Surgery

To remove any cancer remaining after the biopsy. The procedure is called wide local excision. Wide local incision is recommended for small, easily removable recurrent tumors and for patients with a limited number of in-transit tumors.

The surgeon removes the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin), and underlying subcutaneous tissue.

Most surgeons today follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program.

• Primary tumors associated with Stage III disease - 2-4 cm margin - about 3/4 inch to 1 1/2 inch - according to their thickness.

Lymph Node Dissection

Surgery to remove all regional lymph nodes from the area where cancerous lymph nodes were found. If your melanoma was found by sentinel lymph node biopsy this is called a complete lymph node dissection (CLND). If your melanoma was found because your lymph nodes were enlarged this is called a therapeutic lymph node dissection (TLND)

The goal of the surgery is to prevent further spread of the disease through the lymphatic system. Current studies are underway to determine whether CLND and TLND may also prolong survival.

Sentinel Lymph Node 

Biopsy

(SLNB)

Generally not done on patients who have already been diagnosed with Stage III.

Recommended only for patients where it is suspected that there might be melanoma in another nodal basin.

The results of the biopsy will guide the course of treatment.

For more on Sentinel Lymph Node Biopsy click here

Treatment given in addition to a primary cancer treatment is recommended for Stage III Melanoma. These are systemic therapies that go through the bloodstream to reach and affect cancer cells throughout the body.

Interferon is a protein produced by normal cells to fight viral infections and disease. There are now two types of interferon that have been approved by the Food and Drug Administration (FDA) for Stage III melanoma: high-dose interferon (Intron A) and pegylated interferon (Sylatron).

Purpose

• Interferon therapies have been shown to help the body's immune system fight disease more effectively.
• High-dose interferon alfa-2b significantly prolongs disease-free survival in patients with Stage III melanoma. It has not been shown to prolong overall survival. The drug has to be administered frequently at very high doses in order to be effective. Pegylated interferon alfa-2b is designed to provide high levels of interferon in the blood when given by subcutaneous injection once a week.

Treatment Side Effects

• Although there are well-documented benefits of treatment with high-dose interferon, the therapy is associated with side effects, and the therapy is given for over 12 months.
• Pegylated interferon is given over a longer period of time (5 years) but has fewer severe/life threatening events. Recently there has been some use of a shorter course of high-dose interferon, but the results have not been strong enough to change current practice.

For more information on Immunotherapy click here

A)     Yervoy is a monoclonal antibody that has been approved by the FDA for the treatment of unresectable or metastatic melanoma. An unresectable melanoma is a melanoma tumor that cannot be completely removed surgically. In Stage III this can occur because of a lack of clear margins, an inflammatory component, problem location (e.g. the sinonasal area), or a widespread lesion not permitting multiple excisions.

Purpose

• Yervoy is designed to restore and strengthen the immune system by successfully activating T-cells, a critical component of the immune system, thereby sustaining an active immune response to fight the cancer cells.
• Studies indicate that it improves median survival by 4 months.

Treatment of Side Effects

• Yervoy can cause powerful autoimmune reaction in which the immune system attacks normal cells in the body. 15% of patients reported autoimmune reactions that were classified as severe and some fatalities did occur.
• Common side effects resulting from Yervoy include fatigue, diarrhea, nausea and rash. The most common severe immune-mediated adverse reactions are enterocolitis, hepatitis, dermatitis (including toxic epidermal necrolysis), neuropathy, and endorcrinopathy.

B)     Zelboraf is a kinase inhibitor that has been approved by the FDA for the treatment of patients with the BRAF V600E mutation, as determined by an FDA approved test, with unresectable or metastatic melanoma.

An unresectable melanoma is a melanoma tumor that cannot be completely removed surgically. In Stage III this can occur because of a lack of clear margins, an inflammatory component, problem location (e.g. the sinonasal area), or a widespread lesion not permitting multiple excisions.

Purpose

• The BRAF protein is normally involved in regulating cell growth, but is mutated in about half of the patients with late-stage melanomas. Zelboraf works by blocking the function of the V600E-mutated BRAF protein.
• In trial comparing Zelboraf to dacarbazine in patients with the BRAF V600E mutation, the dacarbazine group had a median survival time of 8 months, with 64% still living. Median survival time has still not been reached for patients in the Zelboraf group, with 77% still living.

Treatment Side Effects

• Squamous cell carcinoma occurred in 24% of patients receiving Zelboraf.
• Photosensitivity (skin sensitivity when exposed to the light) often occurs and patients taking Zelboraf should avoid sun exposure.
• Other common side effects resulting from Zelboraf include joint pain, rash, hair loss, fatigue, nausea, itching, and warts.

Radiation Therapy

Radiation therapy has not been proven to be of benefit in randomized, controlled studies.

It is sometimes recommended when the tumor has grown outside the lymph nodes and the doctor is trying to control further spread.

For more information on Radiation Therapy click here

Clinical trials are research studies to evaluate new therapies and improve cancer care. These studies are responsible for most of the advances in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial.

Several experimental treatments are currently being tested in clinical trials.

• Experimental vaccines, GM-CSF, CTLA4-blocking antibodies, interleukins, and others therapies designed to boost the immune system to fight the return of melanoma

• Chemotherapy treatments

Except for chemotherapy, all of these treatments are designed to boost the immune system. These therapies have not yet been shown to extend overall survival in any randomized, controlled, trials in any stage of melanoma and in some cases may even worsen survival rates. Scientists are constantly working to improve the efficacy of these treatments.

For more information on Clinical Trials click here