Tipos de C�ncer   /   Cánceres de la Piel   /   Melanoma   /   Recursos de NCI

NCI/PDQ^® Patients: Melanoma Treatment (PDQ®)

National Cancer Institute
Last Modified: May 18, 2012

TABLE OF CONTENTS

• General Information About Melanoma

• Stages of Melanoma

• Recurrent Melanoma

• Treatment Option Overview

• Treatment Options by Stage
  • Stage 0 (Melanoma in Situ)
  • Stage I Melanoma
  • Stage II Melanoma
  • Stage III Melanoma
  • Stage IV and Recurrent Melanoma

• To Learn More About Melanoma

• Changes to This Summary (05/18/2012)

• Get More Information From NCI

• About PDQ®

General Information About Melanoma

Melanoma is a disease in which malignant (cancer) cells form in the skin cells called melanocytes (cells that color the skin).

Melanocytes are found throughout the lower part of the epidermis. They make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to tan, or darken. Anatomy of the skin, showing the epidermis, dermis, and subcutaneous tissue. Melanocytes are in the layer of basal cells at the deepest part of the epidermis.

The skin is the body's largest organ. It protects against heat, sunlight, injury, and infection. The skin has 2 main layers: the epidermis (upper or outer layer) and the dermis (lower or inner layer).

There are 3 types of skin cancer:

• Melanoma.
• Basal cell skin cancer.
• Squamous cell skin cancer.

When melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma may also occur in mucous membranes (thin, moist layers of tissue that cover surfaces such as the lips). This PDQ® summary is about cutaneous (skin) melanoma and melanoma that affects the mucous membranes. When melanoma occurs in the eye, it is called intraocular or ocular melanoma. (See the PDQ® summary on Intraocular (Eye) Melanoma Treatment for more information.)

Melanoma is more aggressive than basal cell skin cancer or squamous cell skin cancer. (See the PDQ® summary on Skin Cancer Treatment for more information on basal cell and squamous cell skin cancer.)

Melanoma can occur anywhere on the body.

In men, melanoma is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma forms most often on the arms and legs. Melanoma is most common in adults, but it is sometimes found in children and adolescents. See the PDQ® summary on Unusual Cancers of Childhood for more information on melanoma in children and adolescents.)

Unusual moles, exposure to sunlight, and health history can affect the risk of developing melanoma.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk for melanoma. Risk factors for melanoma include the following:

• Having a fair complexion, which includes the following:
  • Fair skin that freckles and burns easily, does not tan, or tans poorly.
  • Blue or green or other light-colored eyes.
  • Red or blond hair.

• Being exposed to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time.
• Having a history of many blistering sunburns, especially as a child or teenager.
• Having several large or many small moles.
• Having a family history of unusual moles (atypical nevus syndrome).
• Having a family or personal history of melanoma.
• Being white.

Being white or having a fair complexion increases the risk of melanoma, but anyone can have melanoma, including people with dark skin.

Possible signs of melanoma include a change in the appearance of a mole or pigmented area.

These and other symptoms may be caused by melanoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

• A mole that:
  • changes in size, shape, or color.
  • has irregular edges or borders.
  • is more than one color.
  • is asymmetrical (if the mole is divided in half, the 2 halves are different in size or shape).
  • itches.
  • oozes, bleeds, or is ulcerated (a hole forms in the skin when the top layer of cells breaks down and the tissue below shows through).

• A change in pigmented (colored) skin.
• Satellite moles (new moles that grow near an existing mole).

For pictures and descriptions of common moles and melanoma, see Common Moles, Dysplastic Nevi, and Risk of Melanoma.

Tests that examine the skin are used to detect (find) and diagnose melanoma.

If a mole or pigmented area of the skin changes or looks abnormal, the following tests and procedures can help find and diagnose melanoma:

• Skin exam: A doctor or nurse checks the skin for moles, birthmarks, or other pigmented areas that look abnormal in color, size, shape, or texture.
• Biopsy: The removal of as much of the abnormal mole or lesion as possible. A pathologist looks at the tissue under a microscope to check for cancer cells. It can be hard to tell the difference between a colored mole and an early melanoma lesion. Patients may want to have their biopsy sample checked by a second pathologist.

A biopsy should be done on any abnormal areas of the skin. These areas should not be shaved off or cauterized (destroyed with a hot instrument, an electric current, or a caustic substance).

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The thickness of the tumor and where it is in the body.
• How quickly the cancer cells are dividing.
• Whether there was bleeding or ulceration at the primary site.
• Whether cancer has spread to the lymph nodes or to other places in the body.
• The number of places cancer has spread to in the body and the level of lactate dehydrogenate (LDH) in the blood.
• The patient's general health.

Stages of Melanoma

After melanoma has been diagnosed, tests are done to find out if cancer cells have spread within the skin or to other parts of the body.

The process used to find out whether cancer has spread within the skin or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Talk with your doctor about what the stage of your cancer is.

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

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Wide local excision: A surgical procedure to remove some of the normal tissue around the area where abnormal tissue was removed. A pathologist then looks at the tissue under a microscope to check for cancer cells.
• Lymph node mapping and sentinel lymph node biopsy: Procedures in which a radioactive substance and/or blue 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. A pathologist views a sample of tissue under a microscope to check for cancer cells. If no cancer cells are found, it may not be necessary to remove more nodes.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, 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 help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For melanoma, pictures may be taken of the chest, abdomen, and pelvis.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.
• 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. For melanoma, the blood is checked for an enzyme called lactate dehydrogenase (LDH). LDH levels that are higher than normal may be a sign of melanoma.

The results of these tests are viewed together with the results of the tumor biopsy to find out the stage of the melanoma.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The method used to stage melanoma is based mainly on the thickness of the tumor and whether cancer has spread to lymph nodes or other parts of the body.

The staging system is based on the following:

• The thickness of the tumor. The thickness is described using the Breslow scale.
• Whether the tumor is ulcerated (has broken the skin).
• Whether the tumor has spread to the lymph nodes and if the lymph nodes are joined together (matted).
• Whether the tumor has spread to other parts of the body.

The following stages are used for melanoma:

Stage 0 (Melanoma in Situ)

In stage 0, abnormal melanocytes are found in the epidermis. These abnormal melanocytes may become cancer and spread into nearby normal tissue. Stage 0 is also called melanoma in situ.

Stage I

In stage I, cancer has formed. Stage I is divided into stages IA and IB.

• Stage IA: In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration.
• Stage IB: In stage IB, the tumor is either:
  • not more than 1 millimeter thick and it has ulceration; or
  • more than 1 but not more than 2 millimeters thick, with no ulceration.

Stage II

Stage II is divided into stages IIA, IIB, and IIC.

• Stage IIA: In stage IIA, the tumor is either:
  • more than 1 but not more than 2 millimeters thick, with ulceration; or
  • more than 2 but not more than 4 millimeters thick, with no ulceration.

• Stage IIB: In stage IIB, the tumor is either:
  • more than 2 but not more than 4 millimeters thick, with ulceration; or
  • more than 4 millimeters thick, with no ulceration.

• Stage IIC: In stage IIC, the tumor is more than 4 millimeters thick, with ulceration.

Stage III

In stage III, the tumor may be any thickness, with or without ulceration. One or more of the following is true:

• Cancer has spread to one or more lymph nodes.
• Lymph nodes may be joined together (matted).
• Cancer may be in a lymph vessel between the primary tumor and nearby lymph nodes.
• Very small tumors may be found on or under the skin, not more than 2 centimeters away from where the cancer first started.

Stage IV

In stage IV, the cancer has spread to other places in the body, such as the lung, liver, brain, bone, soft tissue, or gastrointestinal (GI) tract. Cancer may have spread to places in the skin far away from where it first started.

Recurrent Melanoma

Recurrent melanoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the area where it first started or in other parts of the body, such as the lungs or liver.

Treatment Option Overview

There are different types of treatment for patients with melanoma.

Different types of treatment are available for patients with melanoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

Surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:

• Wide local excision: Surgery to remove the melanoma and some of the normal tissue around it. Some of the lymph nodes may also be removed.
• Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer.
• Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. Sentinel lymph node biopsy of the skin. A radioactive substance and/or blue dye is injected near the tumor (first panel). The injected material is detected visually and/or with a probe that detects radioactivity (middle panel). The sentinel nodes (the first lymph nodes to take up the material) are removed and checked for cancer cells (last panel).

Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.

Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

One type of regional chemotherapy is hyperthermic isolated limb perfusion. With this method, anticancer drugs go directly to the arm or leg the cancer is in. The flow of blood to and from the limb is temporarily stopped with a tourniquet. A warm solution with the anticancer drugs is put directly into the blood of the limb. This gives a high dose of drugs to the area where the cancer is.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

See Drugs Approved for Melanoma for more information.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Interferon and interleukin-2 (IL-2) are types of biologic therapy used to treat melanoma. Interferon affects the division of cancer cells and can slow tumor growth. IL-2 boosts the growth and activity of many immune cells, especially lymphocytes (a type of white blood cell). Lymphocytes can attack and kill cancer cells.

Tumor necrosis factor (TNF) therapy is a type of biologic therapy used with other treatments for melanoma. TNF is a protein made by white blood cells in response to an antigen or infection. Tumor necrosis factor can be made in the laboratory and used as a treatment to kill cancer cells.

See Drugs Approved for Melanoma for more information.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. The following types of targeted therapy are being used in the treatment of melanoma:

• Monoclonal antibody therapy: A cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used with chemotherapy as adjuvant therapy. Ipilimumab is a monoclonal antibody used to treat melanoma.
• Signal transduction inhibitors: A substance that blocks signals that are passed from one molecule to another inside a cell. Blocking these signals may kill cancer cells. Vemurafenib is a signal transduction inhibitor used to treat advanced melanoma or tumors that cannot be removed by surgery.
• Oncolytic virus therapy: A type of targeted therapy that is being studied in the treatment of melanoma. Oncolytic virus therapy uses a virus that infects and breaks down cancer cells but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells.
• Angiogenesis inhibitors: A type of targeted therapy that is being studied in the treatment of melanoma. Angiogenesis inhibitors block the growth of new blood vessels. In cancer treatment, they may be given to prevent the growth of new blood vessels that tumors need to grow.

See Drugs Approved for Melanoma for more information.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI Web site

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options by Stage

A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.

Stage 0 (Melanoma in Situ)

Treatment of stage 0 is usually surgery to remove the area of abnormal cells and a small amount of normal tissue around it.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 melanoma. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage I Melanoma

Treatment of stage I melanoma may include the following:

• Surgery to remove the tumor and some of the normal tissue around it. Sometimes lymph node mapping and removal of lymph nodes is also done.
• A clinical trial of new ways to find cancer cells in the lymph nodes.
• A clinical trial of lymphadenectomy with or without adjuvant therapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I melanoma. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage II Melanoma

Treatment of stage II melanoma may include the following:

• Surgery to remove the tumor and some of the normal tissue around it.
• Lymph node mapping and sentinel lymph node biopsy, followed by surgery to remove the tumor and some of the normal tissue around it. If cancer is found in the sentinel lymph node, a second surgery may be done to remove more nearby lymph nodes.
• A clinical trial of new types of treatment to be used after surgery.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II melanoma. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage III Melanoma

Treatment of stage III melanoma that can be removed by surgery may include the following:

• Surgery to remove the tumor and some of the normal tissue around it. Skin grafting may be done to cover the wound caused by surgery.
• Surgery followed by biologic therapy with interferon if there is a high risk that the cancer will come back.

Treatment of stage III melanoma that cannot be removed by surgery may include the following:

• Targeted therapy with ipilimumab or vemurafenib.
• Regional chemotherapy (hyperthermic isolated limb perfusion). Some patients may also have biologic therapy with tumor necrosis factor.

Treatments that are being studied in clinical trials for stage III melanoma include the following:

• A clinical trial of new kinds of treatments to be used after surgery.
• A clinical trial of treatment with injections into the tumor, such as oncolytic virus therapy.
• A clinical trial of systemic chemotherapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III melanoma. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage IV and Recurrent Melanoma

Treatment of stage IV and recurrent melanoma may include the following:

• Targeted therapy with ipilimumab or vemurafenib.
• Biologic therapy with interleukin-2 (IL-2).
• Chemotherapy.
• Palliative therapy to relieve symptoms and improve the quality of life. This may include:
  • Surgery to remove lymph nodes or tumors in the lung, gastrointestinal (GI) tract, bone or brain.
  • Radiation therapy to the brain, spinal cord, or bone.

Treatments that are being studied in clinical trials for stage IV and recurrent melanoma include the following:

• A clinical trial of biologic therapy.
• A clinical trial of different types of targeted therapy, including signal transduction inhibitors.
• A clinical trial of angiogenesis inhibitors.
• A clinical trial of treatment with injections into the tumor, such as oncolytic virus therapy.
• A clinical trial of surgery to remove all known cancer.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IV melanoma and recurrent melanoma. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

To Learn More About Melanoma

For more information from the National Cancer Institute about melanoma, see the following:

• Melanoma Home Page
• What You Need to Know About Melanoma and Other Skin Cancers
• Skin Cancer Prevention
• Skin Cancer Screening
• Sentinel Lymph Node Biopsy
• Drugs Approved for Melanoma
• Biological Therapies for Cancer: Questions and Answers
• Understanding Cancer Series: Targeted Therapies (Advances in Targeted Therapies)
• Targeted Cancer Therapies

For general cancer information and other resources from the National Cancer Institute, see the following:

• What You Need to Know About Cancer
• Understanding Cancer Series: Cancer
• Cancer Staging
• Chemotherapy and You: Support for People With Cancer
• Radiation Therapy and You: Support for People With Cancer
• Coping with Cancer: Supportive and Palliative Care
• Questions to Ask Your Doctor About Cancer
• Cancer Library
• Information For Survivors/Caregivers/Advocates

Changes to This Summary (05/18/2012)

The PDQ® cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Changes were made to this summary to match those made to the health professional version.

Get More Information From NCI

Call 1-800-4-CANCER

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.

Chat online

The NCI's LiveHelp online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

Write to us

For more information from the NCI, please write to this address:

• NCI Public Inquiries Office
• Suite 3036A
• 6116 Executive Boulevard, MSC8322
• Bethesda, MD 20892-8322

Search the NCI Web site

The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page.