Metastatic Melanoma

What Is Metastatic Melanoma?

Melanoma is a type of skin cancer. When it spreads to other places in your body, it's called metastatic, or advanced. You may also hear your doctor refer to it as stage IV melanoma.

Melanoma often spreads to:

• Tissue under the skin
• Lymph nodes
• Lungs
• Liver
• Brain

Although in many cases metastatic melanoma can’t be cured, treatments and support can help you live longer and better. Doctors have therapies that have greatly increased survival rates. And researchers are working to find new medications that can do even more.

Remember: You still have control over the decisions you make about your treatment and your life. It's important to have people you can talk to about your plans, your fears, and your feelings. So find support and learn about your treatment options. That will help you make the most of your life.

Causes

In most cases, melanoma is caused by exposure to ultraviolet (UV) radiation from the sun or tanning beds. It damages the DNA of your skin cells, and they start to grow out of control.

You can get the disease on parts of your body that don't get sunlight, though, like the palms of your hands and the retinas of your eyes.

You're more likely to get melanoma if you have:

• Fair skin, along with lighter hair and eye color
• Many moles or irregular moles
• A family history of melanoma

Symptoms

If your melanoma has spread to other areas, you may have:

• Hardened lumps under your skin
• Swollen or painful lymph nodes
• Trouble breathing, or a cough that doesn't go away
• Swelling of your liver (under your lower right ribs) or loss of appetite
• Bone pain or, less often, broken bones
• Headaches, seizures, or weakness or numbness in your arms or legs
• Weight loss
• Fatigue

Getting a Diagnosis

Before you have any tests, your doctor will want to know:

• Why did you come in?
• What have you noticed, and when?
• How are you feeling?
• Have you been diagnosed with melanoma before?
• If so, how was it treated?
• Has anyone in your family had melanoma?
• Have you ever used a tanning bed?
• How many times have you had a sunburn?
• Do you wear sunscreen? When? And what type?

If you haven’t already been diagnosed with melanoma, your doctor will do a skin exam. If they think you may have skin cancer, you'll need a biopsy to find out.

You usually get one of three types:

• Punch biopsy. This removes a round piece of skin.
• Excisional biopsy. Your doctor takes out the entire growth.
• Shave biopsy. Your doctor tries to shave off the entire growth.

A doctor will look at the growth under a microscope to see how thick it is. Usually, a thicker tumor means there is a higher risk the cancer will spread.

If you've been diagnosed with melanoma, you may also have a blood test and an imaging test to see if it has spread to other areas.

There are different types of imaging tests:

• Chest X-ray. This uses radiation in low doses to make pictures of the inside of your body.
• CT scan (computerized tomography). It uses powerful X-rays so your doctor can get a detailed look at what's going on inside you.
• MRI (magnetic resonance imaging). It uses powerful magnets and radio waves to make pictures of organs and structures inside your body. It helps show blood flow and can help locate cancer growths.
• PET scan. This test uses radioactive material to look for signs of cancer.

The doctor will also check to see if your lymph nodes are enlarged. Lymph nodes are bean-sized glands under the skin in your neck, underarms, and groin. The doctor uses a thin needle to remove a sample of cells. This is called a fine- needle aspiration biopsy.

The doctor may also do a lymph node biopsy. This removes the lymph nodes most likely to have cancer cells. In this test, the doctor injects a dye into the area where the potential cancer was. It spreads to the nearest lymph nodes, which are removed and tested. If these lymph nodes, called sentinel nodes, don't have cancer, then it's likely the cancer hasn't spread.

The results of these tests help the doctor determine the stage of your cancer and how widespread it is.

You and your doctor will decide on the best treatment plan once you know that information.

Treatment

Although metastatic melanoma is not easy to treat, you do have options. Choosing what's right for you will depend on where and how big the cancer is, what your health is like, and what your wishes are. Since most cases of metastatic melanoma can't be cured, the goals of treatment are to:

• Shrink or stop the growth of the disease where it has spread.
• Stop it from spreading to new areas.
• Make you more comfortable.

Treatment used to be mainly radiation and chemotherapy. Now there are newer drugs available that can work better, studies show. Your treatment may include:

Surgery. Your doctor may remove tumors or lymph glands. Although surgery alone probably won't cure the cancer, it can help you live longer and have fewer symptoms. Your doctor will likely also use one or more other treatments.

Radiation and chemotherapy. These can help some people, depending on the size and location of the cancer.

Immunotherapy. These drugs boost your immune system so it can better attack the cancer. You get immunotherapy through an IV or a shot in high doses. It can have serious side effects, but it can also shrink metastatic melanomas and help some people live longer. These drugs include:

• Ipilimumab (Yervoy): There are two uses for this drug. It can be given to individuals who have had surgery to remove melanoma in order to prevent the melanoma from coming back. It can also be used for late-stage melanoma that cannot be removed by surgery. Ipilimumab is often used in combination with a PD-1 inhibitor.
• Nivolumab (Opdivo) and pembrolizumab (Keytruda) work by inhibiting the PD-1 protein on cells, which enables the body’s immune system to attack melanoma tumors. Combination therapy with ipilimumab and either nivolumab or pembrolizumab has been shown to increase overall survival compared to treating with ipilimumab alone.
• Interferon-alpha and interleukin-2: These older drugs can help some people live longer.

Researchers are studying many other drugs that spur the immune system to fight melanoma.

Targeted therapy. This kind of treatment aims to kill cancer cells without harming healthy ones. They may work for people who have certain changes in genes. Because these treatments target the tumors, they may cause fewer side effects than chemotherapy or radiation.

Some drugs attack a gene called BRAF. About half the people who have melanoma have changes in this gene, which helps cancer cells grow. If you have a tumor with BRAF, these drugs may shrink it and extend your life. They include:

• Dabrafenib (Tafinlar)
• Encorafenib (Braftovi)
• Vemurafenib (Zelboraf)

Vemurafenib (Zelboraf)

Other drugs block an enzyme called MEK. This enzyme is often overactive in some cancers. These drugs, working in combination with a BRAF inhibitor to attack cancer cells, seem to shrink tumors for a longer period of time:

• Binimetinib (Mektovi)
• Cobimetinib (Cotellic)
• Trametinib (Mekinist)

Taking Care of Yourself

Hearing that your cancer has spread is scary, but a lot of research is underway to find new treatments. And there are treatments available to try to stop the disease from spreading, so you can live longer.

It's important to have support and to talk about your fears and feelings, too. Your doctor can help you find a cancer support group.

These tips may help you feel better during melanoma treatment:

• If you lose your appetite, eat small amounts of food every 2 to 3 hours instead of bigger meals. A dietitian can give you other tips on nutrition and eating during your cancer treatment. Ask your doctor for a referral.
• Exercise can help you feel better overall and fight fatigue. But listen to your body, and balance rest and activity.
• Get the kind of emotional support that's right for you. It could be from family, friends, your cancer support group, or a religious group.

What to Expect

Although stage IV melanoma is hard to treat, each case is different, and some people will respond very well to treatment. Talk to your doctor about all your options, and find out more about clinical trials to see if one is right for you.

Get Support

The Melanoma Research Foundation has an online library of free support services, including an online patient community and a phone buddy program. And for more information on metastatic melanoma, go to the web site of the Skin Cancer Foundation.

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