To remove any cancer remaining after the biopsy. The procedure is called wide local excision.

The surgeon removes the rest of the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin), and the underlying subcutaneous tissue, to make certain the whole tumor has been removed.

The width of the margin taken depends upon the thickness of the primary tumor.

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

• Stage 0: 0.5cm margin (less than 1/4 inch)

This allows surgeons to take narrower margins than before, so a much greater amount of normal skin is preserved. However, skin grafting may sometimes be required to cover the wound.

To remove any cancer remaining after the biopsy. The procedure is called wide local excision.

The surgeon removes the rest of the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin), and the underlying subcutaneous tissue, to make certain the whole tumor has been removed.

Margins are taken all the way around the primary tumor. As an example, a 1 cm margin can be approximated by drawing a line that is 1 cm away from the site of the biopsy all the way around. The width of the margin taken depends upon the thickness of the primary tumor.

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

• Stage IA - 1 cm margin - about 3/8 inch - for tumors that have a Breslow depth of 1 millimeter or less.

• Stage IB - 2 cm margin - about 3/4 inch - for tumors with a depth between 1.1 mm and 3.99 mm.

Recent advances in surgery allow surgeons to take narrower margins than before, so a much greater amount of normal skin is preserved. However skin grafting may sometimes be necessary to cover the wound.

Sentinel

Lymph

Node Biopsy

(SLNB)

Sentinel lymph node biopsy is most accurate when it is performed before wide local excision, the surgery to remove the tumor and the surrounding skin.

Recommended for patients with 

• Stage I tumors equal to or greater than than 1.0 mm
• Ulcerated tumors of any thickness
• Positive margins
• Lymphovascular invasion (seeing cancer cells In the lymphatic channels or blood vessels
• The presence of mitosis in young adults (rate at which cells divide)

Purpose

• Determine whether any cancer cells have spread to the sentinel node, the first lymph node to receive drainage from the primary tumor, and the site where melanomas commonly spread to first.

• Further treatment will depend on whether the lymph node biopsy is positive.

Surgery

The surgeon removes the rest of the tumor, including the biopsy site, as well as a surgical margin, (a surrounding area of normal-appearing skin) and underlying subcutaneous tissue to make sure the whole tumor has been removed. The width of the margin taken depends upon the thickness of the primary tumor.

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

• Stage IIA & IIB - 2 cm margin - about .75 inch - for tumors between 1.1 mm and 3.99 mm in depth (Breslow Depth)

• Stage IIC - 2-4 cm margin - about .75 inch to 1.5 inch - for tumors greater than 4 mm; 2 cm margin - about .75 inch - for tumors between 1.1 mm and 3.99 mm in depth (Breslow depth)

Recent advances in surgery allow surgeons to take narrower margins than before, so a much greater amount of normal skin is preserved. 

Sentinel Lymph Node Biopsy

(SLNB)

Sentinel lymph node biopsy is recommended for all Stage II tumors regardless of size.

Sentinel node biopsy is most accurate when it is performed before wide local excision, the surgery to remove the tumor and the surrounding skin.

Purpose

• Determine whether any cancer cells have spread to the sentinel node, the first lymph node to receive drainage from the primary tumor, and the site where melanomas commonly spread to first. 
• Further treatment will depend on whether the lymph node biopsy is positive.

Treatment given in addition to a primary cancer treatment is recommended following surgery for Stage IIB and Stage IIC 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.

• Interferon therapies have been shown to help the body's immune system fight disease more effectively.
• Studies indicate that low dose interferon alfa-2b, a manufactured form of interferon, consistently delays relapse in patients with later Stage II melanoma but does not extend overall survival. High dose interferon alfa-2b is the only adjuvant treatment to significantly prolong disease-free survival in patients with late Stage II Melanoma.

Treatment Side Effects

• Although there are well-documented benefits of treatment with interferon, the therapy is associated with side effects, and it lasts 12 months.

• Recently there has been some use of a shorter course of the therapy or the use of a long-acting, pegylated form of interferon. The results of these studies have not been strong enough to change the current practice.

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 other 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 for any stage of melanoma, and in some cases may even worsen survival rates. Scientists are constantly working to improve the efficacy of these treatments.

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 rest of 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.

CLND and TLND also play an important role in controlling the pain often caused by untreated lymph node disease.

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.

Treatment given in addition to a primary cancer treatment (such as surgery) 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.

• 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 interferons 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 overall median survival by 4 months.

Treatment Side Effects

• Yervoy can cause powerful autoimmune reactions 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 a 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.

• 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.

Clinical

Trials

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.

To remove the cancerous tumors or lymph nodes that have metastasized or spread to other areas of the body, if they are few in number and are causing symptoms.

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

A)     Yervoy is a monoclonal antibody that has been approved by the Federal Drug Administration (FDA) for the treatment of unresectable or metastatic melanoma.

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 overall median survival by 4 months.

• Yervoy can cause powerful autoimmune reactions 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. 

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 a 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 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 effects resulting from Zelboraf include joint pain rash, hair loss, fatigue, nausea, itching, and warts.

C)     Interleukin-2 (IL-2) is approved by the FDA for the treatment of advanced metastatic melanomas. It appears to benefit approximately 16% of patients with disease shrinkage, of which 5% appear to derive long term durable responses.

Purpose

• These are established and experimental systemic therapies that ago through the bloodstream to reach and affect cancer cells throughout the body.
• Chemotherapy uses toxic drugs to destroy cancer cells. Immunotherapy uses natural manufactured substances to help the body's immune systems fight diseases more effectively.

• These treatments may cause severe side effects.

Radiation is used to the shrink the tumors in organs where surgery is not possible or may be complicated, and for relieving symptoms of cancer in the brain or bone..

Radiation therapy uses x-rays and gamma rays to kill cancer cells.

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.

Therapeutic
Lymph
Node
Dissection
(TLND)

Lymph node recurrence, when isolated, may be treated by therapeutic lymph node dissection (TLND).

Surgery to remove all regional lymph nodes from the area where cancerous lymph nodes were found. If your melanoma was found by SLNB, then no additional testing is necessary.

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

TLND also plays an important role in controlling the pain often caused by untreated lymph node disease