• Melanoma is a disease in which malignant (cancer) cells form in the skin cells called melanocytes (cells that colour the skin). Melanocytes are found throughout the lower part of the epidermis. They produce melanin, the pigment that gives skin its natural colour. When skin is exposed to the sun, melanocytes produce more pigment, causing the skin to tan, or darken.
  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. Melanoma may also occur in the eye and is called ocular melanoma or intraocular melanoma.
  
  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.  Risk factors include the following:

Unusual moles

Exposure to natural sunlight, including sunburns during childhood

Exposure to artificial ultraviolet light (tanning machines)

Family or personal history of melanoma

Red or blond hair

White or light-coloured 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 or by other conditions. A doctor should be consulted if any of the following problems occur:

• A mole that: changes in size, shape, or colour; has irregular edges or borders; is more than 1 colour; is asymmetrical ie 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 (coloured) skin.
• Satellite moles (new moles that grow near an existing mole).
   

Tests that examine the skin are used to detect 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 colour, 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 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 tumour.
• The patient’s general health.

Although many people are successfully treated, melanoma can recur.

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 tumour. 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 tumour cells in the body. A small amount of radionuclide 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 tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells.
   
• 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 original tumour biopsy to determine the melanoma stage.

The following stages are used for melanoma:
Stage 0
In stage 0, melanoma is found only in the epidermis (outer layer of the skin). Stage 0 is also called melanoma in situ.

Stage I
Stage I is divided into stages IA and IB.

Stage IA

 In stage IA, the tumour is not more than 1 millimetre (less than 1/16 of an inch) thick, with no ulceration (a hole that forms in the skin when the top layer of cells breaks down and the underlying tissue shows through). The tumour is in the epidermis and upper layer of the dermis.

Stage IB

In stage IB, the tumour is either: not more than 1 millimetre thick, with ulceration, and may have spread into the dermis or the tissues below the skin; or
1 to 2 millimetres (more than 1/16 inch) thick, with no ulceration.

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

Stage IIA

In stage IIA, the tumour is either: 1 to 2 millimetres thick, with ulceration; or
2 to 4 millimetres (a little more than 1/8 of an inch) thick, with no ulceration.

Stage IIB

In stage IIB, the tumour is either: 2 to 4 millimetres thick, with ulceration; or
more than 4 millimetres thick, with no ulceration.

Stage IIC

In stage IIC, the tumour is more than 4 millimetres thick, with ulceration.

Stage III
In stage III, the tumour may be of any thickness, with or without ulceration, and may have spread to 1 or more nearby lymph nodes. Stage III is divided into stages IIIA, IIIB, and IIIC.

Stage IIIA

In stage IIIA, the cancer may have spread to as many as 3 nearby lymph nodes, but can only be seen with a microscope.

Stage IIIB

In stage IIIB, the cancer either: has spread to as many as 3 lymph nodes and may not be visible without a microscope; or has satellite tumours (additional tumour growths within 1 inch of the original tumour) and has not spread to lymph nodes.

Stage IIIC

In stage IIIC, the cancer either: has spread to as many as 4 or more lymph nodes and can be seen without a microscope; or has lymph nodes that may not be moveable; or
has satellite tumours and may have spread to lymph nodes.

Stage IV
In stage IV, the tumour has spread to other organs or to lymph nodes far away from the original tumour.

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.

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. Before starting treatment, patients may want to think about taking part in a clinical trial. 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.

Four types of standard treatment are used:

• Surgery
   
• Surgery to remove the tumour is the primary treatment of all stages of melanoma. The doctor may remove the tumour 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 tumour) during surgery. A radioactive substance and/or blue dye is injected near the tumour. 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.
   
• 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 increase the chances of a cure, 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 the cells 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 in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas.

In treating melanoma, chemotherapy 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. 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 defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Other types of treatment are being tested in clinical trials. Chemoimmunotherapy is the use of anticancer drugs combined with biologic therapy to boost the immune system to kill cancer cells.

Treatment Options By Stage
Stage 0 Melanoma
Treatment of stage 0 melanoma is usually surgery to remove the tumour and a small amount of normal tissue around it.

Stage I Melanoma
Treatment of stage I melanoma may include the following:

• Surgery to remove the tumour and some of the normal tissue around it.
• A clinical trial of surgery to remove the tumour and some of the normal tissue around it, with or without lymph node mapping and selective lymphadenectomy.
• A clinical trial of new techniques to detect cancer cells in the lymph nodes.
• A clinical trial of lymphadenectomy with or without adjuvant therapy.

Stage II Melanoma
Treatment of stage II melanoma may include the following:

• Surgery to remove the tumour and some of the normal tissue around it, followed by removal of nearby lymph nodes.
• Lymph node mapping and sentinel lymph node biopsy, followed by surgery to remove the tumour and some of the normal tissue around it. If cancer is found in the sentinel lymph node, a second surgical procedure can be performed to remove additional nearby lymph nodes.
• Surgery followed by high-dose biologic therapy.
• A clinical trial of adjuvant chemotherapy and/or biologic therapy, or immunotherapy.
• A clinical trial of new techniques to detect cancer cells in the lymph nodes.

Stage III Melanoma
Treatment of stage III melanoma may include the following:

• Surgery to remove the tumour and some of the normal tissue around it.
• Surgery to remove the tumour with skin grafting to cover the wound caused by surgery.
• Surgery followed by biologic therapy.
• A clinical trial of surgery followed by chemotherapy and/or biologic therapy.
• A clinical trial of biologic therapy.
• A clinical trial comparing surgery alone to surgery with biologic therapy.
• A clinical trial of chemoimmunotherapy or biologic therapy.
• A clinical trial of hyperthermic isolated limb perfusion using chemotherapy and biologic therapy.
• A clinical trial of biologic therapy and radiation therapy.

Stage IV Melanoma
Treatment of stage IV melanoma may include the following:

• Surgery as palliative therapy to relieve symptoms and improve quality of life.
• Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• Chemotherapy and/or biologic therapy.
• A clinical trial of new chemotherapy and/or biologic therapy, or vaccine therapy.
• A clinical trial of radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• A clinical trial of surgery to remove all known cancer.

Treatment Options for Recurrent Melanoma
Treatment of recurrent melanoma may include the following:

• Surgery to remove the tumour.
• Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• Palliative treatment with biologic therapy.
• Hyperthermic isolated limb perfusion.
   
• A clinical trial of biologic therapy and/or chemotherapy as palliative therapy to relieve symptoms and improve quality of life.
   

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