Treating Melanoma

A diagnosis of melanoma can bring with it a range of emotions, including fear, panic and sadness. It is important to keep in mind that once diagnosed with melanoma the future is not always grim. When caught early, surgical removal shows a cure rate of approximately 95%. Even patients with more advanced cases should have hope as the cure rate continues to rise.

A patient’s course of therapy is largely determined by the thickness of the primary tumor and stage of the cancer, as every stage requires different treatment. In the earlier stages, surgery is used to remove the primary tumor and determine if all the cancerous cells have been removed.

Once the melanoma has spread to distant organs, surgery cannot cure the cancer. However, surgery may be performed if it is believed that one or more tumors can be completely removed or that surgery can bring some relief from symptoms. In more advanced cases, chemotherapy, immunotherapy, and radiation therapy may be used. Palliative care, care that seeks to relieve suffering and improve quality of life but not cure the cancer, also can be an option. All of these are described below:

Surgery
Once melanoma is confirmed by the biopsy, additional tissue is generally surgically removed from the same site as the original biopsy to determine if any cancer cells remain. While excisional surgery (described below) is the procedure most commonly used, the size of the tumor or location on the body may make another surgical procedure more practical. The surgical procedures used are:

Amputation: When melanoma occurs on a finger or toe, it is sometimes necessary to amputate part of the digit.

Excisional surgery: Also referred to as “re-excision” and “wide surgical excision,” the purpose of this surgical procedure is to remove any remaining tumor along with a margin of tissue. The thicker the melanoma, the more tissue removed. The removed tissue is sent to a laboratory for microscopic examination to determine if any cancer cells remain. When a melanoma is thin and has not spread beyond the original site, this is frequently the only treatment required.

Lymph node dissection: This surgical procedure is not used to remove the primary tumor. Rather the procedure, also known as a lymphadenectomy, involves removing most, or all, of the lymph nodes in a region, such as the armpit or groin, and examining them for cancer. Lymph node dissection may be advised if the melanoma has spread to the nearby lymph nodes.

A lymph node is a mass of lymphatic tissue surrounded by connective tissue. Lymph nodes filter bacteria and other foreign particles, such as cancer cells. If melanoma has begun to spread, it may be possible to find it in the nearest lymph nodes and remove it before it spreads further.

A biopsy is generally performed to find out if the melanoma has spread to the lymph nodes. The biopsy used will depend on several factors, including whether or not a lymph node feels particularly hard or enlarged.

Mohs micrographic surgery: In some cases, Mohs micrographic surgery may be used instead of excisional surgery (described above).

During Mohs surgery, the surgeon first removes any remaining visible tumor along with a thin layer of additional tissue. What makes Mohs unique is that the removed tissue is examined while the patient is undergoing surgery. The removed tissue is prepared for microscopic examination and examined to determine if cancerous cells are present. This process of removing a thin layer of tissue and examining it under a microscope is repeated until cancer cells are no longer seen. All of this occurs while the patient is under local anesthesia. Removing and examining each layer takes about one hour, with most of this time spent looking at the removed tissue. Once skin cancer is no longer visible, the surgical wound is treated as needed. Methods include allowing the wound to heal naturally, closing the wound with stitches, covering the surgical site with skin from another area of the body (skin graft), and moving healthy skin from a nearby area to cover the surgical wound (skin flap).

Mohs may be considered if the primary melanoma is located on the face or another area where it is essential to preserve as much healthy tissue as possible; the tumor is large; it is difficult to determine where the cancer ends; or the melanoma has recurred.

Adjuvant Therapy
Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, surgery may be used to remove tumors; however, other treatment also is necessary. When treatment methods are used in combination, the first method used is called the “primary therapy,” and the following treatment(s) “adjuvant therapy.” When melanoma is clinically confined to the skin or lymph nodes, adjuvant therapy is often considered to reduce the risk of the cancer spreading or recurring after surgery. The goal of adjuvant therapy is to kill any undetected cancer cells. Chemotherapy, immunotherapy, and radiation may all be used as adjuvant therapy.

Chemotherapy
Chemotherapy is the use of cancer-fighting medications to stop the growth of malignant cells. It works by either killing the cells or preventing them from dividing. The chemotherapy used to treat melanoma is taken orally or given as injections. Once the medication enters the bloodstream, it attacks cancer cells as well as some normal cells, such as those that make up hair follicles and line the gastrointestinal tract. This can produce side effects, such as hair loss and nausea. Chemotherapy is usually given in cycles, with each cycle consisting of a treatment period followed by a period of recovery. Side effects generally disappear once chemotherapy is stopped. Combining chemotherapeutic medications may prove more effective in treating melanoma than use of a single medication. Combining chemotherapy medications with immunotherapy may increase effectiveness and reduce side effects.

A modified form of chemotherapy, isolated limb perfusion, is being studied as an alternative to traditional chemotherapy when the melanoma occurs on an arm or leg. Isolated limb perfusion involves temporarily stopping the flow of blood to the affected limb with a tourniquet and administering a high dose of chemotherapeutic medication to the affected area. It is believed that high doses can more effectively destroy the cancerous cells. This has been beneficial for some patients.

Immunotherapy
Also known as “biotherapy,” this form of treatment uses the patient’s own immune system either directly or indirectly to recognize and destroy cancer cells. The purpose is to improve the patient’s own defenses against cancer. Various types of immunotherapy are being used in clinical trials to treat advanced melanoma:

• Cytokine therapy – Cytokines are proteins that naturally occur in the body and act as messengers to initiate disease-fighting responses. Interferon and tumor necroses factor (TNF) are cytokines used in cancer therapy to halt or slow the proliferation of cancer cells.

• Monoclonal antibody therapy – In a laboratory, molecules are produced that will “lock on” to specific cells in order to kill the melanoma cells.

• Vaccine therapy – Still in the experimental stages, physicians are giving some patients who have been treated for melanoma a vaccine in order to stimulate the patient’s ability to destroy cancerous cells.

Immunotherapy is often used in combination with another form of cancer therapy, such as chemotherapy. Combination therapy may be more effective in treating melanoma. Research shows that immunotherapy can help lessen side effects of other therapies.

Radiation
When a patient undergoes radiation therapy, high-energy rays are directed to the area(s) of the body affected by the melanoma in order to kill malignant cells. This form of therapy is not used to treat a single melanoma lesion. Rather, radiation therapy is used as adjuvant therapy, or to treat melanoma that has returned or is widespread. Radiation therapy also is used to relieve symptoms when the melanoma has spread to the bones or brain. At this stage, treatment will not cure the cancer, but it can bring relief. Radiation therapy also may be used in combination with other therapies, such as chemotherapy. To allow normal cells to repair themselves, radiation therapy is given in small doses over a period of weeks. Treatment is usually given 5 days per week for 2 to 8 weeks.

Palliative Care
The purpose of palliative care is to relieve symptoms and improve a patient’s quality of life, not cure the cancer. Patients with all stages of cancer may receive palliative care. For example, a medication used to control nausea during chemotherapy is a form of palliative care because it is treating a symptom not the cancer. Patients with advanced cancer and those who chose not to fight the cancer often receive palliative care to help control the symptoms and pain.

Follow up: A Key Part of Treatment
Once the melanoma has been treated and cancer is no longer detected, your physician will determine how often you should return for follow-up examinations. Follow-up is a key part of treatment as melanoma can return and new melanomas can develop. Early detection and treatment are key to effectively treating cancer.

In addition to regular office visits, you also will be instructed on how to:

• Perform regular self-examinations of your skin and lymph nodes

• Practice sun protection

If you have any questions about how to do the above, be sure to ask. Research shows that the majority of metastases and recurrences are discovered by the patient or a family member.

Reference:
American Academy of Dermatology’s Guidelines of Care for Primary Cutaneous Melanoma
 

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