Skin Cancer Treatment Options

In addition to using the latest treatment options, you can participate in ongoing, clinical trials, examining new approaches to treating skin cancer.

Treatment Options By Stage

Stage 0 Melanoma is usually treated with a wide local excision to remove the tumor and a small amount of normal tissue around it.

Stage I Melanoma is usually treated by wide local excision to remove the tumor and a small amount of normal tissue around it.

Stage II Melanoma treatment options include:

• Wide local excision to remove the melanoma and some of the normal tissue around it, followed by removal of nearby lymph nodes.
• Lymphatic mapping and sentinel lymph node biopsy, followed by wide local excision to remove the tumor and some of the normal tissue around it. If cancer is found in the sentinel lymph node(s), this then becomes classified as Stage III melanoma (see below).
• For thick melanomas (>4 mm Breslow thickness), even with normal lymph nodes, additional adjuvant therapy with high dose interferon alfa-2b is sometimes recommended (see below under Stage III).

Stage III Melanoma (Melanoma that spreads to the lymph nodes) treatment options include:

• Wide local excision to remove the melanoma and some of the normal tissue around it.
• Regional lymph node dissection. Most often, these days, Stage III is diagnosed by finding microscopic spread of the melanoma to the regional lymph nodes (most commonly in the neck, under the arm-called the axilla, or in the groin area) by sentinel lymph node biopsy. Sometimes, however, patients are found to have enlarged lymph nodes full of cancer. In any event, the procedure of choice when there is any sign of cancer in the lymph nodes is to remove all of the lymph nodes in that area, called lymphadenectomy or lymph node dissection. For Stage III melanoma, some patients are cured just by removing these lymph nodes.
• We believe that the best chance of cure for patients with cancer in the lymph nodes is to detect the lymph node metastases early, rather than wait until the lymph nodes become enlarged and full of cancer. Sentinel lymph node biopsy is the best way to find early spread of the melanoma to lymph nodes.
• Once cancer is diagnosed in the lymph nodes, the risk of cancer spreading elsewhere is higher. Therefore, additional therapy is often recommended. The only Food and Drug Administration (FDA) approved therapy is high dose interferon alfa-2b (see melanoma.com).
• Clinical Trials, including melanoma vaccines.
• For patients with a particular pattern of spread of the melanoma called "in-transit disease" (tumor nodules in the skin or under the skin around the original melanoma, spreading toward the lymph nodes), hyperthermic isolated limb perfusion can be used. This is performed as an operation in which a tourniquet is applied to the affected arm or leg, and heated chemotherapy is circulated through the main artery and vein. This can be an effective treatment for advanced disease.

Stage IV Melanoma patients have melanoma that has spread beyond the regional lymph nodes and to distant sites. Most patients are not cured. Treatment options include:

• Surgery: A small fraction of patients with resectable metastases will survive long term, regardless of other types of therapy. In general, patients with Stage IV melanoma that can be surgically removed can often benefit from removing these tumors. Sometimes, surgery is performed as palliative therapy to relieve symptoms and improve quality of life.
• High dose Interleukin-2: This treatment is an immunotherapy that is given in the hospital, and can have significant side effects or toxicity. It is the only FDA-approved immunotherapy for metastatic melanoma. It can result in complete remission for a small fraction of patients (about 7%). Patients with complete remission have all the cancer disappear-sometimes for many years. Some such patients may actually be cured, although longer follow-up is needed to determine how often this happens.
• Biochemotherapy: This is an aggressive combination of chemotherapy drugs, interleukin-2 and interferon. It requires treatment in the hospital. Like high-dose IL-2, it can result in complete remission. The toxicity is significant, and the overall benefit is controversial. This is often given as part of a clinical trial.
• Radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• Chemotherapy alone, such as dacarbazine alone or the three-drug combination of cisplatin, dacarbazine (DTIC) and the carmustine (BCNU), also called the Dartmouth regimen. While chemotherapy alone can help some patients, it is not very effective overall.

Information on specific treatments under study is available under clinical trials, but this section may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI at Cancer.gov.

If the cancer has spread

Surgery

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

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

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.