NCMC: Melanoma Treament

The best treatment available is surgery. Usually the primary tumor is removed and the diagnosis established by examination of tumor slides under a microscope. Often a second operation called "wide re-excision" is performed to remove a larger area around the primary to be sure all tumor cells in that area have been removed. This second surgery may require a skin graft. In addition, it may be recommended that the lymph nodes be evaluated if the examination of the primary tumor indicates a substantial chance that the tumor has spread to the lymph nodes. This is done by a procedure called a "sentinel node biopsy". A small amount of radioactive material or blue dye or both are injected around the site of the primary. This is picked up in the lymphatics and carried to the "sentinel node" the first node draining the primary tumor. This node is removed and examined under the microscope. I f no tumor is present, there is no need for removal of additional nodes at the site. If the tumor is present in the sentinel node, it will be recommended that additional nodes be removed at the site, because they may also be involved with melanoma. The lymph nodes removed would be either in the neck, armpit or groin, depending on the location of the primary tumor. The sentinel node biopsy must be done before the wide re-excision and the two procedures are usually done sequentially during one surgical session.

Slides of the primary tumor reveal information about your particular melanoma. The thickness of the tumor and how deeply it has penetrated the skin are related to chances for a recurrence. A very thin tumor that does not penetrate deeply is considered "low risk". The chances are excellent that this tumor will be cured by the surgery. For patients with a thin melanoma, other than regular checkups, no further treatment is usually required. In other patients, examination of the slides may show that the tumor has a substantial risk of recurrence. For these patients after surgical treatment, consideration may be given to additional therapy aimed at attempting to prevent a recurrence. Such therapy is called "adjuvant therapy" because it is given in addition to surgery in an effort to prevent a recurrence.

We generally recommend that patients with melanoma have regular check-ups every three months for two years, every six months for another two years, and annually after that. During these check-ups the doctor will carefully check the site of the primary and lymph nodes for signs of recurrence. A general check-up will also be done at the time of each check-up to look for spread of the disease not detected by the physical examination. As the patient, you should watch for:

• Any new unusual pigmented lumps appearing around the site of the surgery or elsewhere
• Any lump appearing underneath the skin. These usually do not appear pigmented and are usually painless. Lumps are most likely to be found in the lymph nodes, around the site of the surgery, or between the surgical site and the lymph nodes
• Changes in existing moles that might represent the appearance of a second primary melanoma. These changes in moles might be:

  > Unusual increase in size

  > Change in color

  > Itching or burning

  > Change in the border so that it may appear that the pigment is "spilling out"

  > Increase in height

  > Oozing or bleeding

It depends on what it is and where it is. Surgery in general is the treatment of choice, but cannot always be done. The number of tumors, size and location are important in determining whether surgery is possible. For tumors that cannot be surgically excised, radiation, chemotherapy, immunotherapy, and/or experimental treatments are all possibilities.

Standard cancer treatments include surgery, radiation, chemotherapy or immunotherapy. Immunotherapy is newest modality of cancer treatment and may involve the use of agents called "biological therapy" which may enhance your own immune response to the tumor. It may also involve use of products with immunological activities to directly attack the tumor. Many of these recent technological breakthroughs are the result of genetic engineering and advanced technology.

Immunotherapy is not a substitute for standard therapy, such as surgery, but it may be used to:

• Provide potential therapeutic benefit to patients in an attempt to prevent recurrence after surgery early in the course of the disease.
• Attempt to control tumor growth if tumors recur.

Interferon alpha has both a direct anti-tumor effect in melanoma and an effect in stimulating the immune response. Interferon has also been approved by the FDA for adjuvant therapy of melanoma but the treatment requires the administration of high doses of drug and is associated with severe side effects. The most recent study of interferon as adjuvant therapy for melanoma indicated that it did not prolong survival.

Interleukin-2 is normally produced in limited quantities by the immune system. It is approved by the FDA for treating patients with metastatic melanoma that cannot be surgically excised. When used for this purpose, it must be given in high doses in the hospital and this is associated with considerable toxicity. The response rate is best in patients whose disease is limited to spread in the skin and/.or lymph nodes (Stage IV M1a).