MELANOMA
Melanoma is the most aggressive of all skin cancers. The incidence of melanoma has increased significantly in recent years and one to two percent of all individuals develop melanoma in their lifetimes. As the sixth most diagnosed malignancy, melanoma is also especially treacherous, as it tends to be diagnosed at younger ages, frequently affecting men and women in their 30’s and 40’s. Thankfully, most patients are diagnosed early and outcomes are quite good, with five-year survivals after treatment nearing 90%. This is mainly due to improved diagnostic techniques and increased awareness, as most patients are diagnosed before the melanoma has had a chance to spread outside of its primary site.
Surgery remains the mainstay in the successful management of melanoma patients, particularly those with localized and regional disease (lymph node involvement), and occasionally has a role in patients with metastatic disease (involvement of other organs).
The main goals of surgical therapy are:
- resection of the tumor, hopefully achieving a cure
- local and regional control of the disease, aiming to prevent return of the melanoma at the primary site and in other tissues and organs. This is important as such recurrences may not be amenable to further therapy
- accurate staging so that the patient can better understand his/her prognosis and be provided with further therapy, if deemed appropriate
- palliation in patients with more advanced disease, in hopes of preserving quality of life when cure is not possible.
Recent improvements in the surgical management of melanoma include:
- evidence-based guidelines for margins of excision of the lesion
- introduction of sentinel lymph node biopsy
- innovations in reconstruction techniques after resection. Other promising experimental efforts are currently underway.
From the standpoint of a patient who has melanoma, there are two main facets to surgical therapy to consider. First, in all cases, the area of the melanoma will have to be excised, or removed, with an adequate surrounding “margin” of normal skin and tissues. The extent of the excision depends on the thickness of the melanoma, as determined by a biopsy, and can sometimes be significant, potentially leaving a scar several inches in length. Depending on the location of the melanoma, closure of the tissues may occasionally require skin grafting.
Secondly, screening of the regional lymph nodes, or nodes draining the region of the melanoma, may also be needed, again based on the “thickness” of the melanoma. This procedure, called sentinel lymph node biopsy, is relatively new and aims to evaluate the first few lymph nodes draining the area of the tumor. An x-ray of your lymph node system is performed in radiology after injection of radioactive dye to provide a “road map” delineating the location of the “sentinel lymph node(s)”. Thereafter, in the operating room, the surgeon also injects pigmented dye and uses special probes to pinpoint the location of the lymph node(s) to be removed. Only the desired lymph nodes are biopsied, limiting the size of the incision and the potential complications associated with the procedure.
In general, both the removal of the melanoma and the sentinel lymph node biopsy are done as part of one procedure in the operating room. A pathologist then evaluates the specimen thoroughly to ensure that the melanoma was completely removed and to evaluate the lymph nodes. If there is evidence of inadequate removal of the melanoma or if there is cancer present in the lymph nodes, a return to the operating room will likely be necessary.
This represents, in a nut shell, the basic surgical treatment of melanoma. We realize that it is impossible to answer all questions you may have on this topic in a few paragraphs. As such, we strongly encourage you to bring a list of questions with you when you visit us.
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