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Early melanoma (Stage 1 melanoma)

Very early melanomas are stage 1 on the TNM staging system.  This means they are thinner than 2.0mm or less than 1.0mm thick and ulcerated.  They have not spread anywhere else in the body.  The chances of a very early stage one melanoma spreading are low.  This is because the melanoma has not grown deep enough into the skin to allow the cancerous cells to break away and spread.  Doctors might use the tumour thickness scale to assess the risk of your melanoma coming back.

How is it treated?

Your treatment is to have the affected mole surgically removed.  Depending on how much tissue needs to be removed, your doctor may call this a wide local excision.  As long as your doctor is sure that enough tissue was removed – there should be a margin of healthy tissue removed all around the melanoma – this is all the treatment you need.

What happens after treatment?

Your doctor will probably want you to come for follow up appointments.  After a period of follow up, your doctor may discharge you altogether.  In between appointments, you should be aware of any symptoms that may be important.  You should contact your specialist if you notice:-

  • Any changes in other moles
  • Any dark mole-like spots appearing near where your mole was removed
  • Any enlarged glands (lymph nodes) near to where you had the mole remove

An appointment will be arranged for you to have an extra check up.

Once you have been diagnosed with a melanoma, you should be very careful in the sun, use adequate protection.  You should never use sun beds.  This is very important as your risk of developing another melanoma is higher than average.

Melanoma (Stage 2 and 3) –  What stage 2 and 3 melanoma means

Melanoma that is stage 2 or 3 may sometimes be described by doctors as high risk. This is because there is a possibility that your melanoma could come back in another part of your body. Stage 2 melanomas are thicker than 2.0mm or thicker than 1.0mm and ulcerated. Ulcerated means that the covering layer of skin is broken. And melanomas that are ulcerated are more likely to spread. There is also a higher risk of spread with a thicker melanoma than with a thin one because the melanoma cells have grown deeper into the skin. Some doctors prefer to call stage 2 melanomas between 1.0mm and 4mm intermediate risk. And only those over 4mm thick are high risk.

Your melanoma may also be called high risk if you have –

  • Any nearby lymph nodes that contain melanoma cells
  • A local recurrence of a primary melanoma
  • “In transit” metasteses
  • Local recurrunce means that other nodules of secondary melanoma have grown less than 5cm from your primary melanoma.

‘In transit’ metastases are secondaries that have grown further than 5cm from the primary, but before the nearest group of lymph nodes. Both local recurrence and in transit metastases are a sign that the cancer has begun to spread.
Remember – doctors might be using a different system when they are talking about the risk of your cancer coming back. This can be confusing as doctors might call stage 1 melanomas high risk. These are risks according to the Breslow scale are for Stage 1 melanoma.

How is stage 2 and 3 melanoma treated?
Your first treatment is to have the primary melanoma surgically removed. You may also need to have further surgery to remove more tissue if there are signs from the biopsy results that melanoma cells could have been left behind.

Sentinel node biopsy

This is a technique being studied to help find out the stage of your melanoma.  It is not a treatment but a type of test. The idea is to find out which is the first lymph node to drain tissue fluid from the area where the primary melanoma was. This is the lymph node most likely to contain cancer cells from the primary melanoma, simply because they will get to that node first once they enter the lymphatic system.

Sentinel node biopsy is being tried because it could be a more certain way than needle biopsy of finding out whether cancer cells have spread to your lymph nodes.  If the node doesn’t contain any cancer cells, you won’t need any further lymph node surgery.  If it does contain cancer cells, you will have to come back for another operation.  Your surgeon will then remove all the other nodes in the area because they may contain cancer cells as well.  It is a difficult decision to make and should be considered very carefully.  There are experts who do not believe that this procedure is useful.

Removing your lymph nodes

If any of your lymph nodes are found to have cancer cells, you will then have an operation to have them removed. This can be quite a big operation. The type of surgery you have will depend on where your primary melanoma was in your body. There are large groups of lymph nodes in the, neck, armpit, groin.

So, for example, if you had a melanoma on your leg, the lymph nodes in the groin on the same side will be removed. If you had a melanoma on your scalp or head, the lymph nodes on the same side of your neck would be removed.

There are some side effects from this type of surgery. You are likely to be in some pain after the operation. This should get better as the area heals. But a few people (less than one in ten) do have lasting pain. Particularly if the lymph nodes in the neck have been removed. Shoulder stiffness and pain are the most common problems after the lymph nodes under the arm have been taken out. You may find that you cannot move your arm as freely as you could before the surgery. With lymph node dissection in the groin, swelling of the leg on the same side is the most common problem after surgery. This is called lymphoedema. It can usually be controlled with a combination of exercise, massage and wearing an elastic stocking on the affected arm or leg.

Adjuvant treatment

Treatment that is done after surgery for cancer to try to prevent it coming back is called adjuvant treatment.   You may be asked to join a trial if you had lymph nodes containing cancer cells.

Advanced melanoma (Stage 4)

Advanced melanoma means the cancer has spread from where it started to another part of the body.  This may be called stage 4 melanoma. Your melanoma may have already spread when it is diagnosed.  Or it may come back in another part of the body sometime after you were first diagnosed and treated.  This is called ‘recurrent’ cancer.  Cancer that has spread to another part of the body is called secondary cancer or metastases

Where can melanoma spread to?
Melanoma can spread just about anywhere in the body.

There does not seem to be much of a pattern in where it goes to, unlike some other cancers.  For example, secondary melanoma can occur in the

Lymph nodes

Not all melanomas will spread. And not all will spread to the same places. It is not possible to be definite about this because the same type of cancer can behave completely differently in different people.

Which treatment should I have?

Discuss this with your doctor.  You will hear a lot about  Ipilimumab,  Vemurafenib, Dabrafinib, Trametenib and PD1 treatments.  Some of these drugs are now available on the NHS in England and are life prolonging, some are available via expanded access schemes.  Some patients are not suitable for certain treatments.    Your doctor will tell you if you are a patient that can be treated with these particular drugs.

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