Melanoma: Full guide

What is melanoma?

Melanoma is a type of skin cancer. It starts in melanocytes. These are the cells that make the color (pigment) in your skin.

Melanoma often looks like a new mole or a mole that changes. It can show up anywhere on the body. This includes places that do not get sun, like the soles of the feet or under a nail.

Too much sun or tanning bed light (UV light) is the biggest cause. Fair skin, many moles, unusual moles, and a family history of melanoma also raise the risk. A weak immune system raises it too.

Most melanomas are found early, when surgery alone can often remove them. When melanoma is more advanced, immune treatments and targeted pills now help many people. Your care team will explain what this means for you.

Types

Superficial spreading melanoma

The most common type. It often grows along the top layer of skin for a while before growing deeper. It is often found on the back, chest, arms, or legs.

Nodular melanoma

A type that grows down into the skin quickly. It often looks like a raised bump that may be dark, pink, or red. It needs prompt care.

Lentigo maligna melanoma

Grows in skin that has had a lot of sun over many years, like the face. It is more common in older adults.

Acral lentiginous melanoma

Found on the palms, soles, or under the nails. It is not linked to sun. It is the most common type in people with darker skin.

Desmoplastic melanoma

A rare type that can look like a scar or firm bump with little color. It often responds well to immunotherapy.

Mucosal melanoma

A rare melanoma that starts in moist linings of the body. Examples are the nose, mouth, anus, or genital area. It acts differently from skin melanoma.

Uveal (eye) melanoma

Melanoma that starts inside the eye. It is a very different disease and is treated differently from skin melanoma.

Tests you may have

Full skin check

A doctor looks at your skin from head to toe, including your scalp, feet, and nails. They look for other spots that may need a biopsy.

Biopsy

Removing a spot to look at it under a microscope. For a possible melanoma, the whole spot is usually removed (excisional biopsy). This shows how deep it goes.

Pathology report

The report on your biopsy. It lists the thickness (Breslow depth) and whether the skin on top is broken (ulceration). It also notes how fast the cells divide (mitotic rate). These help set your stage.

Sentinel lymph node biopsy

A small surgery to remove the first lymph nodes that drain the area of the melanoma. A tracer and blue dye help the surgeon find them. It shows if melanoma has reached the nodes.

Lymph node ultrasound

Uses sound waves to look at lymph nodes. It may be used to check nodes over time instead of removing them all.

CT or PET-CT scan

Scans that make detailed pictures of the inside of your body. They check if melanoma has spread. They are usually used for higher stages, not for most thin melanomas.

Brain MRI

A scan that uses magnets to look at the brain. Melanoma can spread to the brain, so this is often done for stage 3 or 4.

Blood tests

These check your blood counts, liver, kidneys, and hormone levels. A test called LDH can help show how active advanced melanoma is.

Gene testing of the tumor

Checks the melanoma for gene changes like BRAF. This matters most for stage 3 and 4, where it can guide treatment.

What the stage means

The stage tells how deep the melanoma is and whether it has spread. It is the most important guide for treatment.

Thickness matters most for early melanoma. Doctors measure it in millimeters (mm). Thinner melanomas are less likely to spread.

Doctors also check for ulceration. This means the skin over the melanoma is broken. Ulceration can raise the stage.

Stage 0

Melanoma in situ. The cancer cells are only in the top layer of skin. Surgery to remove it with a small rim of normal skin is usually all that is needed.

Stage 1

The melanoma is thin and has not spread. Surgery removes it. A sentinel lymph node biopsy may be offered for some, based on thickness and other features.

Stage 2

The melanoma is thicker, or thinner with ulceration, but has not spread to lymph nodes. Surgery removes it. For stage 2B and 2C, immunotherapy after surgery may be offered.

Stage 3

Melanoma has spread to nearby lymph nodes or to skin close to the first spot. Treatment often combines surgery with immunotherapy or targeted pills, before and/or after surgery.

Stage 4

Melanoma has spread to distant places, like the lungs, liver, bones, or brain. Treatment uses medicines that work through the whole body. Some people have long-lasting control of the cancer.

Tumor markers and gene tests

Some melanomas have gene changes that help them grow. Testing for these helps your team choose treatment, mostly for stage 3 and 4.

Immunotherapy can work whether or not your melanoma has a gene change. So everyone with advanced melanoma may be offered it.

A small number of melanomas run in families. Genetic counseling may help if several family members had melanoma or pancreatic cancer.

BRAF

The most common gene change. It is found in about half of skin melanomas, more often in younger people. Pills that block BRAF and a partner protein called MEK can work well.

NRAS

Another common gene change, more often in older people with a lot of sun damage. There is no approved pill that targets it directly yet.

KIT

A gene change seen more in melanomas of the palms, soles, nails, or moist linings. Some people may benefit from a targeted pill.

LDH

A blood test, not a gene test. A high level in advanced melanoma can mean the cancer is more active. It is part of stage 4 staging.

Gene expression profile test

A test on the tumor that some doctors use to estimate risk in stage 1 and 2. It is not yet routine. Thickness and the sentinel node result still matter more.

Inherited gene changes

Changes in genes such as CDKN2A or BAP1 can run in families and raise melanoma risk. A genetic counselor can explain if testing makes sense for you.

Main treatments

Wide local excision

Surgery to remove the melanoma or biopsy scar plus a rim of normal skin around it. This is the main treatment for stage 0 to 2. The size of the rim depends on how thick the melanoma was.

Sentinel node biopsy and lymph node surgery

Checks the first lymph nodes for hidden melanoma. It helps with staging. If the node has melanoma, many people now have regular ultrasounds instead of surgery to remove all the nodes. Removing a group of nodes (lymph node dissection) is mainly for nodes with melanoma that can be felt or seen.

Immunotherapy after surgery (adjuvant)

Medicines called checkpoint inhibitors, like pembrolizumab or nivolumab, given for about a year after surgery. They lower the chance of the melanoma coming back. They are used for some stage 2B, 2C, 3, and removed stage 4.

Immunotherapy before surgery (neoadjuvant)

Some stage 3 melanomas have lymph nodes that can be felt or seen on scans. For these, immunotherapy first, then surgery, is now a standard option. If the melanoma is mostly gone at surgery, some people may not need more treatment after.

BRAF and MEK targeted pills

For melanoma with a BRAF gene change. Two pills are taken together. They can shrink the cancer quickly. They may be used after surgery or for advanced melanoma.

Immunotherapy for advanced melanoma

One or two checkpoint inhibitors given by IV. Choices include one medicine alone, nivolumab plus ipilimumab, or nivolumab plus relatlimab. For many people, even with a BRAF change, immunotherapy is tried first.

TIL therapy

A type of cell therapy. Immune cells called tumor-infiltrating lymphocytes are taken from your tumor and grown in a lab. After a short course of chemotherapy, they are given back by IV, followed by an immune medicine called IL-2. IL-2 can cause serious side effects, so it is given in the hospital with close watching. It is used when melanoma grows after other treatments. It needs a hospital stay at a specialized center.

Injected treatments

Some medicines, such as T-VEC, are made from a changed virus. They are injected right into melanoma spots in the skin or nodes. They can help the body attack the cancer.

Radiation and focused brain radiation

Radiation can ease pain or control spots of melanoma. Stereotactic radiosurgery (SRS) aims very precise beams at small brain tumors.

Clinical trials

Research studies that test new treatments. They are an important option in melanoma at every stage. Ask if a trial is right for you.

Common side effects and what helps

Immune side effects

Immunotherapy can make the immune system attack healthy organs, like the bowels, liver, lungs, skin, or hormone glands. These are more common when two immune medicines are given together. Tell your team about any new symptom early. Most can be treated, often with steroid medicine.

Hormone problems

Immunotherapy can affect the thyroid, pituitary, or adrenal glands. You may feel very tired, cold, or dizzy, or have headaches. Some people need hormone pills for life. Blood tests help find this early.

Diarrhea or colitis

Loose stools or belly pain on immunotherapy can mean the bowel is inflamed (colitis). Call your team the same day. Do not just wait it out.

Fever and chills

Common with some BRAF and MEK pills. Your team will tell you when to pause the pills and when to call. Fever can also mean infection, so always check in.

Skin rash, itching, and sun sensitivity

Can happen with both immunotherapy and targeted pills. Use gentle soap and moisturizer. Some pills make you burn easily, so cover up and use sunscreen.

Fatigue

Feeling very tired is common. Short walks and light activity can help. Rest when you need to. Tell your team if it is new or severe, since it can be a sign of hormone problems.

Eye and heart changes

Some targeted pills can affect vision or heart function. You may have eye exams and heart tests. Report blurry vision or new shortness of breath.

Swelling after lymph node surgery

Removing lymph nodes can cause long-lasting swelling of an arm or leg (lymphedema). A lymphedema therapist, compression garments, and exercise can help.

Low blood counts after TIL therapy

The chemotherapy before TIL therapy lowers blood counts for a while. This raises the risk of infection and bleeding. You will be watched closely in the hospital.

Living with and after melanoma

You will have regular visits with skin and lymph node checks. These are often every few months for the first years, then yearly for life. Some people also have scans.

Check your own skin once a month. Use a mirror or ask a partner to help. Look for new spots or moles that change in size, shape, or color, or that itch or bleed. The ABCDE guide (Asymmetry, Border, Color, Diameter, Evolving) can help.

Protect your skin from the sun. Seek shade, especially in the middle of the day. Wear a hat, sunglasses, and long sleeves. Use broad-spectrum sunscreen with SPF 30 or higher, and reapply it often. Never use tanning beds.

People who have had melanoma have a higher chance of a new melanoma or other skin cancers. Yearly skin checks for life help catch these early.

Close family members may have a higher risk too. Encourage them to check their skin and see a dermatologist.

Many people with advanced melanoma now live for years. Feeling worried about scans or the cancer coming back is common. Support groups, counselors, and social workers can help you and your family.