Surgery to remove the tumor is the primary treatment of all stages of melanoma. A wide local excision is used to remove the melanoma and some of the normal tissue around it. Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery.
Surgical Procedures To Remove Melanoma
Purpose: To remove any cancerous tissue that may remain after the biopsy. Wide excision is the standard surgical procedure for melanoma Stage 0 (in situ), Stage I, Stage II, and most Stage III melanomas.
What Is It?
A surgeon will do a procedure called wide local excision (removal). This means that the area where the melanoma is, as well as a small amount of surrounding normal-looking skin, will be cut out. This is called a wider or safety margin. A pathologist will check the tissue around the melanoma for cancer cells. If the sample doesn’t have any cancer cells, it is called a clear margin. If the margins aren’t clear, you may need further surgery to remove wider margins, or other treatments.
A wide local excision is often performed as a day procedure using a local anesthesia. This means you can go home soon after the surgery, provided there are no complications. People with a melanoma thicker than 1 mm will often have a sentinel node biopsy at the same time and will be given a general anesthetic. 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 tumor has penetrated the skin).
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.
Thickness of Melanoma Determines the Size of the Margin
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:
- 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)
Repairing the Wound
Most people will be able to have the surgical wound drawn together with stitches. When large skin cancers are removed, the wound may be too big to close with stitches. The surgeon may cover it using some skin from another part of your body. This can be done in two ways:
Skin flap – nearby skin and fatty tissue are moved over the wound and stitched.
Skin graft – a layer of skin is taken from another part of your body and placed over the area where the melanoma was removed. Skin grafting is performed when the amount of tissue removed is too great to allow the wound to be closed with stitches or staples. 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.
The decision about whether to do a skin graft or flap will depend on many factors, such as where the melanoma is, how much tissue has been removed and your general health.
In either case, the wound will be covered with a dressing and left for several days. It will then be checked to see if it is healing properly. You will also have dressings on any area that had skin removed for a graft.
Side Effects of Skin Grafting
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.
Recovering from Surgery
You may be uncomfortable for a few days after a wide local excision. Your doctor will prescribe painkillers if necessary. If you have a skin graft, the area on which the skin is grafted may look red and raw immediately after the operation. Eventually this area will heal and the redness will fade. Your medical team will tell you how to keep the wound clean to prevent it from becoming infected. Occasionally, the original skin flap or graft doesn’t take and a new one is required. Your total recovery time will vary depending on the thickness of the melanoma and the extent of the surgery required. Most people recover in a week or two. Your doctor can also give you information about any bleeding, bruising, scarring or numbness you may have after surgery.
Side Effects of Melanoma Surgery
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.
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 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. Sentinal Lympth Node Biopsy 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.
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
Removing the Lymph Nodes: Lymph Node Dissection
It is important to know whether cancer has spread to the lymph nodes. Lymph node mapping and sentinel lymph node biopsy are done to check for cancer in the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. If the sentinel lymph node biopsy showed that the melanoma has spread to your lymph nodes (regional melanoma), they will be removed in an operation called a lymph node dissection or lymphadenectomy. 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. This is performed under a general anesthetic and requires a stay in hospital. The lymph nodes you have removed are likely to be near the location of the primary melanoma. There are large groups of lymph nodes in the neck, armpits and groin.
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
Like most treatments, having your lymph nodes removed can cause side effects, such as:
- Wound pain – Most people will have some pain after the operation. This usually improves as the wound heals. For some people, however, pain may continue after the wound has healed, especially if lymph nodes were removed from the neck. Talk to your medical team about how to manage your pain.
- Neck/shoulder/hip stiffness and pain – These are the most common problems if lymph nodes in your neck, armpit or groin were removed. You may find that you cannot move the affected area as freely as you could before the surgery. It may help to see a physiotherapist.
- Seroma/lymphocoele – This is a collection of fluid in the area where the lymph glands have been removed. It is a common side effect of lymph node surgery. Sometimes this fluid needs to be drained by having a needle inserted into the fluid-filled cavity.
If you do develop an infection, contact your doctor immediately.
If lymph nodes have been surgically removed, swelling of the neck, arm or leg is the most common problem that can occur. Occasionally it can affect the breast tissues. This is called lymphoedema and it happens due to a build-up of lymph fluid in the affected part of the body.
The likelihood of lymphoedema following treatment depends on the extent of the surgery and whether you’ve had radiotherapy that has damaged your lymph nodes. It can develop a few weeks, or even several years, after treatment. Although lymphoedema may be permanent, it can usually be managed.
How to prevent and/or manage lymphoedema:
- Keep the skin healthy and unbroken. This will reduce the risk of infection.
- Wear a professionally fitted compression garment if recommended by a physiotherapist or occupational therapist.
- Always wear gloves for gardening, outdoor work and housework.
- Moisturize your skin daily to prevent dry, irritated skin.
- Use sunscreen to protect your skin from sunburn.
- Don’t pick or bite your nails, or push back your cuticles.
- Avoid scratches from pets, insect bites, thorns, or pricking your fingers.
- Do light exercise to help the lymph flow, such as swimming, bike riding or light weights.
- Massage the affected area to help move fluid.
- Seek medical help urgently if you think you may have an infection.