Melanoma is a type of skin cancer. It begins in the cells that give our skin its color. These cells are called melanocytes. Melanoma can develop in or around a mole, or in other pigmented tissues, such as those found in the eye.
Metastatic melanoma is melanoma that has spread to another area of the body. Melanoma can spread to the:
- Skin - other parts of the skin, sometimes far from where it first started
- Lymph nodes, sometimes far from the original cancer site
The main risk factor for metastatic melanoma is a personal history of melanoma, and the look and behavior of the initial tumor. There are treatments but, as of yet, no cure for metastatic melanoma.
Metastatic melanoma may appear in a number of different ways. Often patients detect it themselves after noticing dark, bumpy growths or lesions on their skin. Other times, metastatic melanoma is picked up during a computed tomography (CT) scan used to monitor high-risk patients.
Regular physical exams and checkups are critical for people at high risk. During a skin exam, a doctor will carefully look over your whole body for unusual spots or moles. Other tests that may be used to find or monitor your disease include:
- CT scan
- Brain MRI or CT scan of the brain
- PET scan
- Other lab or blood work
The symptoms of metastatic melanoma will depend on where it has spread.
Melanoma on the skin is usually found based on the look or feel of the skin. You may notice:
- Lumps or bumps under the skin
- New or changing black marks
- Swollen lymph nodes in the neck, armpit or groin
Melanoma inside the body, usually found on PET or CT scan, may have a variety of symptoms, such as:
- Pain if it is in the bone
- Blood in the stool if it is in bowels or GI tract
- Shortness of breath if it is in the lung
- Seizures if it is in the brain
Tip: Not all melanomas come back on the skin. If you have new symptoms of any kind, you should tell your doctor right away.
Staging and Treatment
Your doctor will consider several factors to figure out how far the disease has spread. These may include:
- Locations of cancer in the body including any distant sites
- Number and size of tumors
- Serum lactate dehydrogenase (LDH) level, an enzyme found in the blood and many body tissues. High levels of LDH may suggest that the tumor has spread to internal organs.
- How you are feeling and symptoms that you report
Metastatic melanoma is sometimes further staged or divided into:
Melanoma has spread to other areas of the skin or distant lymph nodes far from the site of the initial tumor. For example, if your first melanoma appeared on the arm, cancer in the lymph nodes in the armpit of the same arm would be considered local disease. If the lymph nodes in your groin or abdomen now show signs of melanoma, the cancer has spread beyond the initial affected area and is considered metastatic.
Melanoma has spread to the lungs.
The tumor is now found in other organs besides the lungs or the person has high levels of LDH.
New treatments for metastatic melanoma have become available in recent years. These treatment options, along with others being studied in clinical trials, are changing the way the disease is managed and helping some patients live longer.
“There are so many new treatment options for people with metastatic melanoma that much of the information available is historical. There is so much more reason to be optimistic now, patients can do very well.”
Michael Postow, MD, Memorial Sloan-Kettering Cancer Center
Treatment for metastatic melanoma falls into three categories:
- Local therapies, such as surgery and radiation, that only treat the tumor
- Systemic therapies or medications given by mouth or in a vein that travel through the bloodstream to kill the cancer cells
- Palliative care consisting of drug and non-drug therapies designed to help you feel better
Surgery is used to remove cancer tumors or lymph nodes, especially if they are causing symptoms.
Radiation Therapy uses high-energy x-rays to kill cancer cells. With advanced disease, radiation is used mostly to treat cancer symptoms or metastases to the brain.
Immunotherapy activates or triggers the immune system to recognize and fight cancer cells. FDA-approved immunotherapy drugs include:
- Ipilimumab (Yervoy®)
- Proleukin (aldesleukin, commonly known as high dose interleukin-2)
Studies are investigating adoptive cell therapies that select and make immune cells to fight cancer and antibodies against Programmed death-1 receptor axis, among others
Targeted therapies are designed to target specific proteins or stop genetic mutations that can promote cancer. Roughly half of patients with melanoma have a mutated or abnormally activated BRAF gene, which signals cancer cells to grow. The following drugs may be effective in treating these people:
- Vemurafenib (Zelboraf®) and Dabrafenib (Tafinlar®) are drugs that shut down the abnormal BRAF protein.
- Trametinib (Mekinist™) blocks a different protein called MEK. This protein is in the same family as the BRAF protein.
Some patients benefit from chemotherapy. Chemotherapy can be given by mouth or through a vein (intravenously). Chemotherapy drugs most often used for metastatic melanoma include:
- Dacarbazine (DTIC-Dome®) – given through a vein
- Temozolomide (TEMODAR®) - given as a pill, but may not be covered by health insurance because it is very similar to dacarbazine (See Coping with the Cost of Care for useful information)
Palliative Care is a critical part of cancer care, regardless of what type of treatment you are getting. It can help address physical symptoms such as pain, fatigue, and appetite changes, and emotional symptoms such as stress, depression, and anxiety.
Clinical Trials may offer patients access to the most promising therapies for metastatic disease. Clinical trials test novel therapies or new ways to use or combine drugs or techniques that are already approved. Ask your doctor if a clinical trial, locally or elsewhere, would be suitable for you.
Patients who respond to the newer therapies often live longer but every patient is different. For some patients with advanced disease, radiation or surgery may be better options. With many therapies, the cancer cells eventually learn to outsmart the medication. For this reason, it is important to learn about other treatments that are available or under study.
Continuous monitoring of your disease and regular doctor’s visits will be part of any treatment plan. Be sure to keep follow-up appointments and take all medications as prescribed.
Managing Side Effects
Living with metastatic melanoma means that you will be on various treatments for much of your life. All treatments can have side effects. It helps to learn about possible side effects and what to watch for so that you and your caregivers will know what to expect. You may not experience all or even many of them. Always tell your doctors and nurses how you are feeling to get the best possible relief. Ask for the name and contact information for the person to call, email, message or fax between appointments if you have a question or a problem. Find out the best way to communicate with them.
Be sure to report any new or worsening symptoms to your doctor or nurse as soon as you notice them. This is especially important if you are taking one of the newer medications, which can have life-threatening side effects. A health care provider who is aware of symptoms can work with you to manage them and help you stay on your treatment plan.
Common Side Effects by Treatment
Immunotherapy - rash, itching, diarrhea, endocrine disorders
Targeted therapy - fatigue, muscle/joint pain, diarrhea, skin growths, rash/itching
Chemotherapy - fatigue, nausea, and potential for infection
Radiation and Surgery - The side effects of radiation and surgery depend on the part of the body being treated, and the procedure(s) used.
Questions to Ask Your Doctor
- Who do you recommend for a second opinion?
- Which treatment(s) do you recommend and why?
- Am I eligible for a clinical trial here or elsewhere?
- What will this treatment mean for my day-to-day life?
- What kind of side effects might I experience, for how long, and how can I manage them?
- How do I know if a treatment is working?
- What should my family and friends expect?
- Has my melanoma been tested for BRAF or other abnormal genes?
- Can my pain be better controlled?
- What else can I do to stay as healthy as possible?
- What other resources are available to me both in and outside the hospital? (for example, a patient advocate, social worker, nutritionist or counselor)
- What is the risk of my melanoma coming back?
- How often do I need to see my doctor?
- Can I be followed by my dermatologist/internist, or should I be seeing an oncologist too?
- What other ways will my health be monitored?