Partner Management

Partner Management 

Partner management refers to a continuum of activities designed to increase the number of infected persons brought to treatment and disrupt transmission networks. Part of this continuum is partner notification — the process by which providers or public health authorities learn about the sex- and needle-sharing partners of infected patients and help to arrange for partner evaluation and treatment. Clinical-care providers can obtain this information and help to arrange for evaluation and treatment of sex partners directly or by cooperating with state and local health departments. The types and comprehen- siveness of existing partner services and the specific STDs for which they are offered vary by provider, public health agency, and geographic area. Ideally, persons referred to such services should also receive health counseling and should be referred for other health services as appropriate. Data are limited regarding whether partner notification effectively decreases exposure to STDs and whether it reduces the incidence and prevalence of these infections in a com- munity.

 Nevertheless, evaluations of partner notification interventions have documented the important contribution this approach can make to case-finding in clinical and com- munity contexts (65). When partners are treated, index patients have reduced risk for reinfection. Therefore, providers should encourage persons with STDs to notify their sex partners and urge them to seek medical evaluation and treatment. Further, providers can ask patients to bring partners with them when returning for treatment. Time spent with index patients to counsel them on the importance of notifying partners is associ- ated with improved notification outcomes (66). When patients diagnosed with chlamydia or gonorrhea indicate that their partners are unlikely to seek evaluation and

treatment, providers can offer patient-delivered partner therapy (PDPT), a form of expedited partner therapy (EPT) in which partners of infected persons are treated without previous medi- cal evaluation or prevention counseling. Because EPT might be prohibited in some states and is the topic of ongoing legislation in others (67), providers should visit www.cdc.gov/std/ept to obtain updated information for their individual jurisdiction. Any medication or prescription provided for PDPT should be

accompanied by treatment instructions, appropriate warnings about taking medications (if the partner is pregnant or has an allergy to the medication), general health counseling, and a statement advising that partners seek personal medical evalu- ation, particularly women with symptoms of STDs or PID. The evidence supporting PDPT is based on three clinical trials that included heterosexual men and women with chla- mydia or gonorrhea. The trials and meta-analyses revealed that the magnitude of reduction in reinfection of index case-patients compared with patient referral differed according to the STD and the sex of the index case-patient (68–71). However, across trials,

 reductions in chlamydia prevalence at follow-up were approximately 20%; reductions in gonorrhea at follow-up were approximately 50%. Rates of notification increased in some trials and were equivalent to patient referral without PDPT in others. Existing data suggest that PDPT also might have a role in partner management for trichomoniasis; however, no single partner management intervention has been shown to be more effective than any other in reducing reinfection rates (72,73). No data support the use of PDPT in the routine management of patients with syphilis. No studies have been published involving PDPT for gonorrhea or chlamydia among MSM. Public health program involvement with partner notifica- tion services varies by locale and by STD. Some programs have considered partner notification in a broader context, developing interventions to address sexual and social networks in which persons are exposed to STDs. 

Prospective evaluations incorporating the assessment of venues, community structure, and social and sexual contacts in conjunction with partner notification efforts have improved case-finding and illustrated transmission networks (74,75). While such efforts are beyond the scope of individual clinicians, support of and collaboration with STD programs by clinicians are critical to the success of social network-based interventions.

Female Condoms

Female Condoms

 Laboratory studies indicate that the female condom (Reality) is an effective mechanical barrier to viruses, includ- ing HIV, and to semen. The first female condom approved for use in the United States consisted of a lubricated polyure- thane sheath with a ring on each end that is inserted into the vagina. A newer version made from nitrile is now available in the United States. A limited number of clinical studies have evaluated the efficacy of female condoms in providing protection from STDs, including HIV (31,32). Although female condoms are costly compared with male condoms, sex partners should consider using a female condom when a male condom cannot be used properly. The female condom also has been used for STDs/HIV protection during receptive anal intercourse (33); although it might provide some protection in this setting, its efficacy remains unknown.

Cervical Diaphragms

 In observational studies, diaphragm use has been demon- strated to protect against cervical gonorrhea, chlamydia, and trichomoniasis (34). A recent trial examined the effect of use of a diaphragm plus polycarbophil (Replens) lubricant on HIV acquisition in women in Africa relative to male condom use alone. The study revealed that neither the diaphragm nor the lubricant gel provided additional protective effect when compared with the use of condoms alone (35). Likewise, no difference by study arm in the rate of acquisition of chlamydia or gonorrhea occurred; however, data from participants who reported following the protocol for the use of these products suggested that consistent use of the diaphragm plus gel might reduce acquisition of gonorrhea (36). Diaphragms should not be relied on as the sole source of protection against HIV infec- tion. Diaphragm and nonoxynol-9 (N-9) spermicide use have been associated with an increased risk for bacterial urinary-tract infections in women (37).

Topical Microbicides and Spermicides

 Studies examining nonspecific topical microbicides for the prevention of HIV and STD have demonstrated that these products are ineffective (38,39). Studies of spermicides containing N-9 have demonstrated that they should not be recommended for STDs/HIV prevention (40), and more recent randomized controlled trials have failed to show a pro- tective effect against HIV acquisition for BufferGel (a vaginal buffering agent), Carraguard (a carrageenan derivative) (41), cellulose sulfate (an HIV entry inhibitor), (42) and SAVVY (1.0% C31G, a surfactant) (43,44). Initial results from a study in which participants used 0.5% PRO2000 vaginal gel (a synthetic polyanion polymer that blocks cellular entry of HIV) on a daily basis appeared promis- ing, reducing the rate of HIV acquisition by 30% relative to no gel (45). However, a recent randomized trial of approximately 9,000 women failed to show any protective effect (46).


 Condoms and n-9 Vaginal Spermicides

 Condoms lubricated with spermicides are no more effec- tive than other lubricated condoms in protecting against the transmission of HIV and other STDs (www.cdc.gov/condo- meffectiveness/latex.htm). Furthermore, frequent use of sper- micides containing N-9 has been associated with disruption of the genital epithelium, which might be associated with an increased risk for HIV transmission (40). Therefore, use of condoms lubricated with N-9 is not recommended for STD/ HIV prevention; in addition, spermicide-coated condoms cost more, have a shorter shelf-life than other lubricated condoms, and have been associated with urinary-tract infection in young women (37).

How is melanoma skin cancer treated?

How is melanoma skin cancer treated? 

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.
The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.
Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.

General treatment information 

Once melanoma has been diagnosed and staged, your cancer care team will discuss your treatment options with you. Depending on your situation, you may have different types of doctors on your treatment team. These doctors may include:

• A dermatologist: A doctor who treats diseases of the skin
• A surgical oncologist (or oncologic surgeon): A doctor who uses surgery to treat cancer
• A medical oncologist: A doctor who treats cancer with medicines such as chemotherapy, immunotherapy, or targeted therapy

• A radiation oncologist: A doctor who treats cancer with radiation therapy
Many other specialists might be part of your treatment team as well, including physician assistants (PAs), nurse practitioners (NPs), nurses, nutrition specialists, social workers, and other health professionals. To learn more about who may be on your cancer care team, see Health Professionals Associated With Cancer Care.

It’s important to discuss all of your treatment options as well as their possible side effects with your treatment team to help make the decision that best fits your needs. If there is anything you do not understand, ask to have it explained. (See the section “What should you ask your doctor about melanoma skin cancer?” for some questions to ask.)

Based on the stage of the cancer and other factors, your treatment options might include:

• Surgery 
• Immunotherapy 
• Targeted therapy 
• Chemotherapy 
• Radiation therapy 

Early-stage melanomas can often be treated effectively with surgery alone, but more advanced cancers often require other treatments. Sometimes more than one type of treatment is used. Follow this link to learn more about the most common treatment options based on the stage of the melanoma.

When time permits, getting a second opinion is often a good idea. It can give you more information and help you feel good about the treatment plan that you choose.
Surgery for melanoma skin cancer
Surgery is the main treatment option for most melanomas, and usually cures early stage melanomas.
Wide excision

When a diagnosis of melanoma is made by skin biopsy, the site will probably need to be excised again to help make sure the cancer has been removed completely. This fairly minor surgery will cure most thin melanomas.

Local anesthesia is injected into the area to numb it before the excision. The site of the tumor is then cut out, along with a small amount of normal non-cancerous skin at the edges. The normal, healthy skin around the edges of the cancer is referred to as the margin. The wound is carefully stitched back together afterward. This will leave a scar.

The removed sample is then viewed under a microscope to make sure that no cancer cells were left behind at the edges of the skin that was removed.

Wide excision differs from an excisional biopsy. The margins are wider because the diagnosis is already known. The recommended margins vary depending on the thickness of the tumor. Thicker tumors need larger margins (both at the edges and in the depth of the excision).

Tumor thickness Recommended margins 

In situ 0.5 cm  
1 mm (about 1/25 of an inch) or less 
1 cm 
1 to 2 mm 1 to 2 cm 
2 to 4 mm 2 cm 
Over 4 mm 2 cm 

These margins might need to be altered based on where the melanoma is on the body and other factors. For example, if the melanoma is on the face, the margins may be smaller to avoid large scars or other problems. Smaller margins may increase the risk of the cancer coming back, so be sure to discuss the options with your doctor. 

Mohs surgery: In some situations, the surgeon may use Mohs surgery. This type of surgery is used more often for some other types of skin cancer, but not all doctors agree on using it for melanoma. In this procedure, the skin (including the melanoma) is removed in very thin layers. Each layer is then viewed under a microscope for cancer cells. If cancer cells are seen, the surgeon removes another layer of skin. The operation continues until a layer shows no signs of cancer. In theory, this allows the surgeon to remove the cancer while saving as much of the surrounding normal skin as possible.
Amputation: If the melanoma is on a finger or toe and has grown deeply, part or all of that digit might need to be amputated.

Lymph node dissection 

In this operation, the surgeon removes all of the lymph nodes in the region near the primary melanoma. For example, if the melanoma is on a leg, the surgeon would remove the nodes in the groin region on that side of the body, which is where melanoma cells would most likely travel to first.
Once the diagnosis of melanoma is made from the skin biopsy, the doctor will examine the lymph nodes near the melanoma. Depending on the thickness and location of the melanoma, this may be done by physical exam, or by imaging tests (such as CT or PET scans) to look at nodes that are not near the body surface.

If the nearby lymph nodes feel abnormally hard or large, and a fine needle aspiration (FNA) biopsy or excisional biopsy finds melanoma in a node or nodes, a lymph node dissection is usually done.
If the lymph nodes are not enlarged, a sentinel lymph node biopsy may be done, particularly if the melanoma is thicker than 1 mm. (See the section “How is melanoma of the skin diagnosed?” for a description of this procedure.) If the sentinel lymph node does not contain cancer, then there is no need for a lymph node dissection because it’s unlikely the melanoma has spread to the lymph nodes. If the sentinel lymph node contains cancer cells, removing the remaining lymph nodes in that area with a lymph node dissection is usually advised. This is called a completion lymph node dissection.
It’s not clear if a lymph node dissection can cure melanomas that have spread to the nodes. This is still being studied. Still, some doctors feel it might prolong a patient’s survival and at least avoid the pain that may be caused by cancer growing in these lymph nodes.

A full lymph node dissection can cause some long-term side effects. One of the most troublesome is called lymphedema. Lymph nodes in the groin or under the arm normally help drain fluid from the limbs. If they are removed, fluid may build up. This can cause limb swelling, which may or may not go away. If severe enough, it can cause skin

problems and an increased risk of infections in the limb. Elastic stockings or compression sleeves can help some people with this condition. For more information, see our document Understanding Lymphedema (for Cancers Other Than Breast Cancer).

Lymphedema, along with the pain from the surgery itself, is a main reason why lymph node dissection is not done unless it is necessary. Sentinel lymph node biopsy, however, is unlikely to have this effect. It is important to discuss the possible risks of side effects with your doctor before having either of these procedures done.

Surgery for metastatic melanoma 

If melanoma has spread from the skin to distant organs such as the lungs or brain, the cancer is very unlikely to be curable by surgery. Even when only 1 or 2 metastases are found by imaging tests such as CT or MRI scans, there are likely to be other areas of metastasis that are too small to be found by these scans.

Surgery is sometimes done in these circumstances, but the goal is usually to try to control the cancer rather than to cure it. If 1 or even a few metastases are present and can be removed completely, this surgery may help some people live longer. Removing metastases in some places, such as the brain, might also relieve symptoms and help improve a person’s quality of life.
If you have metastatic melanoma and surgery is offered as a treatment option, talk to your doctor and be sure you understand what the goal of the surgery would be, as well as its possible benefits and risks.  

Immunol therapy for melanoma skin cancer 

Immunotherapy is the use of medicines to stimulate a patient’s own immune system to recognize and destroy cancer cells more effectively. Several types of immunotherapy can be used to treat patients with melanoma.

Immune checkpoint inhibitors for advanced melanoma  

An important part of the immune system is its ability to keep itself from attacking normal cells in the body. To do this, it uses “checkpoints”, which are molecules on immune cells that need to be turned on (or off) to start an immune response. Melanoma cells sometimes use these checkpoints to avoid being attacked by the immune system. But newer drugs that target these checkpoints hold a lot of promise as melanoma treatments.

PD-1 inhibitors 

Pembrolizumab (Keytruda) and nivolumab (Opdivo) are drugs that target PD-1, a protein on immune system cells called T cells that normally help keep these cells from attacking other cells in the body. By blocking PD-1, these drugs boost the immune response against melanoma cells, which can often shrink tumors and help people live longer (although it’s not yet clear if these drugs can cure melanoma).

These drugs are given as an intravenous (IV) infusion every 2 or 3 weeks.
Side effects of these drugs can include fatigue, cough, nausea, itching, skin rash, decreased appetite, constipation, joint pain, and diarrhea.

Other, more serious side effects occur less often. These drugs work by basically removing the brakes from the body’s immune system. Sometimes the immune system starts attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, or other organs.
It’s very important to report any new side effects to your health care team promptly. If serious side effects do occur, treatment may need to be stopped and you may get high doses of corticosteroids to suppress your immune system.

CTLA-4 inhibitor 

Ipilimumab (Yervoy) is another drug that boosts the immune response, but it has a different target. It blocks CTLA-4, another protein on T cells that normally helps keep them in check.
This drug is given as an intravenous (IV) infusion, usually once every 3 weeks for 4 treatments. In patients with melanomas that can’t be removed by surgery or that have spread to other parts of the body, this drug has been shown to help people live an average of several months longer, although it’s not clear if it can cure the melanoma.

The most common side effects from this drug include fatigue, diarrhea, skin rash, and itching.  
Serious side effects seem to happen more often with this drug than with the PD-1 inhibitors. Like the PD-1 inhibitors, this drug can cause the immune system to attack other parts of the body, which can lead to serious problems in the intestines, liver, hormone-making glands, nerves, skin, eyes, or other organs. In some people these side effects have been fatal.

It’s very important to report any new side effects during or after treatment to your health care team promptly. If serious side effects do occur, you may need to stop treatment and take high doses of corticosteroids to suppress your immune system.

Cytokines for advanced melanoma 

Cytokines are proteins in the body that boost the immune system in a general way. Man- made versions of cytokines, such as interferon-alfa and interleukin-2 (IL-2), are sometimes used in patients with melanoma. They are given as intravenous (IV) infusions, at least at first. Some patients or caregivers may be able to learn how to give injections under the skin at home. Both drugs can help shrink advanced (stage III and IV) melanomas in about 10% to 20% of patients when used alone. These drugs may also be given along with chemotherapy drugs (known as biochemotherapy) for stage IV melanoma.

Side effects of cytokine therapy can include flu-like symptoms such as fever, chills, aches, severe tiredness, drowsiness, and low blood cell counts. Interleukin-2, particularly in high doses, can cause fluid to build up in the body so that the person swells up and can feel quite sick. Because of this and other possible serious side effects, high-dose IL-2 is given only in the hospital, in centers that have experience with this type of treatment.

Interferon-alfa as adjuvant therapy  

Patients with thicker melanomas often have cancer cells that have spread to other parts of the body. Even if all of the cancer seems to have been removed by surgery, some of these cells may remain in the body. Interferon-alfa can be used as an added (adjuvant) therapy after surgery to try to prevent these cells from spreading and growing. This may delay the recurrence of melanoma, but it is not yet clear if it improves survival.

High doses must be used for the interferon to be effective, but many patients can’t tolerate the side effects of high-dose therapy. These can include fever, chills, aches, depression, severe tiredness, and effects on the heart and liver. Patients getting this drug need to be closely watched by a doctor who is experienced with this treatment.

When deciding whether to use adjuvant interferon therapy, patients and their doctors should take into account the potential benefits and side effects of this treatment.
Bacille Calmette-Guerin (BCG) vaccine

BCG is a germ related to the one that causes tuberculosis. BCG does not cause serious disease in humans, but it does activate the immune system. The BCG vaccine works like a cytokine by enhancing the entire immune system. It is not directed specifically at melanoma cells. It is sometimes used to help treat stage III melanomas by injecting it directly into tumors.
Imiquimod cream

Imiquimod (Zyclara) is a drug that is applied as a cream. It stimulates a local immune response against skin cancer cells. For very early (stage 0) melanomas in sensitive areas on the face, some doctors may use imiquimod if surgery might be disfiguring. It can also be used for some melanomas that have spread along the skin. Still, not all doctors agree it should be used for melanoma.
The cream is applied anywhere from once a day to 2 times a week for around 3 months. Some people have serious skin reactions to this drug. Imiquimod is not used for more advanced melanomas.
Newer treatments

Some other types of immunotherapy have shown promise in treating melanoma in early studies. At this time they are available only through clinical trials (see “What’s new in research and treatment of melanoma skin cancer?”).

To learn more about this type of treatment, see our document Cancer Immunotherapy.
Targeted therapy for melanoma skin cancer

As doctors have found some of the gene changes that make melanoma cells different from normal cells, they have begun to develop drugs that attack these changes. These targeted drugs work differently from standard chemotherapy drugs, which basically attack any quickly dividing cells. Sometimes, targeted drugs work when chemotherapy doesn’t. They can also have less severe side effects. Doctors are still learning the best way to use these drugs to treat melanoma.

More topic:.................

1. What is cancer?
2. What is melanoma skin cancer?  
3. Melanoma skin cancers 
4. What are the key statistics about melanoma skin cancer?  
5. What are the risk factors for melanoma skin cancer? 
6.  what causes melanoma skin cancer? 
7. Can melanoma skin cancer be found early? 
8. How is melanoma skin cancer diagnosed? 
9. Magnetic resonance imaging (MRI) scan 
10. How is melanoma skin cancer staged? 
11. What are the survival rates for melanoma skin cancer, by stage? 

What are the survival rates for melanoma skin cancer, by stage?

What are the survival rates for melanoma skin cancer, by stage? 


Survival rates are often used by doctors as a standard way of discussing a person’s prognosis (outlook). Some people may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. If you don’t want to know them, stop reading here and skip to the next section.

The 5-year and 10-year survival rates refer to the percentage of patients who live at least this long after their cancer is diagnosed. Of course, many people live much longer than 5 or 10 years (and many are cured).

To get 5- and 10-year survival rates, doctors have to look at people who were treated at least 5 or 10 years ago. Improvements in treatment since then may result in a better outlook for people being diagnosed with melanoma now.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen in any person's case. Many factors other than the stage of the melanoma can also affect a person's outlook, such as the genetic changes in the cancer cells and how well the cancer responds to treatment. Even when taking these other factors into account, survival rates are at best rough estimates. Your doctor can tell you how the numbers below apply to you, as he or she knows your situation best.

The following survival rates are based on nearly 60,000 patients who were part of the 2008 AJCC Melanoma Staging Database. These are observed survival rates. They include some people diagnosed with melanoma who may have later died from other causes, such as heart disease. Therefore, the percentage of people surviving the melanoma itself may be higher.

Stage IA: The 5-year survival rate is around 97%. The 10-year survival is around 95%.
Stage IB: The 5-year survival rate is around 92%. The 10-year survival is around 86%.
Stage IIA: The 5-year survival rate is around 81%. The 10-year survival is around 67%.
Stage IIB: The 5-year survival rate is around 70%. The 10-year survival is around 57%.
Stage IIC: The 5-year survival rate is around 53%. The 10-year survival is around 40%.
Stage IIIA: The 5-year survival rate is around 78%. The 10-year survival is around 68%.*
Stage IIIB: The 5-year survival rate is around 59%. The 10-year survival is around 43%.
Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.

Stage IV: The 5-year survival rate is about 15% to 20%. The 10-year survival is about 10% to 15%. The outlook is better if the spread is only to distant parts of the skin or distant lymph nodes rather than to other organs, and if the blood level of lactate dehydrogenase (LDH) is normal.

*The survival rate is higher for stage IIIA cancers than for some stage II cancers. This is likely because the main (primary) tumor is often less advanced for IIIA cancers, although this is not clear.
Other factors affecting survival

Other factors aside from stage can also affect survival. For example:
• Older people generally have shorter survival times, regardless of stage. The biggest drop in survival begins at age 70.

• Melanoma is uncommon among African Americans, but when it does occur, survival times tend to be shorter than when it occurs in whites. Some studies have found that melanoma tends to be more serious if it occurs on the sole of the foot or palm of the

hand, or if it is in a nail bed. (Cancers in these areas make up a larger portion of melanomas in African Americans than in whites.)

• People with melanoma who have weakened immune systems, such as people who have had organ transplants or who are infected with HIV, also are at greater risk of dying of their melanoma.

Sexually Transmitted Diseases Treatment

Sexually Transmitted Diseases Treatment Guidelines, 2015


The term sexually transmitted diseases (STDs) is used to refer to a variety of clinical syndromes caused by pathogens that can be acquired and transmitted through sexual activity. Physicians and other health-care providers play a critical role in preventing and treating STDs. These guidelines for the treat- ment of STDs are intended to assist with that effort. Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed. These recommendations should be regarded as a source of clinical guidance and not prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. They are applicable to various patient-care settings, including family- planning clinics, private physicians’ offices, managed care orga- nizations, and other primary-care facilities. These guidelines focus on the treatment and counseling of individual patients and do not address other community services and interven- tions that are essential to STD/human immunodeficiency virus (HIV) prevention efforts.

Methods:

These guidelines were developed using a multistage process. Beginning in 2008, CDC staff members and public and private sector experts knowledgeable in the field of STDs systematically reviewed literature using an evidence-based approach (e.g., published abstracts and peer-reviewed journal articles), focusing on the common STDs and information that had become available since publication of the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (1). CDC staff members and STD experts developed background papers and tables of evidence that summarized the type of study (e.g., randomized controlled trial or case series), study population and setting, treatments or other interventions, outcome measures assessed, reported findings, and weaknesses and biases in study design and analysis. CDC staff then developed a draft document on the basis of this evidence-based review. In April 2009, this information was presented at a meeting of invited consultants (including public- and private-sector professionals knowledgeable in the treatment of patients with STDs), where all evidence from the literature reviews pertaining to STD management was discussed. Specifically, participants identified key questions regarding STD treatment that emerged from the literature reviews and discussed the information available to answer those ques- tions. Discussion focused on four principal outcomes of STD therapy for each individual disease: 

1) treatment of infection based on microbiologic eradication; 

2) alleviation of signs and symptoms;

 3) prevention of sequelae; and 

4) prevention

of transmission. Cost-effectiveness and other advantages (e.g., single-dose formulations and directly observed therapy [DOT]) of specific regimens also were discussed. The consultants then assessed whether the questions identified were relevant, ranked them in order of priority, and answered the questions using the available evidence. In addition, the consultants evaluated the quality of evidence supporting the answers on the basis of the number, type, and quality of the studies. 

Clinical Prevention Guidance The prevention and control of STDs are based on the following five major strategies: 

•education and  counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services; 

• identification of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services;

 • effective diagnosis, treatment, and counseling of infected persons;

 • evaluation, treatment, and counseling of sex partners of persons who are infected with an STD; and 

• pre-exposure vaccination of persons at risk for vaccine- preventable STDs.

How is melanoma skin cancer staged?

Melanoma skin cancer staged

The stage of a cancer is a description of how widespread it is. For melanoma, this includes its thickness in the skin, whether it has spread to nearby lymph nodes or any other organs, and certain other factors. The stage is based on the results of physical exams, biopsies, and any imaging tests (CT or MRI scan, etc.) or other tests that have been done. These tests are described in the section “How is melanoma skin cancer diagnosed?” 

The stage of the melanoma is very important in planning your treatment and estimating your prognosis (outlook). 

The American Joint Committee on Cancer (AJCC) TNM staging system 

A staging system is a standard way to describe how far a cancer has spread. The system most often used to stage melanoma is the American Joint Commission on Cancer (AJCC) TNM system. It can be complicated, so ask your doctor if you have any questions about the stage of your cancer. The TNM system is based on 3 key pieces of information: 

• T stands for tumor (how far it has grown within the skin and other factors). The T category is assigned a number (from 0 to 4) based on the tumor’s thickness (how far down it has grown). It may also be assigned a small letter a or b based on ulceration and mitotic rate, which are explained below.

 

• N stands for spread to nearby lymph nodes (bean-sized collections of immune system cells, to which cancers often spread first). The N category is assigned a number (from 0 to 3) based on whether the melanoma cells have spread to lymph nodes or are found in the lymphatic channels connecting the lymph nodes. It may also be assigned a small letter a, b, or c, as described below. 

• The M category is based on whether the melanoma has metastasized (spread) to distant organs, 

which organs it has reached, and on blood levels of a substance called LDH. 

There are 2 types of staging for melanoma: 

• Clinical staging is based on what is found on physical exams, biopsy/removal of the main melanoma, and any imaging tests that are done.

  

• Pathologic staging uses all of this information, plus what is found during biopsies of lymph nodes or other organs if they are done.   

The pathologic stage (determined after the lymph node biopsy) may actually be higher than the clinical stage (determined before the lymph node biopsy) if the biopsy finds cancer in new areas. Doctors use the pathologic stage if it is available, as it gives a more accurate picture of the extent of the cancer, but in many cases lymph node biopsies are not needed. 

T categories  

The T category is based on the thickness of the melanoma and other key factors seen in the skin biopsy. 

Tumor thickness: The pathologist looking at the skin biopsy measures the thickness of the melanoma under the microscope. This is called the Breslow measurement. In general, melanomas less than 1 millimeter (mm) thick (about 1/25 of an inch) have a very small chance of spreading. As the melanoma becomes thicker, it has a greater chance of spreading.  

Mitotic rate: To measure the mitotic rate, the pathologist counts the number of cells in the process of dividing (mitosis) in a certain amount of melanoma tissue. A higher mitotic rate (having more cells that are dividing) means that the cancer is more likely to grow and spread. The mitotic rate is used to help stage thin melanomas (T1; see below). 

Ulceration: Ulceration is a breakdown of the skin over the melanoma. Melanomas that are ulcerated tend to have a worse prognosis.  

The possible values for T are: 

TX: Primary (main) tumor cannot be assessed. 

T0: No evidence of primary tumor. 

Tis: Melanoma in situ. (The tumor remains in the epidermis, the outermost layer of skin.) 

T1a: The melanoma is less than or equal to 1.0 mm thick (1.0 mm = 1/25 of an inch), without ulceration and with a mitotic rate of less than 1/mm2. 

T1b: The melanoma is less than or equal to 1.0 mm thick. It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2. 

T2a: The melanoma is between 1.01 and 2.0 mm thick without ulceration. 

T2b: The melanoma is between 1.01 and 2.0 mm thick with ulceration. 

T3a: The melanoma is between 2.01 and 4.0 mm thick without ulceration. 

T3b: The melanoma is between 2.01 and 4.0 mm thick with ulceration. 

T4a: The melanoma is thicker than 4.0 mm without ulceration. 

T4b: The melanoma is thicker than 4.0 mm with ulceration. 

N categories 

The possible values for N depend on whether or not a sentinel lymph node biopsy was done.  

The clinical staging of the lymph nodes, which is done without the sentinel node biopsy, is listed below. 

NX: Nearby (regional) lymph nodes cannot be assessed. 

N0: No spread to nearby lymph nodes. 

N1: Spread to 1 nearby lymph node. 

N2: Spread to 2 or 3 nearby lymph nodes, OR spread of melanoma to nearby skin (known as satellite tumors) or toward a nearby lymph node area (known as in-transit tumors) without reaching the lymph nodes. 

N3: Spread to 4 or more lymph nodes, OR spread to lymph nodes that are clumped together, OR spread of melanoma to nearby skin (satellite tumors) or toward a lymph node area and into the lymph node(s). 

Following a lymph node biopsy, the pathologic stage can be determined, in which small letters may be added in some cases: 

• Any Na (N1a or N2a) means that the melanoma is in the lymph node(s), but it is so small that it is only seen under the microscope (also known as microscopic spread).  

• Any Nb (N1b or N2b) means that the melanoma is in the lymph node(s) and was large enough to be visible on imaging tests or felt by the doctor before it was removed (also known as macroscopic spread). 

• N2c means the melanoma has spread to very small areas of nearby skin (satellite tumors) or has spread to skin lymphatic channels around the tumor (without reaching the lymph nodes). 

M categories  

The M values are: 

M0: No distant metastasis. 

M1a: Metastasis to skin, subcutaneous (below the skin) tissue, or lymph nodes in distant parts of the body, with a normal blood LDH level. 

M1b: Metastasis to the lungs, with a normal blood LDH level. 

M1c: Metastasis to any other organs, OR distant spread to any site along with an elevated blood LDH level. 

Stage grouping 

Once the T, N, and M groups have been determined, they are combined to give an overall stage, using Roman numerals I to IV (1 to 4) and sometimes subdivided using capital letters. This process is called stage grouping. In general, patients with lower stage cancers have a better outlook for a cure or long-term survival. 

Stage 0 

Tis, N0, M0: The melanoma is in situ, meaning that it is in the epidermis but has not spread to the dermis (lower layer).  

Stage IA 

T1a, N0, M0: The melanoma is less than 1.0 mm in thickness. It is not ulcerated and has a mitotic rate of less than 1/mm2. It has not been found in lymph nodes or distant organs.  

Stage IB 

T1b or T2a, N0, M0: The melanoma is less than 1.0 mm in thickness and is ulcerated or has a mitotic rate of at least 1/mm2, OR it is between 1.01 and 2.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.  

Stage IIA 

T2b or T3a, N0, M0: The melanoma is between 1.01 mm and 2.0 mm in thickness and is ulcerated, OR it is between 2.01 and 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.  

Stage IIB 

T3b or T4a, N0, M0: The melanoma is between 2.01 mm and 4.0 mm in thickness and is ulcerated, OR it is thicker than 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.  

Stage IIC 

T4b, N0, M0: The melanoma is thicker than 4.0 mm and is ulcerated. It has not been found in lymph nodes or distant organs.  

Stage IIIA 

T1a to T4a, N1a or N2a, M0: The melanoma can be any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread. 

Stage IIIB 

One of the following applies: 

T1b to T4b, N1a or N2a, M0: The melanoma can be any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread.  

T1a to T4a, N1b or N2b, M0: The melanoma can be any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.  

T1a to T4a, N2c, M0: The melanoma can be any thickness, but it is not ulcerated. It has spread to small areas of nearby skin (satellite tumors) or lymphatic channels (in-transit tumors) around the original tumor, but the nodes do not contain melanoma. There is no distant spread.  

Stage IIIC 

One of the following applies: 

T1b to T4b, N1b or N2b, M0: The melanoma can be any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.  

T1b to T4b, N2c, M0: The melanoma can be any thickness and is ulcerated. It has spread to small areas of nearby skin (satellite tumors) or lymphatic channels (in-transit tumors) around the original tumor, but the nodes do not contain melanoma. There is no distant spread.  

Any T, N3, M0: The melanoma can be any thickness and may or may not be ulcerated. It has spread to 4 or more nearby lymph nodes, OR to nearby lymph nodes that are clumped together, OR it has spread to nearby skin (satellite tumors) or lymphatic channels (in transit tumors) around the original tumor and to nearby lymph nodes. The nodes are enlarged because of the melanoma. There is no distant spread.  

Stage IV 

Any T, any N, M1(a, b, or c): The melanoma has spread beyond the original area of skin and nearby lymph nodes to other organs such as the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes. Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes

1. What is cancer?
2. What is melanoma skin cancer?  
3. Melanoma skin cancers 
4. What are the key statistics about melanoma skin cancer?  
5. What are the risk factors for melanoma skin cancer? 
6.  what causes melanoma skin cancer? 
7. Can melanoma skin cancer be found early? 
8. How is melanoma skin cancer diagnosed? 
9. Magnetic resonance imaging (MRI) scan 

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Magnetic resonance imaging (MRI) scan

Magnetic resonance imaging (MRI) scan 

Like CT scans, MRI scans give detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays to create pictures. A contrast material might be injected, just as with CT scans, but is used less often.

MRI scans are very helpful in looking at the brain and spinal cord.
MRI scans take longer than CT scans – often up to an hour – and are a little more uncomfortable. You may have to lie inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Newer, more open MRI machines can sometimes be used instead, but the images might not be as sharp in some cases. The MRI machine also makes loud buzzing noises, so some places provide earplugs to help block this noise out.

Positron emission tomography (PET) scan 

A PET scan can help show if the cancer has spread to lymph nodes or other parts of the body. It is most useful in people with more advanced stages of melanoma – it is not usually done in people with early-stage melanoma.

For this test, you are injected with a radioactive substance (usually a type of sugar related to glucose, known as FDG). The amount of radioactivity used is very low and will pass out of the body over the next day or so. Because cancer cells in the body are growing quickly, they absorb more of the radioactive sugar. After about an hour, you are moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not detailed like a CT or MRI scan, but it can provide helpful information about your whole body.

Many centers have special machines that can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT scan.
For more information on these imaging tests, see our document Imaging (Radiology) Tests.
Blood tests

Blood tests aren’t used to diagnose melanoma, but some tests may be done before or during treatment, especially for more advanced melanomas.
Doctors often test blood for levels of a substance called lactate dehydrogenase (LDH) before treatment. If the melanoma has spread to distant parts of the body, a high LDH level is a sign that the cancer may be harder to treat. This affects the stage of the cancer (see “How is melanoma skin cancer staged?”).

Other tests of blood cell counts and blood chemistry levels may be done in a person who has advanced melanoma to see how well the bone marrow (where new blood cells are made), liver, and kidneys are working during treatment.

MORE TOPIC

1. What is cancer?
2. What is melanoma skin cancer?  
3. Melanoma skin cancers 
4. What are the key statistics about melanoma skin cancer?
5. What are the risk factors for melanoma skin cancer? 
6.  what causes melanoma skin cancer? 
7. Can melanoma skin cancer be found early? 
8. How is melanoma skin cancer diagnosed?