Malignant Melanoma Treatment Options & Procedures

Malignant melanoma treatment options can vary from patient to patient. In general, the earlier the melanoma is detected, the less invasive and risky the treatment is. Common treatments include surgical excision, sentinel node biopsy, open lymph node biopsy, neck dissection, radiation therapy and chemotherapy.

Excision

Excision is the surgical removal of melanoma. As well as the melanoma, a border of healthy-looking skin and the tissue and fat beneath, are all removed during the surgery. Local anesthetic is used for small areas while larger areas may require general anesthesia. For small areas, stitches are used to close the area and there are rarely problems with healing. In larger areas or those on visible areas like the face or hands, a skin graft may be necessary. Healing time depends on the size of the area and method of closure. Larger areas or those closed with skin grafts take longer to heal. It is usually successful on early stages of cancer. In later stages, it does not cure the disease, but may slow the spread and make the patient more comfortable.

Side Effects/Risks

Side effects may include pain and tenderness at the wound site. Risks include scarring, site infection, excessive bleeding, or skin graft rejection.

Sentinel Node Biopsy

A sentinel node biopsy, sometimes called a sentinel lymph node biopsy, is a procedure done to determine if the cancer has spread. The sentinel lymph node is usually the first place cancer spreads (metastasises) to. In some patients, there may be multiple nodes. Patients are typically given a general anesthesia, although local anesthetic may be used on rare occasions. The surgeon injects a low level radioactive substance into the tumor. It combines with fluids travelling to the lymph nodes. A handheld Geiger counter is passed over the area to locate the lymph node affected. In some cases, nuclear imaging may be used aswell. To improve precision, a special blue dye can also be injected into the tumor. When it reaches the sentinel node, it colours it blue, making identification easier. The surgeon makes a small incision, usually a half inch in size. The sentinel node or nodes are removed and examined by a pathologist. If cancer is found, more nodes may be removed, either during the biopsy or in a subsequent surgery. The incision is stitched closed and most patients are able to return home the same day.

Side Effects/Risks

Risks include anesthesia complications, allergic reaction to the dye, wound infection, bleeding or scarring. Side effects may include temporary skin and urine discoloration and localised pain and swelling.

Open Lymph Node Biopsy

An open lymph node biopsy may be done to determine the stage of the cancer or remove cancerous nodes. It makes detection and identification of cancer easier. Local anesthetic is typically used on surface nodes while general anesthesia is used for nodes found deeper in the body, such as the chest or abdomen. Once anesthesia has been administered, the surgeon makes an incision and removes part or all of the lymph nodes. It is sent to a pathologist for examination. The incision is stitched closed and bandaged. After spending time in recovery, the patient returns home.

Side Effects/Risks

Pain and swelling are common. Biopsies done on deeper lymph nodes are usually more painful. Risks include infection, bleeding or anesthesia complications.

Neck Dissection

Neck dissection is commonly done on patients with skin cancer on the face or neck or those suspected to have a secondary tumor to the neck. There are several types of this malignant melanoma treatment.

1. In radical neck dissection, all lymph nodes and major structures on the same side as the melanoma (ipsilateral cervical lymph nodes) are removed. The spinal accessory nerve to the trapezius muscle is also removed along with the corresponding internal jugular vein and the sternocleidomastoid muscle (this muscle is one of a pair - acting alone, it tilts the head to its own side and rotates it so that the face is turned towards the opposite side.)

2. In modified radical surgery, all lymph nodes are removed but at least one of the other structures noted above are left.

3. Selective neck dissection leaves some lymph nodes in place.

4. Extended neck dissection is like radical surgery with the addition of other lymph nodes or structures, such as skin or the nerve that attaches to the tongue(hypoglossal nerve).

General anaesthetic is used and an incision is made along the crease of the neck. In some types, an additional incision is made vertically towards the collarbone. The selected areas are removed, two drains are placed in the neck and the incisions are closed with nylon stitches or staples. Patients remain in the hospital generally for a few days after surgery for monitoring. Drains are usually removed three to five days after surgery and the stitches or staples can be removed six to ten days after surgery.

Side Effects/Risks

Initial common side effects that we have been made aware of are pain, swelling and difficulty eating. Longer term side effects range from neck stiffness, aching neck and back muscles, dry mouth and numbness. Risks include excessive bleeding, reaction to anaesthesia, damage to nerves or blood vessels, infection and lymphatic leak.

Radiation Therapy

According to Cancer Research UK, there are various reasons why radiotherapy is used as a malignant melanoma treatment.

1. It can be used to destroy tumours that are in difficult to reach areas such as the eye (ocular or uveal melanoma).

2. It can be used as a palliative treatment to reduce discomfort and extend life.

3. It is used before surgery to shrink a tumor making it easier to remove (in the case of melanomas that have spread to other organs).

4. As an adjuvant treatment after surgery to make sure any tiny cancer cells that may have been missed are destroyed.

Treatment regimens vary again depending on the individual case. Patients are exposed to high doses of radiation several times a week for a short period of time.

Side Effects/Risks

Nausea, vomiting, fatigue and hair loss in the affected area are common. Radiotherapy commonly causes pain around the area that is being treated. This is due to healthy skin cells that have been damaged by the radiation during treatment. Although it does not take long for these damaged areas to heal, they can be quite painful. Diarrhea may also occur when the abdomen or pelvis is treated.

Chemotherapy

According to Cancer Research UK, there is currently no proof that chemotherapy stops recurrent melanoma or that it is successful at treating advanced melanomas.

Chemotherapy is sometimes used as a malignant melanoma treatment as it seeks out cancer cells and destroys them. It tends to be used for the following reasons -

1. To treat melanomas that have returned near to the original site.
2. If the cancer has spread to other areas of the body.
3. As an adjuvant treatment to try and stop the cancer from coming back.

Medication is given in tablet form by mouth or through a drip usually for a few days then with a few weeks rest to recover. After this, the cycle begins again. This may continue for several sessions until enough chemotherapy has been received. When melanoma is confined to a limb, a special type of chemotherapy called isolated limb perfusion may be performed. It is administered under a general anesthetic and a surgeon briefly separates the limb's blood supply from the body and injects medication into the artery. This allows higher doses to be used while protecting organs from serious side effects. It is still regarded as an experimental procedure and clinical trials are still required to determine the most effective drugs for this therapy.

Side Effects/Risks

Loss of hair, nausea and vomiting, sores in the mouth, decreased appetite, fatigue, lowered resistance to infections and bruising easier are common. These usually disappear once treatment is complete. Risks involve infection because of decreased immune resistance and potential harm to organs.

Summary

The earlier malignant melanoma is detected, the better odds the patient has of surviving. Although there are no actual cures for melanoma, cure rates are significantly higher if the tumor is removed in the very early stages. In later stages, a malignant melanoma treatment may not offer a cure, but it can make patients more comfortable and give more time.