METASTATIC MELANOMA

Metastatic melanoma is a severe form of skin cancer that spreads to other parts of the body. This type of cancer begins in melanocytes, the cells responsible for producing melanin, the pigment that gives skin its color. When melanoma spreads beyond the skin to distant organs, it is called metastatic or stage IV melanoma.

Causes

Several factors can contribute to the development of metastatic melanoma:

Ultraviolet (UV) Radiation: Prolonged exposure to UV radiation from the sun or tanning beds is a primary cause.
Genetics: A family history of melanoma increases the risk.
Skin Type: Individuals with fair skin, light hair, and blue or green eyes are at higher risk.
Moles: Atypical or numerous moles can elevate the risk of melanoma.
Immune System Suppression: Conditions or medications that weaken the immune system can contribute to melanoma.

Common Sites for Metastatic Melanoma

Tissue Under the Skin
Lymph Nodes
Lungs
Liver
Brain

Characteristics of Melanoma

Appearance Changes: Melanoma often begins with changes in an existing mole. The mole may become asymmetrical, its color may turn uneven, and it might start growing and becoming hard or lumpy.
Aggressiveness: Melanomas are aggressive and require surgical removal to prevent spreading.
Cells Affected: Melanomas originate in melanocytes, the cells responsible for producing melanin, which gives skin its color.
Primary Cause: The main cause of melanoma is exposure to ultraviolet (UV) radiation from sunlight or tanning beds.

Prevalence

Metastatic melanoma is less common than other skin cancers but is more aggressive. It accounts for about 1% of all skin cancers but causes the majority of skin cancer deaths. Annually, approximately 100,000 new cases of melanoma are diagnosed in the United States, with a significant portion progressing to metastatic stages.

Symptoms

When melanoma spreads to other parts of the body, you might experience various symptoms, including:

Hardened Lumps: Noticeable lumps under the skin.
Swollen Lymph Nodes: Lymph nodes may become swollen or painful.
Respiratory Issues: Persistent cough or trouble breathing.
Liver Changes: Swelling under your lower right ribs or a loss of appetite.
Bone Problems: Pain in the bones or, less commonly, fractures.
Neurological Symptoms: Headaches, seizures, or weakness/numbness in your arms or legs.
General Symptoms: Unexplained weight loss and fatigue

Risk Factors

Several risk factors can increase the likelihood of developing metastatic melanoma:

Age: Risk increases with age.
Gender: Men are at a higher risk than women.
Sun Exposure: Frequent sunburns, especially in childhood, significantly raise the risk.
Geographic Location: Living in sunny or high-altitude areas increases UV exposure.

Diagnosis

If melanoma is suspected, your doctor will perform a skin exam. To confirm the diagnosis, a biopsy is necessary. The types of biopsies include:

Punch Biopsy: Removes a small, round piece of skin.
Excisional Biopsy: Removes the entire growth.
Shave Biopsy: Shaves off the growth from the skin’s surface.

A pathologist will examine the biopsy under a microscope to determine the thickness of the tumor. Generally, a thicker tumor indicates a higher risk of cancer spreading.

Additional Tests for Diagnosed Melanoma

If melanoma is confirmed, further tests help determine if it has spread:

Blood Tests and Imaging Tests: To detect metastasis.
- Chest X-ray: Uses low-dose radiation for internal images.
- CT Scan: Uses powerful X-rays for detailed internal views.
- MRI: Utilizes powerful magnets and radio waves to create detailed images of organs and tissues.
- PET Scan: Employs radioactive material to identify cancerous activity.
- Checking for elevated levels of lactate dehydrogenase (LDH) can indicate advanced melanoma.

Lymph Node Examination

The doctor will also check for enlarged lymph nodes, which are small glands located in the neck, underarms, and groin. This can involve:

Fine-Needle Aspiration Biopsy: A thin needle extracts a sample of cells from the lymph nodes.
Lymph Node Biopsy: The doctor injects dye near the cancer site, which travels to the nearest lymph nodes (sentinel nodes). These nodes are then removed and tested.

Determining the Stage and Treatment Plan

The results from these tests help determine the stage of your melanoma, indicating how far the cancer has spread. With this information, you and your doctor can devise the most appropriate treatment plan.

Treatments

Metastatic melanoma, while challenging to treat, has several treatment options available. Your treatment choice depends on the location and size of the cancer, your overall health, and your personal preferences. Here are the primary goals and treatment methods:

Treatment Goals

Control Cancer Growth: Shrink or stop the growth of the disease where it has spread.
Prevent Spread: Stop the cancer from spreading to new areas.
Enhance Comfort: Improve quality of life by reducing symptoms.

Treatment Methods

Surgery
- Purpose: Removal of tumors or lymph glands.
- Effectiveness: Surgery alone may not cure cancer but can help extend life and alleviate symptoms.
- Combination: Often used alongside other treatments.
Radiation and Chemotherapy
- Usage: Can help depending on the cancer’s size and location.
- Role: Historically primary treatments, now often supplemented with newer therapies.
Immunotherapy
- Function: Boosts the immune system to better attack cancer.
- Administration: Given through an IV or as a high-dose shot.
- Effectiveness: Can shrink metastatic melanomas and extend life.
- Common Drugs:
  - Ipilimumab (Yervoy):
    - Prevents melanoma from returning post-surgery.
    - Used for late-stage melanoma not removable by surgery.
    - Often combined with PD-1 inhibitors for better outcomes.
  - PD-1 Inhibitors:
    - Nivolumab (Opdivo), Nivolumab-Relatlimab-RMBW (Opdualag), Pembrolizumab (Keytruda):
    - Block PD-1 protein, enhancing immune response against tumors.
    - Combination therapy with ipilimumab increases survival rates.
  - Older Drugs:
    - Interferon-alpha and Interleukin-2: Help extend life for some patients.
Targeted Therapy
- Purpose: Aims to kill cancer cells while sparing healthy ones.
- Specificity: Works for people with certain genetic changes, causing fewer side effects than chemotherapy or radiation.
- Common Drugs Targeting BRAF Gene:
  - Dabrafenib (Tafinlar)
  - Encorafenib (Braftovi)
  - Vemurafenib (Zelboraf)
  - Function: These drugs shrink tumors and prolong life in patients with BRAF mutations.
- MEK Inhibitors:
  - Binimetinib (Mektovi)
  - Cobimetinib (Cotellic)
  - Trametinib (Mekinist)
  - Usage: Often used with BRAF inhibitors to extend the duration of tumor shrinkage.

Making Treatment Decisions

Choosing the right treatment involves considering the specific characteristics of your melanoma and your personal health goals. Here are some steps to help guide your decision:

Consult with Specialists: Work with a team of healthcare providers to understand your options.
Consider Clinical Trials: Look into new and emerging treatments that might be available through clinical trials.
Evaluate Support Systems: Lean on family, friends, and support groups to help you make informed decisions and cope with the treatment process.
Stay Informed: Keep up-to-date with the latest research and advancements in melanoma treatments.

Home Care Tips

Patients can manage symptoms and improve quality of life with these home care strategies:

Skin Protection: Using sunscreen, wearing protective clothing, and avoiding peak sun hours.
Healthy Diet: Consuming a balanced diet to maintain strength and overall health.
Hydration: Drinking plenty of fluids to stay hydrated.
Pain Management: Using prescribed pain relievers and consulting healthcare providers for pain control strategies.
Emotional Support: Seeking support from friends, family, or cancer support groups. The Melanoma Research Foundation offers various support services, including an online patient community and a phone buddy program. The Skin Cancer Foundation also provides valuable information.

Prevention

Preventing metastatic melanoma involves several proactive steps:

Sun Safety: Regular use of broad-spectrum sunscreen with SPF 30 or higher.
Avoid Tanning Beds: Steering clear of indoor tanning devices.
Regular Skin Checks: Performing monthly self-examinations and annual dermatologist visits.
Protective Clothing: Wearing hats, sunglasses, and long-sleeved clothing when outdoors.

Understanding What to Expect

Stage IV melanoma is challenging to treat, but each case is unique. Some individuals respond very well to treatment. Discuss all available options with your doctor, including the possibility of participating in clinical trials for new treatments.

When to See a Doctor

Consult a doctor if you notice:

Changes in Moles: Alterations in size, shape, color, or texture.
New Growths: Appearance of new moles or skin lesions.
Unusual Symptoms: Persistent headaches, unexplained pain, or other concerning symptoms.

Outlook/Prognosis

The prognosis for metastatic melanoma varies based on several factors, including the extent of spread, the patient’s overall health, and the response to treatment. While metastatic melanoma is challenging to cure, advancements in treatment options have significantly improved survival rates and quality of life for many patients.

Sources

American Cancer Society
National Cancer Institute
Skin Cancer Foundation
Mayo Clinic
World Health Organization
WebMD