Surgery is the first step of treatment for the majority of melanomas, and often the only treatment necessary. It is also used for lymph node evaluation and dissection, as well as in the management of selected patients with advanced melanoma.
Purpose: To remove any cancerous tissue that may remain after the biopsy
What is it?
Standard surgical procedure for melanoma in situ, Stage I, Stage II and most Stage III melanomas.
The surgeon removes the tumor, including the biopsy site, as well as a surrounding area of normal-appearing skin and underlying subcutaneous tissue, to make certain the whole tumor has been removed.
If a sentinel lymph node biopsy is needed, this is often done at the same time.
The width of the margin taken depends upon the thickness of the primary tumor (how deeply the tumour has penetrated the skin).
Surgery for primary melanoma involves the removal of skin, which will leave a scar. The size and appearance of the scar depends on a number of factors:
- The size and thickness of the tumor
- The location of the tumor on the body
- Whether, when healing, there is a tendency to develop raised scars called keloids
Other side effects can include infection, numbness and swelling.
Purpose: To replace the skin where the tumor has been removed, when the amount of tissue removed is too great to allow the wound to be closed with stiches or staples.
What is it?
A procedure, usually performed by a surgical oncologist or a plastic surgeon, where skin from another part of the body is used to cover the site of the surgical removal of the tumor. The skin used to cover the incision is usually taken from areas that are hidden and covered with clothing.
Grafts can be full thickness or spit thickness. Since the side effects and appearance between the two are different, ask your doctor to explain which type is planned.
Due to improved surgical techniques, grafting can usually be avoided. Less than 10% of patients with primary melanoma require a skin graft.
Skin grafting increases the risk of bleeding, graft failure, infection, poor healing, altered sensation, altered hair growth or contraction of the graft leading to decreased mobility.
In extreme cases, the entire graft can be lost, leading to either very delayed healing or the need for a second surgery.
Recent advances in our understanding of melanoma often mean surgeons can take narrower margins than they used to, so a much greater amount of normal skin is preserved. Most surgeons today follow the guidelines adopted and recommended by the National Institutes of Health and the World Health Organization Melanoma Program, based on large randomized, controlled trials.
The guidelines describe how much normal skin should be taken from along the margin of the tumor, based on the size of the tumor and the stage of melanoma:
Thickness of Melanoma and Size of Margin
Melanoma in situ (Stage 0): At least 0.5 centimeter (cm) (less than 0.25 inch)
1 millimeter (mm) or less: 1 cm (about 0.375 inch)
1.1 mm – 2.0 mm: 1 cm or 2 cm depending on the location of the tumor and other factors (about 0.375 inch to about 0.75 inch)
Greater than 2 mm: 2 cm (about 0.75 inch)
Sentinel Lymph Node Biopsy (SLNB)
Purpose: In patients where there is a risk that the melanoma has spread to the lymph nodes, a SLNB can lead to the earlier diagnosis and treatment of Stage III melanoma. The sentinel lymph node is removed for evaluation because of all the lymph nodes, it is the most likely to contain melanoma. Lymphatic mapping is used to guide the lymph node biopsy.
What is it?
Sentinel lymph node biopsy (SLNB) is surgery in which only the sentinel lymph node(s) – the very first lymph node (or nodes) to receive drainage from an area – is identified and biopsied.
SLNB is often conducted in conjunction with lymphatic mapping, in which blue dye is injected into the skin around the tumor, along with a small amount of radioactive substance. The dye gives the surgeon a visual reference.
A small group of patients may:
Develop a lymphocele, a collection of fluids that builds up under the incision where the lymph node was removed
Develop lymphedema swelling of the arm or left and increased risk of infection (described below).
The blue dye that is injected during lymphatic mapping may leave a discoloration at the injection site that may not go away for many months.
Lymph Node Dissection
Purpose: In patients where it is known that the melanoma has spread to the lymph nodes, the removal of all the lymph nodes in that region is often recommended. This is done to prevent symptoms from the growth of melanoma in the nodes, such as pain, and to hopefully interrupt the spread of the disease to distant sites.
What is it?
Surgery to remove all regional lymph nodes from the area where cancerous lymph nodes were found.
In some patients the lymph nodes closest to the primary melanoma feel enlarged, and a fine needle biopsy or excisional biopsy finds melanoma in a node or nodes.
In other patients the nodes are not enlarged, but a SLNB is performed and it shows that there is cancer in one or more nodes.
Whether a complete lymph node dissection increases survival after removal of a positive sentinel node remains uncertain, so clinical trials are currently underway to determine if everyone with a positive sentinel node really needs a full node dissection. However, for people with positive nodes found by examination, scans or as a recurrence after prior treatment of the melanoma, there is widespread agreement that a complete node dissection should be done.
Lymphedema is a swelling of the arm or leg from which the nodes have been removed, caused by a buildup of lymph that may require therapy and may not ever go away.
Each part of the body is associated with a specific group of lymph nodes. Lymph nodes in the groin help drain lymph from the leg, nodes in the underarm help drain the arm and nodes in the neck help drain the head. When these nodes are removed, lymph may build up beyond the site of lymph node surgery and cause swelling of the subcutaneous tissues.
Increased risk of infection because it is harder for the body to fight infection in an area where nearby lymph nodes removed. It will be important to protect your arms or legs from cuts, scratches, bruises or burns that may lead to infection.
If you do develop an infection, contact your doctor immediately.
Surgery for Advanced (Stage IV) Melanoma
Purpose: In carefully selected cases, patients with only one or a few sites of metastatic melanoma may be candidates for surgery to remove all known disease. In other cases, surgery may be used to relieve symptoms.
What is it?
Removal of cancerous tumors that have spread to other locations in the body.
It may also be used to remove a lump or tumor that is suspected to be melanoma but where the diagnosis may not be certain.
Surgery for metastatic melanoma may also be considered when treatment with drug therapy has led to dramatic shrinkage, but one or a few relatively small areas of disease remain.
The typical risks associated with surgery.
Site-specific risks may vary, for example, surgery for brain metastases may harm normal parts of the brain and cause neurological problems.