What Type of Surgery Is Performed to Remove Melanoma?
Surgery is the first treatment step for the majority of melanomas, and often the only treatment necessary. Surgery is also used for lymph node evaluation and dissection, as well as for selected patients with advanced melanoma.
Types of Surgery For Removing Melanoma
Wide Local Excision
Purpose: To remove any cancerous tissue that may remain after the biopsy.
What Is It? WLE is the standard surgical procedure for the primary tumor on the skin. In other words, WLE is used to remove the primary tumor from your body.
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.
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 mean surgeons can often take narrower margins than in the past, so more normal skin is preserved. The surgical margin guidelines adopted and recommended by the National Comprehensive Cancer Network (NCCN) for wide local excision of the primary melanoma range from 0.5 cm to 2 cm:
Thickness (Breslow Depth) of Melanoma Determines the Size of the Margin
Tumor Thickness Surgical Margin
In Situ 0.5-0.1 cm
Less than or equal to 1 mm 1.0 cm
Greater than 1.0mm to 2.0 mm 1.0-2.0 cm
Greater than 2.0 to 4.0 mm 2.0 cm
Greater than 4.0 mm 2.0 cm
Side Effects: Surgery for primary melanoma involves the removal of skin, which will leave a scar. The size and appearance of the scar depend on a number of factors:
- The size and thickness of the tumor
- The location of the tumor on the body
- The tendency to develop raised scars called keloids (some people develop keloids; others don’t)
Other side effects can include infection, numbness, and swelling.
Note: If a sentinel lymph node biopsy is warranted, it is often performed at the same time as the wide local excision.
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 in which 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 of the body that are hidden or typically 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 side effects may include 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.
Sentinel Lymph Node Biopsy (SLNB)
Purpose: In patients where the risk that the melanoma has spread to the lymph nodes is greater than 10% (primary tumor is greater than 1mm in depth), a SLNB is performed to look for that spread. The sentinel lymph node(s) is the most likely to contain melanoma, so it is identified and removed for evaluation. 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 the tumor area – is removed and biopsied.
Lymphatic mapping, a procedure in which blue dye is injected into the skin around the tumor, along with a small amount of radioactive substance, is performed in conjunction with SLNB. The dye gives the surgeon a visual reference to find the sentinel lymph node(s).
Side Effects: A small percentage of patients may
- Develop a lymphocele, a collection of fluid that builds up under the incision where the lymph node was removed
- Develop lymphedema, swelling of the entire arm or leg where the lymph node was removed
- Experience skin discoloration from the blue dye used for lymphatic mapping at the injection site that can remain for many months
Lymph Node Dissection
Purpose: In patients whose melanoma has spread to several lymph nodes, the removal of all the lymph nodes in that region may be recommended.
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 are noted on imaging or feel enlarged or hardened; a fine needle biopsy or excisional biopsy finds melanoma in a node or nodes, and lymph node dissection may be recommended. In this case the surgery is called therapeutic lymph node dissection (TLND). The surgery is performed to possibly stop the spread of the disease to distant sites.
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. In this case, the surgery is called completion lymph node dissection (CLND). The surgery is performed to possibly stop the spread of the disease to distant sites.
Recent studies indicate that CLND after finding one or more positive lymph nodes via SLNB may not be warranted in patients with no clinical evidence of enlarged lymph nodes. These studies have shown that CLND does not improve overall survival over observation with ultrasound of the nodal region and repeat imaging alone. Whether to perform a CLND, therefore, should be a topic for you and your physician to discuss. A number of factors should be considered, including location of melanoma, the number of lymph nodes involved, follow-up requirements, your age, and the risk of recurrence. 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 CLND should be performed.
Side Effects: Patients may
- 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; lymphedema may require therapy and may not go away
- Experience increased risk of infection because it is harder for the body to fight infection in an area where nearby lymph nodes were removed
It is important for patients who have undergone CLND to protect arms and 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: 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
- 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