Tests After Diagnosis

What Happens After Being Diagnosed With Melanoma?

The following information will help you understand what further tests might be ordered after an initial melanoma diagnosis and why they would be used.

Nearly all melanoma diagnoses that emerge from a biopsied skin sample will be staged as Stage 0, Stage I, or Stage II because that sample doesn’t reveal whether the melanoma has metastasized (spread) into lymph nodes (Stage III) or organs elsewhere in the body (Stage IV). A rare exception—when a biopsied skin sample would not be staged as Stage 0, I, or II—would be a skin biopsy that turns out to be a metastasized tumor that is a result of spreading from another primary tumor elsewhere on the skin.

If you have been given a melanoma diagnosis of Stage 0, Stage I, or Stage II, you should see a dermatologist who has experience with melanoma to discuss your next steps. Your dermatologist will study the pathology report, gather your complete medical history, and perform a complete physical examination if these things have not already been done. S/he will refer you to other physicians as necessary.

Your dermatologist will refer you to a general surgeon or a surgical oncologist for a wide local excision. A wide local excision is the standard surgical procedure for early-stage primary melanoma, in which the tumor, including the biopsy site and a surgical margin (the area of normal tissue around the biopsy site), are removed. The goal is complete removal of the Stage 0, Stage I, or Stage II tumor.

Your doctor will compare the details in your pathology report, your history, and your examination results with accepted guidelines that assess the risk of spread (metastases). If the risk is low that your melanoma has spread, you will likely not receive any further tests to look for spread.

If there is a certain amount of risk of spread, further testing might be ordered to look for potential spread. Factors such as ulceration, the Breslow depth of the tumor, and age are all considered in risk assessment. Further testing may include the following:

Sentinel Lymph Node Biopsy (SLNB)
Lymph nodes, part of the body’s lymphatic system, are small bean-shaped organs that help fight infection. There are large groups of lymph nodes on both sides of the neck, in the armpits, and in the groin. If there is high enough risk that the melanoma has grown into the inner layers of the skin and into the lymphatic system, your doctor may order a sentinel lymph node biopsy. The presence or absence of melanoma cells in the lymph nodes is one of the most important prognostic factors we have since it indicates whether there is high risk of recurrence as well as the type of treatment you may need.

The SLNB is a surgical procedure during which a small amount of radioactive substance is injected into the area where the melanoma was removed. The lymph nodes that absorb the injected fluid first are the sentinel lymph nodes. There are usually between one and five sentinel nodes.

If the cancer has spread, the sentinel nodes are the most likely node to have cancer within them. The surgeon will remove these nodes and check them for cancer cells. The removal of the sentinel lymph nodes is usually done under a general anesthetic at the same time as the wide local excision.

Fine Needle Aspiration Biopsy 
During the physical exam, your doctor will have felt the lymph nodes nearest the melanoma to see if they are enlarged, irregular, or firm, because such nodes may indicate the cancer has spread to the lymph nodes. If they are enlarged, irregular, or firm, your doctor may recommend a fine needle aspiration biopsy. A fine needle aspiration biopsy is performed with local anesthetic. A slender needle is placed through the skin and into the suspicious lymph node. A small tissue sample is removed when the needle is withdrawn. An ultrasound or CT scan is often used to guide the needle to the correct node. The sample is then examined under a microscope to see if it contains cancer.

X-Ray
An x-ray may be used to look for spread.

Ultrasound
An ultrasound uses sound waves to create a picture of the internal organs, including collections of lymph nodes, called lymph node basins, and soft tissue. The picture can reveal potential spread.

Computed Tomography (CT or CAT) Scan
A CT scan creates a 3-dimensional picture of the inside of the body using x-rays taken from different angles. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. If melanoma has spread, a CT scan can be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein and/or given as a liquid to swallow.

Magnetic Resonance Imaging (MRI)
An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye is injected into a patient’s vein.

Positron Emission Tomography (PET) or PET-CT Scan
A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body and identify areas in which melanoma may have spread.

If your doctor performs one or more of these tests and spread is revealed, you will be re-staged to account for the new information. If you have a sentinel lymph node biopsy or fine needle aspiration biopsy, you will also receive a new pathology report for that biopsy. Just like with the skin biopsy pathology report, details of your melanoma will be given, as well as the TNM staging information.

If your doctor performs one or more of these tests and no spread is revealed, your stage remains the one that was given to you after your skin biopsy. You should continue seeing a dermatologist to check for new melanomas and any indication of spread or recurrence.

If you are Stage IIB or IIC, you should consider seeing a medical oncologist who specializes in melanoma. In years past, only patients Stage III and higher were referred to medical oncologists and offered treatment. But now there are clinical trials open or opening that are studying whether giving certain treatments at Stage IIB and IIC will help prevent the recurrence of melanoma versus giving no drug treatment, which is the standard of care now.