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How We Diagnose Melanoma

  • At the Center for Melanoma Oncology at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC), our specialists care for you and manage your diagnosis as a team. Because we are a specialized center, your testing and care are coordinated from your first appointment. This leads to fewer appointments for you, since you're able to see different specialists on the same day.

    We are one of the few centers in the world with a team of pathologists and clinicians who focus exclusively on diagnosing and evaluating melanoma. This gives us in-depth experience with the disease and an extraordinary depth of knowledge.

    If you are diagnosed with melanoma, our team uses a series of tests to better understand the extent of the disease and to determine the right treatment for you.

    Initial diagnosis

    Your doctor may conduct the following tests and procedures:

    • A skin exam checks for moles, birthmarks, or other pigmented areas that look abnormal in color, size, shape, or texture.
    • During a biopsy, your doctor may remove all or part of the abnormal skin and a small amount of normal tissue around it. A pathologist looks at the tissue under a microscope to check for cancer cells. If the abnormal mole or lesion is cancerous, the sample of tissue may also be tested for certain gene changes.

    DF/BWCC dermatopathologists work closely with our Center for Molecular Diagnostics to get a complete picture of your tumor in order to direct the right therapy, based on both the tumor type and the molecular features of the tumor. Our dermatopathologists are specifically trained to look at tissue of the skin, and also have extensive experience in evaluating pigmented lesions. If your biopsy was taken elsewhere, we will review the slides to confirm the diagnosis.

    Novel approaches to melanoma treatment

    Our team:

    • Led the Phase III trial of ipilimumab, the first drug to demonstrate a survival benefit in patients with advanced melanoma.
    • Identified two mutations that collectively occur in 71 percent of malignant melanoma tumors. This discovery could lead to targeting these mutations in cancer treatment or prevention.
    • Is actively studying melanoma tumors' microenvironments to better understand how some melanomas continue to grow despite anti-cancer drugs.
    • Is working to expand and enhance a patient information database that links clinical data to blood and tissue samples. This data-rich resource gives investigators the opportunity to better understand the biology of melanoma in order to improve treatments.

    Staging

    The process used to find out whether cancer cells have spread within the skin or to other areas in the body is called staging. This process determines your prognosis and your treatment plan.

    When cancer spreads to another part of the body, it is called metastasis.

    • Cancer cells break away from the site where they originated (the primary tumor) and travel through the lymph system or blood.
    • A metastatic tumor is the same type of cancer as the primary tumor. For example, if melanoma spreads to the lung, the cancer cells in the lung are melanoma cells. The disease is called metastatic melanoma, not lung cancer, and is treated as melanoma.

    The following tests and procedures may be used in the staging process:

    • Physical exam and history: An exam of the body to check general health as well as signs of disease, such as lumps or anything else that seems unusual. A history of your health habits and past illnesses and treatments will also be taken.
    • Lymph node mapping and sentinel lymph node biopsy: If a lymph node near the cancer site is enlarged, your doctor may remove some cells from the lymph node or the whole lymph node. If the original melanoma is thick, your doctor may remove the lymph node that appears most likely to have cancer cells.

      During this procedure, a radioactive substance and/or dye is injected near the tumor. 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.

    Blood tests and imaging tests, such as an X-ray, CT scan, MRI, and PET scan, are used to see if the cancer has spread:

    • X-ray: A type of energy beam that can go through the body and onto film, making a picture of areas inside your body.
    • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen, and pelvis, 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 enable the organs or tissues to show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
    • MRI (magnetic resonance imaging) with gadolinium: A procedure that uses a magnet, radio waves, and a computer to take a series of detailed pictures of areas inside the body. A substance called gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI).
    • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and shows where glucose is being used in the body. Malignant tumor cells appear brighter in the images because they are more active and take up more glucose than normal cells.
    • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. Higher levels of an enzyme called lactate dehydrogenase (LDH) may be a sign of more advanced melanoma.

    The results of these tests are viewed, along with the results of the biopsy, to determine the stage of the melanoma.

    The stage is based on:

    • The depth of the original melanoma and other pathologic features of the original melanoma.
    • Whether cancer cells have spread to nearby lymph nodes or to other parts of the body.

    The following stages are used for diagnosing melanoma:

    Stage 0 (melanoma in situ)

    In stage 0, melanoma is only in the epidermis (outer layer) of the skin. It is usually curable when removed with adequate margins.

    Stage 0 melanoma in situ. Abnormal melanocytes are in the epidermis (outer layer of the skin).
    Stage I
    • Stage IA: In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (the skin surface does not appear broken down) or mitoses (fast-growing cells).
    • Stage IB: In stage IB, the tumor is either:
      • Not more than 1 millimeter thick, and it has ulceration or mitoses.
      • Between 1 and 2 millimeters thick, with no ulceration.
       
    Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin). In stage IB, the tumor is either not more than 1 millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick, with no ulceration. Skin thickness is different on different parts of the body.
    State II
    • Stage IIA: In stage IIA, the tumor is either:
      • Between 1 and 2 millimeters thick, with ulceration.
      • Between 2 and 4 millimeters thick, with no ulceration.
       
    • Stage IIB: In stage IIB, the tumor is either:
      • Between 2 and 4 millimeters thick, with ulceration.
      • More than 4 millimeters thick, with no ulceration.
       
    • Stage IIC: In stage IIC, the tumor is more than 4 millimeters thick, with ulceration.
    Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.
    Stage III

    The tumor may be any thickness, with or without ulceration. One or more of the following applies:

    • Cancer has spread to one or more lymph nodes.
    • The melanoma cells have spread to adjacent tissues.
    Stage III melanoma. The tumor may be any thickness, with or without ulceration (a break in the skin), and (a) cancer has spread to one or more lymph nodes; (b) lymph nodes with cancer may be joined together (matted); (c) cancer may be in a lymph vessel between the primary tumor and nearby lymph nodes; and/or (d) very small tumors may be found on or under the skin, not more than 2 centimeters away from the primary tumor.
    Stage IV

    The cancer has spread to other places in the body, including organs, distant skin areas, or lymph nodes far from the original growth.

    Stage IV melanoma. The tumor has spread to other parts of the body.