Surgery

Surgery is the first treatment step for the majority of melanomas, and often the only treatment necessary. It is also used for lymph node evaluation and dissection, as well as for selected patients with advanced melanoma.

Surgical Procedures

Wide Excision

Purpose: To remove any cancerous tissue that may remain after the biopsy.

What Is It?
Wide excision is the standard surgical procedure for melanoma Stage 0 (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).

Side Effects
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.

Skin Grafting

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 stitches or staples.

What Is It?
Skin grafting is 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.

Side Effects
Skin grafting increases the risk of bleeding, graft failure, infection, poor healing, altered sensation, altered hair growth, and 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.

Margins

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 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 Determines the Size of the Margin

  • Melanoma in situ: At least 0.5cm margin (less than 0.25 inch)
  • 1mm or less: 1cm margin (about 0.375 inch)
  • 1.1mm – 2.0mm: 1cm or 2cm margin depending on the location of the tumor and other factors (about 0.375 inch to about 0.75 inch)
  • Greater than 2mm: 2cm margin (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?
SLNB is a surgical procedure in which only the sentinel lymph node(s) – the very first lymph node(s) to receive drainage from an area – is removed and biopsied.

SLNB is often performed at the same time as lymphatic mapping, a procedure 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.

Side Effects
A small group of patients may experience the following:

  • Develop a lymphocele, a collection of fluids that builds up under the incision where the lymph node was removed
  • Develop lymphedema, a swelling of the arm or left leg left with an increased risk of infection
  • Blue dye that is injected during lymphatic mapping may leave a discoloration at the injection site that can remain for many months

Learn more about SLNB

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, such as pain, caused by growth of melanoma in the nodes, and to possibly stop the spread of the disease to distant sites.

What Is It?
Lymph node dissection is 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.

Side Effects
Patients may experience the following:

  • Develop lymphedema, which is a swelling of the arm or leg nearest to where the nodes have been removed, and caused by a buildup of lymph that may require therapy and may not go away
  • Experienced increased risk of infection because it is harder for the body to fight infection in an area where nearby lymph nodes were removed

Important
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 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?
Surgery may be used to remove 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.

Side Effects
Patients may experience the following:

  • Typical risks associated with surgery
  • Site-specific risks, for example, surgery for brain metastases may harm normal parts of the brain and cause neurological problems

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