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Melanoma

Surgery for Melanoma

Surgery is an integral component in the management of melanoma and is used to confirm a diagnosis, determine prognosis, and treat the cancer.

Surgical Biopsy

A biopsy is a procedure to remove the abnormal tissue and a small amount of normal tissue around it. Patients may want to have the sample of tissue checked by a second pathologist. If the abnormal mole or lesion is cancer, the sample of tissue may also be tested for certain genomic changes and biomarkers.

The most important initial feature that is obtained from biopsy at the time that the melanoma is diagnosed is the thickness of the melanoma (Breslow thickness, measured in millimeters).  A pathologist determines this thickness by examining the melanoma under a microscope and measuring the lesion from the top to the bottom.  Based on the thickness of the tumor, melanoma is divided into 3 general categories:

The thicker a melanoma is determined to be at the time of diagnosis, the greater the chance that it has spread.  In general, melanoma spreads to the lymph nodes in the region of the primary cancer first.1,2,3,4

Lymph Node Mapping & Sentinel Lymph Node Biopsy

Lymphatic mapping and sentinel lymph node biopsy (SLNB) are used to assess the presence of melanoma cells in the regional lymph nodes in order to help determine which patients may require regional lymph node dissections (LNDs) and systemic adjuvant therapy following surgical removal of the cancer.

A SLNB is typically performed in patients with a primary melanoma greater than 1 mm and considered in patients with thin melanomas (< 1 mm) and adverse prognostic factors, such as vertical growth phase, Clark Level IV, regression, and ulceration.

During a SLNB a radioactive substance or blue dye is injected near the cancer. The substance or dye flows through the lymph tubes and nodes where cancer may have spread. The nodes with the radioactive substance or dye are then removed and a pathologist evaluates a sample of tissue from the removed node to check for cancer cells. If no cancer cells are found, it may not be necessary to remove more nodes.

SLNB should be performed prior to wide excision of the primary melanoma to ensure accurate lymphatic mapping. If metastatic melanoma is detected, a complete lymph node dissection (CLND) can be performed in a second procedure. Patients can be considered for CLND if the sentinel node(s) is microscopically or macroscopically positive.5

Complete Lymph Node Dissection

A complete lymph node dissection (CLND) may be performed in the neck, armpit or groin, depending on the site of the primary tumor and presence of palpable lymph nodes. Chronic side effects of removing lymph nodes vary, depending on the extent of disease, body habits of the patient, and inclusion of postoperative radiation to the site, but may include numbness, and swelling of the associated extremity, which is called lymphedema. Patients should discuss the risk of lymphedema and potential benefit of CLND with their doctor as there is some controversy regarding the role of CLND.5

Surgical Treatment of Stage I-II Melanoma

Stage I-II Melanoma – surgical removal with pathologically confirmed negative margins. Efforts been made to reduce the amount of normal skin removed without compromising the cure rate achieved with surgery. A melanoma greater than 1 millimeter appears to require a greater surgical margin to reduce the rate of recurrence at the site of origin. Most surgeons recommend a surgical margin of 2 centimeters (almost an inch) surrounding the entire cancer for melanomas greater than 1 mm. The need for skin grafting occurs in approximately 10% of patients.  Over 90% of patients with melanomas of less than 1 mm are cured following surgical removal of the melanoma.1,2,3,4

Stage III Melanoma – Standard surgical treatment for patients with stage III melanoma is removal of the primary cancer with up to 2-centimeter (over an inch) margins of the adjacent skin, depending on the thickness of the primary tumor, and removal of all of the regional lymph nodes. Outcomes of patients with stage III melanoma relate primarily to the extent of lymph node metastasis.1,2,3,4

Stage IV Melanoma – Surgery plays a role in the management of some patients with metastatic melanoma. Patients who have a limited number of lung metastases may benefit from surgical removal if they have favorable other prognostic features, such as a long period of time between diagnosis and recurrence. Surgery in some patients can eradicate disease that has incompletely responded to systemic therapy and some of these patients will survive cancer-free. Surgery can also relieve symptoms of obstruction and bleeding. Selected patients with metastatic melanoma to the gastrointestinal tract can experience prolonged survival following surgical removal of the melanoma.1,6

Recurrent Melanoma – A frequently asked question is whether a second surgery can also provide benefit to patients who have a recurrence, or return of the cancer, after already having one surgery for metastatic melanoma. Researchers reviewed the treatment outcomes for 211 patients with stage IV metastatic melanoma who were deemed clinically free of cancer after surgery. The melanoma recurred in 131 of these patients after an average of 8 months but ranging up to 7.5 years following initial treatment. After a second surgical removal of cancer from 1 to 3 sites to which the cancer had spread in the body, the average survival time after surgery was 18 months. At 5 years after surgery, 20% of patients in whom removal of all detectable cancer was complete were alive. The longer the interval between the initial treatment and the recurrence, the longer the survival time was after the repeat surgery. These findings show that a second surgery may benefit patients who have a recurrence of metastatic melanoma, provided that the surgical removal of all detectable cancer was complete. This is an important treatment option for patients with metastatic melanoma for whom other treatments are ineffective or for those who have a partial response to biologic therapies (or immunotherapies) or chemotherapy.6

The available data suggests that surgery plays a role in the management of some patients with metastatic melanoma. Patients who have a limited number of lung metastases may benefit from surgical removal if they have favorable other prognostic features, such as a long period of time between diagnosis and recurrence. Surgery in some patients can eradicate disease that has incompletely responded to chemotherapy and/or biological therapy and some of these patients will survive cancer-free for over 5 years. Surgery can also relieve symptoms of obstruction and bleeding. Selected patients with metastatic melanoma to the gastrointestinal tract can experience prolonged survival following surgical removal of the melanoma.6

References


1 Wagner JD, Gordon MS, Chuang TY, et al.: Current therapy of cutaneous melanoma. Plast Reconstr Surg 105 (5): 1774-99; quiz 1800-1, 2000.

2 Cohn-Cedermark G, Rutqvist LE, Andersson R, et al.: Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0 mm. Cancer 89 (7): 1495-501, 2000.

3 Balch CM, Soong SJ, Smith T, et al.: Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. Ann Surg Oncol 8 (2): 101-8, 2001.

4 Heaton KM, Sussman JJ, Gershenwald JE, et al.: Surgical margins and prognostic factors in patients with thick (>4mm) primary melanoma. Ann Surg Oncol 5 (4): 322-8, 1998.

5 Wong SL, Balch CM, Hurley P, et al.: Sentinel lymph node biopsy for melanoma: American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline. J Clin Oncol 30 (23): 2912-8, 2012.

6 Journal of Surgical Oncology, Vol 71, No 4, pp 209-213, 1999

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