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Melanoma


Diagnosing melanoma

Physical examination

If you notice any changes to your skin, your doctor will examine you using a handheld magnifying instrument called a dermoscope, looking carefully at any spots you have identified as changed or suspicious. They will consider the signs known as ABCDE guidelines:

  • Asymmetry – are the halves of each mole different?
  • Border – are the edges uneven, scalloped or notched?
  • Colour – are there differing shades and colour patches?
  • Diameter – is the spot greater than 6 mm across?
  • Evolving – has the spot changed over time (size, shape, surface, colour, bleeding, itching)?

Some types of melanoma, such as nodular and desmoplastic melanomas, don’t fit the ABCDE criteria, so your doctor may also assess whether the spot is elevated, firm or growing.

Your guide to best cancer care

A lot can happen in a hurry when you’re diagnosed with cancer. The guide to best cancer care for melanoma can help you make sense of what should happen. It will help you with what questions to ask your health professionals to make sure you receive the best care at every step.

Please note: work is currently underway to refresh the guide to best cancer care for melanoma.

Read the guide

Removing the mole

If the doctor suspects that a spot on your skin may be melanoma, the whole spot is removed (excision biopsy) for examination by a tissue specialist called a pathologist.

The doctor will use a scalpel to remove the spot and a small amount (2 mm margin) of healthy tissue around it. The wound will usually be closed with stitches. It is recommended that the entire mole is removed rather than a small sample. This helps ensure an accurate diagnosis and accurate staging of any melanoma found.

You will have a follow-up appointment to check the wound and remove the stitches. If a diagnosis of melanoma is confirmed, you will probably need further surgery, such as a wide local excision.

Checking lymph nodes

Lymph nodes are part of your body's lymphatic system, which removes excess fluid from tissues, absorbs fatty acids, transports fat, and produces immune cells. There are large groups of lymph nodes in the neck, armpits and groin. Sometimes melanoma can travel through the lymph vessels to other parts of the body.

Your doctor may feel the lymph nodes near the melanoma to see if they are enlarged. To test whether the melanoma has spread, your doctor may recommend that you have a fine needle biopsy or a sentinel lymph node biopsy:

Fine needle biopsy

If any lymph nodes feel enlarged or lumpy, you will probably have a fine needle biopsy. This uses a thin needle to take a sample of cells from the enlarged lymph node, which is then examined under a microscope to see if it contains cancer cells. If cancer is found in the lymph nodes, you may need to have surgery to remove them.

Sentinel lymph node biopsy

If the Breslow thickness of the melanoma is over 1 mm or sometimes for people with melanoma between 0.8 mm to 1 mm, you may be offered a sentinel lymph node biopsy.

This biopsy finds and removes the first lymph node that the melanoma would be likely to spread to (the sentinel node). Sometimes more than one sentinel node is found and removed. The removed lymph nodes are then checked for melanoma cells under a microscope. It is usually done at the same time as the wide local excision.

To find the sentinel lymph node, a small amount of radioactive dye is injected into the area where the initial melanoma was found. The surgeon removes the node that absorbs the injected fluid to check for cancer cells. If they are found in the sentinel lymph node, further tests may be done, and systemic treatment may be offered.

Understanding the pathology report

If you have melanoma, the report from the pathologist will provide your treatment team with information to help determine the stage, plan treatment, and work out your prognosis. The following factors may be included:


Breslow thickness

This is a measure of the thickness of the tumour in millimetres to its deepest point in the skin. The thicker a melanoma, the more likely it could return (recur) or spread to other parts of the body. 


Clark level

This describes how many layers of skin the tumour has gone through. It is rated on the scale of I–V, with I the shallowest and V the deepest. Breslow thickness is much more important than Clark level in assigning a stage to a melanoma.


Ulceration

The breakdown or loss of the outer layer of skin over the tumour is known as ulceration. It is a sign of rapid tumour growth.


Mitotic rate

Mitosis is the process by which one cell divides into two. The pathologist counts the number of actively dividing cells to calculate how quickly the melanoma cells are dividing.


Margins

This is the area of normal skin around the melanoma. The report will describe how wide the margin is and whether any melanoma cells were found at the edge of the removed tissue.


Regression

This refers to inflammation or scar tissue in the melanoma, which suggests that some melanoma cells have been destroyed by the immune system. In the report, the presence of lymphocytes (immune cells) in the melanoma indicates inflammation.

Further tests

Many people will need only a biopsy, but you may need further tests such as blood tests or imaging scans to get more information about the melanoma. You may also have these tests during treatment or as part of follow-up care after treatment finishes.

  • Ultrasound – high-frequency soundwaves are used to create pictures of the inside of your body.
  • CT scan – uses x-ray beams to create detailed, cross-sectional pictures.
  • MRI scan – uses a powerful magnet and radio waves to create detailed cross-sectional pictures.
  • PET-CT scan – a specialised imaging test, which involves injecting a glucose solution containing a small amount of radioactive material in the arm, to help cancer cells show up brighter on the scan.

Staging melanoma

The pathology report and any other test results will show whether you have melanoma and whether it has spread to other parts of the body. This is known as staging and it helps your team recommend the most appropriate treatment for you. 

Stages 0, I and II are called early or localised melanoma, while stage III is referred to as regional melanoma. Stage IV melanoma has spread to other parts of the body and is called advanced or metastatic.

Gene mutation testing

If the melanoma has spread (stage III or IV), further tests can help work out whether you have a particular gene change (mutation) that may be causing the cancer cells to multiply and grow. These genetic mutations are due to changes in cancer cells – they are not the same thing as genes passed through families.

Approximately 40% of people with melanoma have a mutation in the BRAF gene and approximately 15% have a mutation in the NRAS gene. C-KIT is a rare mutation affecting less than 4% of people with melanoma.

Genetic tests can be done on the sample removed during surgery and the results will help determine your treatment options. 

Prognosis

Prognosis means the predicted outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the disease. Instead, your doctor can discuss any concerns you have.

Melanoma can be treated most effectively in its early stages when it is still confined to the top layer of the skin (epidermis). The deeper a melanoma penetrates into the lower layer of the skin (dermis), the greater the risk that it could spread to nearby lymph nodes or other organs.

In recent years, clinical trials have led to new drug treatments that continue to improve the prognosis for people with melanoma that has spread from the primary site (advanced melanoma).

Understanding Melanoma

Download our Understanding Melanoma booklet to learn more.

Download now

 

 

Expert content reviewers:

A/Prof Robyn Saw, Surgical Oncologist, Melanoma Institute Australia, The University of Sydney and Royal Prince Alfred Hospital, NSW; Craig Brewer, Consumer; Prof Bryan Burmeister, Radiation Oncologist, GenesisCare Fraser Coast and Hervey Bay Hospital, QLD; Tamara Dawson, Consumer, Melanoma & Skin Cancer Advocacy Network; Prof Georgina Long, Co-Medical Director, Melanoma Institute Australia, and Chair, Melanoma Medical Oncology and Translational Research, Melanoma Institute Australia, The University of Sydney and Royal North Shore Hospital, NSW; A/Prof Alexander Menzies, Medical Oncologist, Melanoma Institute Australia, The University of Sydney, Royal North Shore and Mater Hospitals, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Paige Preston, Chair, Cancer Council’s National Skin Cancer Committee, Cancer Council Australia; Prof H Peter Soyer, Chair in Dermatology and Director, Dermatology Research Centre, The University of Queensland Diamantina Institute, and Director, Dermatology Department, Princess Alexandra Hospital, QLD; Julie Teraci, Clinical Nurse Consultant and Coordinator, WA Kirkbride Melanoma Advisory Service, WA. 

Page last updated:

The information on this webpage was adapted from Understanding Melanoma - A guide for people with cancer, their families and friends (2021 edition). This webpage was last updated in June 2021. 

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