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Treatment of melanoma

Multiple black 'satellite' melanoma metastases
Multiple black 'satellite' melanoma metastases
 

Local disease 

In most patients, surgery is required to remove (or excise) the entire tumour. Generally, one to two centimetres of normal skin surrounding the lesion must also be removed. Occasionally, skin grafting may be necessary to promote healing and replace skin that has been removed.

 

If an enlarged lymph node (or gland) is present, it may be biopsied at the time of the wide local excision. Even if enlarged lymph nodes cannot be detected, the lymph nodes may be evaluated during or after the surgical removal of the melanoma.

 

In the majority of cases, enlarged lymph nodes are not visible, and the only way to determine if they are affected is to take a sample of the lymph node during surgery. The sample is then examined under a microscope to determine if abnormal cells are present. This is typically accomplished with a surgical technique known as sentinel lymph node (SLN) biopsy.

 

The sentinel lymph node (SLN) technique is based upon the theory that when tumour cells migrate, they spread to one or a few lymph nodes before involving other nodes. Further, these nodes can be identified by injecting a blue dye or radioactive material around the primary tumour before the wide local excision, and then searching for the node that has taken up the dye or the radioactive tracer at the time of surgery.

 

SLN biopsy has become the standard technique for assessing the status of regional lymph nodes and is recommended for staging of most patients with newly diagnosed primary melanomas. However, patients whose melanomas are less than 1 mm in thickness (thin melanomas) may not require SLN, since the likelihood of tumour spread to the regional lymph nodes is less than 10 percent.

 

In contrast, SLN biopsy may be advised for thin melanomas with other high-risk features, such as ulceration, Clark's level IV or V (the tumour has invaded deeper levels of the skin), or if there are significant areas of regression (spontaneous loss of tumour cells).

 

Based upon the pathologic disease stage, the optimal treatment is chosen. For patients with localized disease who have no evidence of distant metastases, the goals of treatment are:

  • Complete surgical removal of the primary melanoma
  • Evaluation of regional lymph nodes for evidence of tumour involvement
  • Preventing further spread or disease recurrence

 

There are now data, not convincing to all but enough to have changed current, standard practice in the USA, to support the routine use of adjuvant alpha interferon (in high dosage and after surgery) for such high risk patients without metastatic disease to distant organs.

 

Alpha interferon adjuvant therapy in stage 2 and 3 disease is still under investigation, but at present it is the only

 

Advanced disease

Treatment of advanced metastatic melanoma focuses on shrinking or eliminating the metastatic lesions, preventing further spread of the disease, and ensuring patient comfort. In most cases, it is not possible to completely eliminate the cancer. Depending on the location and extent of the metastases, treatment may involve the use of medical treatments (chemotherapy or immunotherapy), surgery, or radiation therapy.

 

Chemotherapy and immunotherapy treatments may be given alone or in combination. Most of these treatments must be given into a vein (intravenously) or injected under the skin, although a few can be given in pill form.

 

Each medication is given over a period of time, often several months or more, depending upon how the patient responds. Patients are monitored for signs of drug toxicity or side effects. Many side effects are temporary and can be managed so that patient discomfort is minimised.


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