Melanoma Treatment Options

Surgery is the main treatment for the vast majority of patients. This is also the only treatment performed for patients with stage 0, stage I and most types of stage II melanomas. Other treatment options include chemotherapy, immunotherapy and radiotherapy, either alone or combined. 

The extent of the treatment will depend on the stage of the cancer, on the characteristics of the tumor and on the risks for the patient. 

Treatments listed below have their benefits, their risks and their contraindications. It is recommended that patients ask their doctors about the expected benefits and risks of every treatment in order to be informed about the consequences of the treatment. For some treatments, several possibilities are available and the choice should be discussed according to the balance between benefits and risks. 

Treatment plan for in situ melanoma (stage 0)

An in situ melanoma is limited to the epidermis and has not spread beyond it. The treatment consists of removing the tumor. 

After the diagnosis has been confirmed by the biopsy, an excision of the tumor (called wide excision) is performed in order to achieve appropriate safety margins for a malignant tumor. After injection of a local anaesthetic around the tumor, the tumor is removed with a margin of 0.5 cm of normal tissue around and below the tumor. 

Treatment plan for stage I to stage III melanoma

Stage I and stage II melanomas do not spread to the lymph nodes while stage III melanomas do. The most important treatment consists of a complete removal of the melanoma and of the lymph nodes where cancer cells have spread. When the clinical and radiological examinations do not show spreading of the cancer to the lymph nodes or when it is unclear, a procedure called sentinel lymph node biopsy is usually needed and performed during the same surgical intervention. 

Surgery 

After the diagnosis has been confirmed by the biopsy, an excision with a safety margin of the tumor (called wide excision) is performed in order to achieve appropriate safety margins for a malignant tumor. When the clinical and radiological examinations do not show spreading of the cancer to the lymph nodes or when it is unclear, a procedure called sentinel lymph node biopsy is usually performed during the same surgical intervention. When it is clear that the cancer has spread to the lymph nodes, the removal of all regional lymph nodes is performed during the same surgical intervention. The operation is usually performed under general anaesthesia but can sometimes be performed under local anaesthesia depending on the location of the melanoma and on the decision of the anaesthesiologist and surgeon. 

The tumor is removed 

  • With a margin of 1 cm of normal tissue around and below the tumor when the tumor thickness is 2 mm or less; 
  • With a margin of 2 cm of normal tissue around and below the tumor when the tumor thickness is more than 2 mm. The margins may be smaller when the melanoma is located on the face (for aesthetic reasons) or on other places like palm, sole of the foot or under the nail for reasons related to the healing of wounds 

One or several lymph nodes may be removed 

Sentinel lymph node biopsy is a procedure performed for all stage I and stage II patients, except for patients whose tumors are 1mm thick or less. 

After injection of a marker near the tumor, the marker will naturally be led to lymphatic vessels and then to lymph nodes. With the help of a probe, the surgeon will be able to identify in which lymph node(s) the marker is located. Since the tumor cells (if they were to spread) would also first be led to these lymph nodes, the surgeon will remove the lymph node(s) to check if cancer cells are present. A rapid examination of the lymph nodes will be made while the patient is still in surgery. If cancer cells are found in the lymph node(s), the surgeon will remove other lymph nodes in the same area. 

This sentinel lymph node biopsy helps doctors to be more accurate in defining the stage of the cancer, but there is no evidence that it has any therapeutic role. 

Extensive lymph node dissection of the surrounding lymph node region(s) is performed for patients for whom it is suspected according to the clinical or radiological examination that the tumor spread to the lymph nodes. This consists of removing all lymph nodes in the region(s) towards which the lymph vessels around the tumor are directed. 

Adjuvant therapy is a therapy given in addition to surgery. No adjuvant therapy is needed for stage I and stage IIA. 

Adjuvant therapy when surgical removal of tumor and lymph nodes involved is complete 

For patients with stage IIB, stage IIC and stage III melanoma for which the surgery removed all lymph nodes, there is no standard adjuvant therapy. The only adjuvant therapy option today is a synthetic form of interferon‐alfa. Interferon‐alfa is a natural substance produced by the white blood cells and involved in the immune response against viruses, bacteria and tumor cells. Interferon‐alfa used as a treatment is a synthetic interferon produced in the laboratory. It is injected into the body with the goal of improving the immune response, in this case, against tumor cells. Interferon‐alfa can delay the time before the cancer comes back. An impact on life expectancy of the patients is not proven yet. 

Chemotherapy, mistletoe extracts and hormone therapies are not beneficial. Immunotherapy with interleukin‐2, cancer vaccines and a combination of immunotherapy and chemotherapy are experimental and not to be used outside of controlled clinical trials. In general, since there is no consensus on what the best adjuvant therapy, if any, could be, adjuvant therapies should be preferentially given in the context of clinical trials in specialised centres. 

Additional treatments when surgical removal is not complete 

In some cases, it is not possible to remove the whole tumor and all loco‐regional metastases by surgery. In such a situation, other therapies can help to kill the remaining cancer cells still present locally. This can be done by radiotherapy or by local application of high-dose chemotherapy if the melanoma is located on the arm or leg. 

Radiotherapy uses radiation to damage and kill cancer cells. Radiation is produced by an external source and then directed at the tumor at the lymph nodes. There are two main situations where radiotherapy can be used to control the (re‐)growth of the tumor when surgery could not remove all tumor cells: 

  1. Lentigo maligna melanoma is a special type of melanoma, usually large and occurring in the elderly. Either because patients are too old or because the melanoma is too large, complete removal may not be feasible. 
  2. Incomplete removal of loco‐regional metastases (satellite, in‐transit or lymph nodes) because they are too large or there are too many of them. 

Isolated limb perfusion is a surgical technique aiming at injecting a high dose of chemotherapy into the limb (arm or leg) where the melanoma is located. This requires a temporary derivation of the blood circulation to and from the limb by surgery. Different drugs can be injected into the isolated limb and the most common are melphalan, TNF‐alfa or both. Thanks to this technique, high concentrations of these drugs can be obtained in the limb with very limited diffusion to the rest of the body. This therapy is complicated and should be restricted to experienced centres.

 

 


Source: Melanoma: a guide for patients ‐ Information based on ESMO Clinical Practice Guidelines ‐ v.2011.2