, veins, arteries, fatty tissue, nerves, lymph vessels, oil glands, and subcutaneous tissue. The pullout shows a close-up of the squamous cell and basal cell layers of the epidermis above the dermis with blood vessels. Melanin is shown in the cells. A melanocyte is shown in the layer of basal cells at the deepest part of the epidermis.

Anatomy of the skin, showing the epidermis, dermis, and subcutaneous tissue. Melanocytes are in the layer of basal cells at the deepest part of the epidermis.

The skin is the body's largest organ. It protects against heat, sunlight, injury, and infection. The skin has 2 main layers: the epidermis (upper or outer layer) and the dermis (lower or inner layer).

When melanoma starts in the skin, the disease is called cutaneous melanoma. This PDQ summary is about cutaneous (skin) melanoma. Melanoma may also occur in the eye and is called intraocular or ocular melanoma. (See the PDQ summary on Intraocular (Eye) Melanoma Treatment for more information.)

There are 3 types of skin cancer:

Melanoma is more aggressive than basal cell skin cancer or squamous cell skin cancer. (See the PDQ summary on Skin Cancer Treatment for more information on basal cell and squamous cell skin cancer.)

Melanoma can occur anywhere on the body.

In men, melanoma is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma often develops on the arms and legs. Melanoma usually occurs in adults, but it is sometimes found in children and adolescents.

Unusual moles, exposure to sunlight, and health history can affect the risk of developing melanoma.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for melanoma include the following:

  • Unusual moles.
  • Exposure to natural sunlight.
  • Exposure to artificial ultraviolet light (tanning booth).
  • Family or personal history of melanoma.
  • Being white and older than 20 years.
  • Red or blond hair.
  • White or light-colored skin and freckles.
  • Blue eyes.

Possible signs of melanoma include a change in the appearance of a mole or pigmented area.

These and other symptoms may be caused by melanoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

  • A mole that:
    • changes in size, shape, or color.
    • has irregular edges or borders.
    • is more than 1 color.
    • is asymmetrical (if the mole is divided in half, the 2 halves are different in size or shape).
    • itches.
    • oozes, bleeds, or is ulcerated (a hole forms in the skin when the top layer of cells breaks down and the underlying tissue shows through).
  • Change in pigmented (colored) skin.
  • Satellite moles (new moles that grow near an existing mole).

Tests that examine the skin are used to detect (find) and diagnose melanoma.

If a mole or pigmented area of the skin changes or looks abnormal, the following tests and procedures can help detect and diagnose melanoma:

  • Skin examination: A doctor or nurse examines the skin to look for moles, birthmarks, or other pigmented areas that look abnormal in color, size, shape, or texture.
  • Biopsy: A local excision is done to remove as much of the suspicious mole or lesion as possible. A pathologist then looks at the tissue under a microscope to check for cancer cells. Because melanoma can be hard to diagnose, patients should consider having their biopsy sample checked by a second pathologist.

Suspicious areas should not be shaved off or cauterized (destroyed with a hot instrument, an electrical current, or a caustic substance).

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The stage of melanoma (whether cancer is found in the outer layer of skin only, or has spread to the lymph nodes, or to other places in the body.
  • Whether there was bleeding or ulceration at the primary site.
  • The location and size of the tumor.
  • The patient's general health.

Although many people are successfully treated, melanoma can recur (come back).

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Stages of Melanoma

After melanoma has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

The process used to find out whether cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

  • Wide local excision: A surgical procedure to remove some of the normal tissue surrounding the area where melanoma was found, to check for cancer cells.
  • Lymph node mapping and sentinel lymph node biopsy: Procedures in which a radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to have spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist then checks the sentinel lymph nodes for cancer cells. If no cancer cells are detected, it may not be necessary to remove additional nodes.
  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For melanoma, pictures may be taken of the chest, abdomen, and pelvis.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
  • Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.

The results of these tests are viewed together with the results of the tumor biopsy to determine the melanoma stage.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The Clark levels are used for thin tumors to describe how deep the cancer has spread into the skin:

Clark levels of melanoma; drawing shows skin with five thin melanoma lesions of different depths. The first lesion is a Clark Level I melanoma where the cancer is in the epidermis only. In the second lesion (Clark Level II melanoma), the cancer has begun to spread into the papillary dermis (upper layer of the dermis). In the third lesion (Clark Level III melanoma), the cancer has spread through the papillary dermis into the papillary-reticular dermal interface but not into the reticular dermis (lower layer of the dermis). In the fourth lesion (Clark Level IV melanoma), the cancer has spread into the reticular dermis. In the fifth lesion (Clark Level V melanoma), the cancer has spread into the subcutaneous tissue.

Clark levels of melanoma. In Clark Level I, the cancer is in the epidermis only. In Clark Level II, the cancer has begun to spread into the papillary dermis (upper layer of the dermis). In Clark Level III, the cancer has spread through the papillary dermis into the papillary-reticular dermal interface but not into the reticular dermis (lower layer of the dermis). In Clark Level IV, the cancer has spread into the reticular dermis. In Clark Level V, the cancer has spread into the subcutaneous tissue.

Level I

The cancer is in the epidermis only.

Level II

The cancer has begun to spread into the papillary dermis (upper layer of the dermis).

Level III

The cancer has spread through the papillary dermis (upper layer of the dermis) into the papillary-reticular dermal interface (the layer between the papillary dermis and the reticular dermis).

Level IV

The cancer has spread into the reticular dermis (lower layer of the dermis).

Level V

The cancer has spread into the subcutaneous layer (below the skin).

The following stages are used for melanoma:

Stage 0 (Melanoma in Situ)

Stage 0 melanoma; drawing shows skin anatomy with an abnormal area on the surface of the skin. Both normal and abnormal melanocytes and melanin are shown in the epidermis (outer layer of the skin). Also shown are the dermis (inner layer of the skin) and the subcutaneous tissue below the dermis.

Stage 0 melanoma. Abnormal melanocytes are in the epidermis (outer layer of the skin).

In stage 0, abnormal melanocytes are found in the epidermis (Clark level I). These abnormal melanocytes may become cancer and spread into nearby normal tissue. Stage 0 is also called melanoma in situ.

Millimeters; drawing shows millimeters (mm) using everyday objects. A sharp pencil point shows 1 mm, a new crayon point shows 2 mm, and a new pencil-top eraser shows 5 mm.

Millimeters (mm). A sharp pencil point is about 1 mm, a new crayon point is about 2 mm, and a new pencil eraser is about 5 mm.

Stage I

Two-panel drawing of stage I melanoma. The first panel shows a stage IA tumor that is not more than 1 millimeter thick, with no ulceration (break in the skin). The second panel shows two stage IB tumors. One tumor is not more than 1 millimeter thick, with ulceration, and the other tumor is more than 1 but not more than 2 millimeters thick, with no ulceration. Also shown are the epidermis (outer layer of the skin), the dermis (inner layer of the skin), and the subcutaneous tissue below the dermis.

Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin). In stage IB, the tumor is either not more than 1 millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick, with no ulceration. Skin thickness is different on different parts of the body.

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

Stage II

Three-panel drawing of stage II melanoma. The left panel shows two stage IIA tumors. One tumor is more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin); the other tumor is more than 2 but not more than 4 millimeters thick, with no ulceration. The right panel shows two stage IIB tumors. One tumor is more than 2 but not more than 4 millimeters thick, with ulceration; the other tumor is more than 4 millimeters thick, with no ulceration. The bottom panel shows a stage IIC tumor that is more than 4 millimeters thick, with ulceration. Also shown are the epidermis (outer layer of the skin), the dermis (inner layer of the skin), and the subcutaneous tissue below the dermis.

Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.

Stage II is divided into stages IIA, IIB, and IIC.

Stage III

Stage III melanoma; drawing shows a primary tumor on the lower arm. Cancer is also shown in lymph nodes in the armpit region. The pullout shows cancer in a lymph node and lymph vessels in the arm near the tumors.

Stage III melanoma. The tumor may be any thickness with or without ulceration. It has spread either (a) into a nearby lymph vessel and may have spread to nearby lymph nodes; OR (b) to 1 or more lymph nodes, which may be matted (not moveable). Skin thickness is different on different parts of the body.

In stage III, the tumor may be any thickness, with or without ulceration, and either:

  • has spread into a nearby lymph vessel and may have spread into nearby lymph nodes; or
  • has spread to 1 or more lymph nodes, which may be matted (not moveable).

Stage IV

Stage IV melanoma; drawing shows that the primary tumor has spread to other parts of the body, such as the brain, lung, liver, lymph nodes, small intestine, or bone. The pullout shows cancer in the lymph nodes, lymph vessels, and blood vessel.

Stage IV melanoma. The tumor has spread to other parts of the body.

In stage IV, the cancer has spread to other places in the body.

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Recurrent Melanoma

Recurrent melanoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the original site or in other parts of the body, such as the lungs or liver.

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Treatment Option Overview

There are different types of treatment for patients with melanoma.

Different types of treatment are available for patients with melanoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Four types of standard treatment are used:

Surgery

Surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:

  • Local excision: Taking out the melanoma and some of the normal tissue around it.
  • Wide local excision with or without removal of lymph nodes.
  • Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and examined to see whether they contain cancer.
  • Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed for biopsy. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. Sentinel lymph node biopsy of the skin. Three-panel illustration showing a radioactive substance and/or blue dye is injected near the tumor (first panel), the injected material is detected visually and/or with a probe (middle panel), and the sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel).

    Sentinel lymph node biopsy of the skin. A radioactive substance and/or blue dye is injected near the tumor (first panel), the injected material is detected visually and/or with a probe (middle panel), and the sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel).

Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.

Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

In treating melanoma, anticancer drugs may be given as a hyperthermic isolated limb perfusion. This technique sends anticancer drugs directly to the arm or leg in which the cancer is located. The flow of blood to and from the limb is temporarily stopped with a tourniquet, and a warm solution containing anticancer drugs is put directly into the blood of the limb. This allows the patient to receive a high dose of drugs in the area where the cancer occurred.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site (see also: clinical trials at the Masonic Cancer Center)

Chemoimmunotherapy

Chemoimmunotherapy is the use of anticancer drugs combined with biologic therapy to boost the immune system to kill cancer cells.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibody therapy is a type of targeted therapy being studied in the treatment of melanoma.

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used in combination with chemotherapy as adjuvant therapy.

Vaccine therapy

Vaccine therapy is a type of biologic therapy. Cancer vaccines work by helping the immune system recognize and attack specific types of cancer cells. Vaccine therapy can also be a type of targeted therapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's clinical trials database.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

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Treatment Options by Stage

A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.

Stage 0 (Melanoma in Situ)

Treatment of stage 0 is usually surgery to remove the area of abnormal cells and a small amount of normal tissue around it.

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage 0 melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage I Melanoma

Treatment of stage I melanoma may include the following:

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage II Melanoma

Treatment of stage II melanoma may include the following:

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage II melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage III Melanoma

Treatment of stage III melanoma may include the following:

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage IV Melanoma

Treatment of stage IV melanoma may include the following:

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IV melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

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Treatment Options for Recurrent Melanoma

Treatment of recurrent melanoma may include the following:

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent melanoma (see also: clinical trials at the Masonic Cancer Center) . For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

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To Learn More About Melanoma

For more information from the National Cancer Institute about melanoma, see the following:

For general cancer information and other resources from the National Cancer Institute, see the following:

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Changes to This Summary (12/22/2009)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

Date last modified: 2009-12-22

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