Caregivers provide information about Melanoma
As caregivers, we help many people who have been diagnosed with melanoma. When you have been diagnosed with melanoma, the next step is that you will be advised what “stage” of melanoma you have. A diagnosis of melanoma is then staged by the pathologist giving an assessment of the depth the melanoma invades into the skin to determine how limited or advanced this skin cancer is.
The prognosis of melanoma and the treatment options available to patients very much depend on the stage at which the cancer is diagnosed.
The four stages of melanoma are determined by reviewing different features.
In Stage 0 melanoma, the malignant tumour is still confined to the upper layer of the skin. 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. There is no evidence the cancer has spread to the lymph nodes or distant sites.
Stage 1 melanoma is defined as a melanoma that is up to 2mm thick. A Stage 1 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 1 Melanoma: 1A, 1B, referring to whether ulceration is not present (A) or present (B).
Stage 2 melanoma is defined by tumour thickness and ulceration. There is no evidence the cancer has spread to the lymph nodes or distant sites (metastasis). There are three subclasses of Stage 2: 2A, 2B, 2C.
Stage 3 melanoma is defined by the presence of lymph node involvement along with ulceration in the skin melanoma. For Stage 3 melanoma, the depth of the melanoma no longer matters. There is no evidence the cancer has spread to distant sites (metastasis). There are three subclasses of Stage 3 melanoma: 3A, 3B, 3C. The subclasses relate to the size and number of glands that contain the melanoma cells.
Stage 4 melanoma occurs when the melanoma has spread beyond the original site and regional lymph nodes to more distant areas of the body. The blood level of LDH in the patient may or may not be elevated. The significance of this is that it provides biochemical evidence of metastatic spread. The most common sites of metastasis are to vital organs (lungs, abdominal organs, brain and bone), soft tissues (skin, subcutaneous tissues) and distant lymph nodes (lymph nodes beyond the primary tumour region).
What to expect from the medical profession
Here is what to expect when you schedule a visit to your doctor after detecting skin changes:
Complete Medical History
The doctor will first take a complete medical history to learn about your symptoms and risk factors. You will be asked your age, when you first discovered the area of concern on your skin, and if any features of that area have changed since your discovery. The doctor will ask about past exposures to known causes of skin cancer, such as sun exposure. You will also be asked whether you or your family have a history of atypical moles or skin cancer, particularly melanoma.
Complete Skin Examination
You will be asked to undress completely and be given a gown. The suspicious mole or lesion will be evaluated with the naked eye for size, shape, colour, texture, and any evidence of bleeding, oozing, or scaling. The doctor will then perform a thorough and systematic examination of the rest of your body to check for other spots or moles that may be related to your skin cancer. This will include scalp, nails, palms, soles, ears, and areas not exposed to the sun, including beneath the breasts or under any rolls of flesh.
Lymph Node Evaluation
The doctor will palpate (feel) the lymph nodes nearest the suspicious lesion, (in the groin, or underarm, or neck). If the nodes are enlarged or unusually firm, additional tests may be recommended to evaluate whether cancer has spread to the regional lymph nodes.
A doctor who suspects that a skin spot is melanoma will perform a biopsy. In this procedure (usually performed with a local anaesthetic to numb the area), the doctor removes the suspect lesion using techniques that preserve the entire lesion so that the thickness of the potential cancer and its margins (healthy tissue around the lesion that is removed to make sure no cancer cells remain) can be carefully examined.
Any skin samples taken by a biopsy or an excision are sent for microscopic examination, and a pathology report is issued by the pathologist (a doctor who specializes in interpreting and evaluating cells, tissues, and organs to diagnose disease). The pathology report describes many aspects of the melanoma, including the size, the thickness of the lesion, the mitotic rate, and the presence or absence of ulceration, lymphatic response, regression, satellite lesions, and blood/nerve invasion.
Other Tests For Melanoma
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. The doctor may order various tests to determine if or where the melanoma has spread.
Your doctor may consider these factors when choosing a diagnostic test:
Your age and medical condition
The type of cancer
Severity of symptoms
Previous test results
Some standard diagnostic tests:
Blood tests: No special blood tests are needed for localised melanoma and there are no reliable ones that can indicate specifically whether or not a melanoma has spread. Testing for elevated levels of LDH (serum lacate dehydrogenase), an enzyme found in the blood, may indicate the presence of metastatic disease.
Chest x-ray: It is taken to make sure melanoma has not spread to the lungs, the lymph nodes in the mediastinum (space in the chest between the lungs), or the bones of the rib cage.
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.
CT scan: A CTscan of the chest, head, abdomen, or pelvis, may be recommended if it is suspected that the melanoma has spread. A rotating x-ray beam takes a series of pictures of the body from many angles. A computer combines the information from all the pictures and makes a detailed, cross-sectional image of the body. Except for possible minor discomfort from the injection of intravenous dye to highlight certain tissues in the body that may otherwise be hard to see, this is a painless procedure.
MRI (magnetic resonance imaging): Like the CT scan, MRI is only used when it is suspected that the melanoma has spread. It may be recommended in place of a CT scan. The only difference is that the cross-sectional images of the body are created by magnetic fields instead of x-rays. MRI is particularly useful for looking at the brain, spinal cord, and examining specific areas in the bone. It may also be used if the results from other imaging tests are unclear or there is a concern about exposure to radiation.
PET scan (positron emission tomography): For a PET scan, radioactive glucose (a form of sugar) is injected into the body. Cancer cells usually absorb glucose more quickly than normal cells, so they may light up on the PET scan. However, since a number of normal body activities also use large amounts of glucose, false-positive results are fairly common and their results should be verified by other tests. Newer devices combine PET and CT scans.
If the physical examination shows evidence of a suspected melanoma, your doctor will recommend a skin biopsy, a procedure to remove all or part of the mole for evaluation under a microscope.
The biopsy provides 2 important pieces of information:
Whether the mole is benign or malignant
If malignant, how deeply the tumour has penetrated the skin and whether there are associated signs of ulceration
A skin biopsy is quick and about as uncomfortable as having blood drawn. The physician will clean the area to be biopsied with alcohol and then inject a small amount of local anaesthetic. Because the anaesthetic makes the skin swell and has a low pH, it burns for about 5 to 10 seconds. It is similar to the anaesthetic used by dentists. Once the anaesthetic has taken effect, the doctor will use a scalpel, a razor blade, or a small circular blade called a “punch” to free a small piece of skin. Because the skin is numb, the patient can feel pressure but no pain during this part of the procedure. If a deep biopsy is taken, 1 or 2 stitches are used to close the wound. If the biopsy is superficial, the wound is left open to heal like deep scrape. The whole process usually takes about 5 minutes.
Often, skin samples are sent to a dermatopathologist, a pathologist with additional training and certification in making diagnoses from skin biopsies.
What to Ask Your Doctor Before a Biopsy
You may find it helpful to print out these questions and bring them with you to your next doctor’s visit.
What information do you hope to gain from the biopsy?
What is the likelihood that the biopsy will establish a diagnosis?
Can the diagnosis be established by any other methods?
How is the biopsy done?
Is the procedure painful? Is a local or general anesthetic involved?
How safe is the biopsy procedure?
Can the biopsy be performed in your office or must the procedure be done in a hospital?
Will you be removing the entire lesion or a part of the lesion? Why?
How many samples will be removed?
How large is the tissue fragment to be removed?
How long will the procedure take? Can I go about my normal daily activities afterward?
Will I have pain or scarring afterward?
Will I need stitches?
How do I take care of the biopsy site?
What should I do if I think I have an infection?
What does an infection at a biopsy site look like?
Are there any complications that might arise as a result of the biopsy procedure? If complications develop, what should I do or whom should I contact?
Who will interpret the biopsy?
How long will I wait until a result is available?
How will I be informed about the result of the biopsy?
Any skin samples taken by a biopsy or an excision are sent for microscopic examination, and a pathology report is issued by the pathologist or dermatopathologist, (a pathologist who specializes in skin biopsies.) The pathology report further describes many aspects of the melanoma, including the type, the depth of invasion, the tissue level of invasion, the presence or absence of a lymphatic response, ulceration, mitotic count, regression, satellite lesions, and blood/nerve invasion.
Additionally, the pathology report will describe whether the excised lesion is a primary melanoma, in which case it would be described using the terms above, or a metastatic melanoma deposit. A metastatic melanoma is one in which the cancer cells spread within the subcutaneous skin tissue in the site of the original tumour. These lesions are often called “in-transit metastases.”
The presence or absence of melanoma cells in the lymph nodes is one of the most important prognostic factors we have, since it determines what the melanoma will do in the future and therefore the type of treatment you will need.
After The Surgery
The sentinel nodes removed by your surgeon will be examined under a microscope by a dermatapathologist to determine if there is melanoma in the lymph nodes.
If the sentinel lymph nodes do not show cancer, then it is unlikely that the cancer has spread to the lymph nodes and no further surgery is necessary.
If it is shown that there is melanoma in the lymph nodes but nowhere else, then the remaining lymph nodes in that area are removed. This is called a therapeutic lymphadenectomy (TLND)