Surgery

Surgery is the standard treatment for melanoma. Your surgeon removes the tumor and a margin of normal tissue around it. This procedure, called Wide Local Excision, reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has attacked the skin.

In most cases, additional surgery is performed to remove normal-looking tissue around the tumor to ensure all melanoma cells are removed. This is often necessary, even for thin melanomas. The recommended margins of normal skin to be removed depend on the thickness of the melanoma, and are as follows:

*Margins wider than 2 cm have not been shown to improve survival, but for patient with very thick melanomas, some surgeons feel that removal of a wider margin may reduce the risk of local recurrence.

In almost all cases, the melanoma is removed with an elliptical incision and the defect is sewn together resulting in a straight-line scar. If a large area of tissue is taken out, or for areas where it is difficult to perform simple closure of the incision (such as the face or the hand or foot) your surgeon may do a skin graft, which uses skin from another part of the body, such as the thigh or hip, to replace the skin that was removed. Otherwise, rearrangement of the skin around the melanoma using a "rotation flap" or "advancement flap" can allow closure of the incision. Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease also has spread to other parts of the body. Two procedures are used to remove the lymph nodes:

• Sentinel Lymph Node Biopsy, concentrates on locating the sentinel nodes - the first nodes to receive the drainage from tumor and therefore the first to develop cancer. This procedure is done after the biopsy of the melanoma but before the wider removal of the tumor. A radioactive substance is injected near the melanoma and its movement is tracked on a computer screen. A blue dye is also injected around the melanoma site to aid in sentinel node identification. The first lymph node(s) to take up the substance is called the sentinel lymph nodes. Your surgeon removes the sentinel node(s) to check for cancer cells. It is not possible to check for melanoma in the lymph node reliably on the day of surgery. It takes several days for the pathologists to determine the presence or absence of melanoma cells in the lymph node.
• If a sentinel node contains cancer cells, your surgeon will recommend removal of the rest of the lymph nodes in the area. However, if a sentinel node is removed, examined and found to be normal, the chance of finding cancer in any of the remaining nodes is unlikely and no other nodes need to be removed. This spares many patients the need for a more extensive operation and greatly decreases the risk of complications.
• The side effects of the procedure include urine that appears green for 24 hours following the procedure and skin that is temporarily stained blue because of the dye used in the procedure. In general, however, sentinel lymph node biopsy is a minor outpatient procedure, performed at the same time as wide local excision of the melanoma. While bleeding, infection, and other complications of surgery can occur, these are rare. The sentinel node biopsy usually amounts to a small incision with a lymph node biopsy that heals up well.
• Lymph node dissection - your surgeon removes all the lymph nodes in the area of the melanoma. This used to be performed, in some centers, for all patients with intermediate thickness melanomas. With the introduction of sentinel lymph node biopsy, this is no longer necessary. Now, the larger procedure of complete regional lymph node dissection is only necessary for patients who are found to have cancer in the sentinel node, or for patients who have enlarged nodes full of cancer at the time the melanoma is diagnosed. Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. You also may receive biological therapy. Surgery is usually not effective in controlling melanoma that has spread to other parts of the body. In such cases, physicians may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy or a combination of these methods.

Surgery Side Effects

The side effects of surgery depend primarily on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be managed with medicine. Discuss pain relief with your physician or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each person.

Scarring also may be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as possible while still protecting against recurrence. In general, the scar from surgery to remove an early stage melanoma is a small 2 to 4-inch line that fades with time. How noticeable the scar is depends on location of the melanoma, how well you heal, and whether you develop raised scars called keloids.

When a tumor is large and thick, your physician must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large areas, these scars still will be quite visible.

Surgery to remove the all the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling lymphedema. While this may happen in 10 - 30 percent of patients who undergo complete lymph node dissection, this is very rare after just having a sentinel lymph node biopsy. Your physician or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, you will need to protect arms or legs from cuts, scratches, bruises, insect bites or burns that may lead to infection. If an infection does develop, see your physician immediately.

Follow-up Care

Melanoma patients have an increased risk of developing new skin cancers. Some also are at risk of a recurrence of the original melanoma in nearby skin or in other parts of the body.

To help detect a new or recurrent melanoma as early as possible, you should follow your physician's recommended schedule for regular checkups. It is especially important for patients who have dysplastic nevi and a family history of melanoma to have frequent checkups. Examine your skin monthly using a skin self-exam, and follow your physician's advice about how to reduce your chance of developing another melanoma.

The chance of recurrence is greater for patients whose melanoma was thick or had spread to nearby tissue than for patients with very thin melanomas. Follow-up care for those who have a high risk of recurrence may include x-rays, blood tests and regular scans of the chest, liver, bones and brain.