Melanoma Surgery

Clinical Evaluation:

Signs of melanoma include a change in the way a mole or pigmented area looks, specifically a mole that:

• changes in size, shape, or color.
• has irregular edges or borders.
• is more than one color.
• is asymmetrical (if the mole is divided in half, the 2 halves are different in size or shape).
• itches.
• oozes, bleeds, or is ulcerated (a hole forms in the skin when the top layer of cells breaks down and the tissue below shows through).

Certain factors affect prognosis (chance of recovery) and treatment options:

• The thickness of the tumor and where it is in the body.
• How quickly the cancer cells are dividing.
• Whether there was bleeding or ulceration of the tumor.
• How much cancer is in the lymph nodes.
• The number of places cancer has spread to in the body.
• The level of lactate dehydrogenase (LDH) in the blood.
• Whether the cancer has certain mutations (changes) in a gene called BRAF.
• The patient’s age and general health.

After melanoma has been diagnosed, various tests may be done to find  out if cancer cells have spread within the skin or to other parts of the body.  These may include:

• Lymph node mapping and sentinel lymph node biopsy : Procedures in which a radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist views a sample of tissue under a microscope to check for cancer cells. If no cancer cells are found, it may not be necessary to remove more nodes.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For melanoma, pictures may be taken of the chest, abdomen, and pelvis.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• MRI (magnetic resonance imaging) with gadolinium : A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. A substance called gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (nMRI).

The staging of melanoma depends on the following:

• The thickness of the tumor.
• Whether the tumor is ulcerated (has broken through the skin).
• Whether the tumor has spread to the lymph nodes and if the lymph nodes are joined together (matted).
• Whether the tumor has spread to other parts of the body.

The following stages are used for melanoma:

Stage 0 melanoma in situ. Abnormal melanocytes are in the epidermis (outer layer of the skin).

Stage I melanoma.

• In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin).
• In stage IB, the tumor is either not more than 1 millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick, with no ulceration. Skin thickness is different on different parts of the body.

Stage II melanoma.

• In stage IIA, the tumor is either more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration.
• In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration.
• In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.

Stage III melanoma.

• The cancer has spread to one or more lymph nodes.

Stage IV melanoma.

• The cancer has spread to other parts of the body, such as the brain, lung, liver, lymph nodes, small intestine, and bone.

Recurrent Melanoma

• Recurrent melanoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the area where it first started or in other parts of the body.

Surgery for melanoma may include:

• Wide excision of the melanoma with 1-2 cm margins
• Sentinel Lymph Node Biopsy (SLNB), which is removal of the lymph node most likely to have had cancer spread.
• Completion Lymph Node Dissection (CLND), which is recommended in cases with obvious spread of melanoma to the surrounding lymph nodes.

Possible complications of melanoma excision and sentinel lymph node biopsy surgery include but are not limited to the following:
Infection, bleeding, swelling, scarring, numbness, skin discoloration, poor wound healing, displeasure with the cosmetic outcome, need for additional procedures, nerve weakness, failure to identify the sentinel lymph node, false negative biopsy (<5% chance the cancer has spread but the sentinel node biopsy does not identify it), and allergic or other negative reactions to one or more of the medications or substances used in the operation.

In addition to helping doctors stage cancers and estimate the risk that tumor cells have developed the ability to spread to other parts of the body, surgical excision and sentinel lymph node biopsy (SLNB) may help some patients avoid more extensive lymph node surgery. Removing additional nearby lymph nodes to look for cancer cells may not be necessary if the sentinel node is negative for cancer. All lymph node surgery can have adverse effects, and some of these effects may be reduced or avoided if fewer lymph nodes are removed.

Researchers have investigated whether patients with melanoma whose sentinel lymph node is negative for cancer and who have no clinical signs of other lymph node involvement can also be spared more extensive lymph node surgery at the time of primary tumor removal. A meta-analysis of 71 studies that involved data from 25,240 patients suggests that the answer to this question is “yes.” This meta-analysis found that the risk of regional lymph node recurrence in patients with a negative SLNB was 5 percent or less (4).

Another question posed by researchers is whether SLNB plus the removal of the remaining regional lymph nodes (called completion lymph node dissection, or CLND) if the sentinel lymph node is positive for cancer has a therapeutic benefit for melanoma patients in terms of disease-free survival and melanoma-specific survival (length of time until death from melanoma). To address this question, NCI, the National Institutes of Health, and the John Wayne Cancer Institute conducting a large phase III clinical trial called the Multicenter Selective Lymphadenectomy Trial II, or MSLT-II. In this trial, more than 1,900 patients with positive sentinel lymph nodes but no clinical evidence of other lymph node involvement were randomly assigned to immediate CLND or regular ultrasound examination of the remaining regional lymph nodes and CLND if signs of additional lymph node metastasis appear. The patients in this trial were followed for 10 years, and the results showed no survival benefit to those patients who underwent an immediate CLND. For those patients with obvious clinical disease in the lymph nodes, a completion lymphadenectomy does have therapeutic benefit.

Surgery to remove the tumor is the primary treatment of all stages of melanoma. A wide local excision with 1-2 cm margins around the primary lesion is the method used to remove the melanoma and some of the normal tissue around it to ensure the entire malignancy is excised. Skin grafting (taking skin from another part of the body to replace the skin that is removed) or rearrangement of adjacent tissues may be done to cover the wound caused by surgery.

In melanomas with any potentially aggressive characteristics (depth > 1 mm, ulcerations, invasion of nerves or blood vessels, location in the head & neck), lymph node mapping and sentinel lymph node biopsy (SLNB) may be recommended to check for cancer in the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. The sentinel node is then checked for the presence of cancer cells by a pathologist. If cancer is found, the surgeon may remove additional lymph nodes, either during the same biopsy procedure or during a follow-up surgical procedure. SLNB is usually done at the same time the primary tumor is removed. However, the procedure can also be done either before or after removal of the tumor.