Treatment options

There are many treatment options available depending on the stage of melanoma.
The most common treatment for localised (early stage) melanoma is surgery, and in the majority of cases, this is the only treatment required.

More advanced cases of melanoma where the cancer has spread to other parts of the body may require treatments such as chemotherapy, radiotherapy, immunotherapy or targeted molecular therapy.

Your doctor will recommend the best treatment option based on how far the melanoma has progressed together with other factors such as your age and general health.

Surgery

Surgery is the most common treatment for melanoma, however its purpose varies depending on how far the cancer has progressed.

For early stage melanoma, a biopsy may be all that’s required i.e. removal of the tumour by excising it . A wide local excision may also be required, where the skin surrounding the melanoma is removed to reduce the risk of recurrence of the melanoma at that site. This may be effective by  preventing  adjacent melanocytes from  evolving into melanoma.

For later stage melanoma, surgery is used as a diagnostic tool to assess how far the cancer has spread. Patients may require more invasive surgery to remove lymph nodes.

Biopsy

A biopsy is a relatively simple procedure that involves the removal of a mole or suspected melanoma. A local anaesthetic is given to numb the area around the melanoma and the wound is usually closed with a few stitches. The excised tissue is then sent to a pathologist who assesses the tumour progression, it’s depth and risk of spreading.

Wide Local Excision

Even though an initial biopsy often removes all the recognisable melanoma, wide local re-excision is usually recommended to further reduce the risk of the melanoma recurring.

This involves removing the melanocytes adjacent to the melanoma that may be susceptible to turning into melanoma themselves.

A wide local excision usually removes a 1-2cm margin around the site of the original melanoma, however this amount varies depending on the depth of the tumour and how far it has spread into the lower layers of the skin. Most Wide Local Excisions are closed with stitches, however larger excisions may require skin grafts or skin flaps.

Wide Local Excision

A. This is the melanoma that needs to be removed.
B. An area around the melanoma, a margin, helps ensure that all cancer cells are removed. The width of the margin depends on the thickness of the melanoma.

Sentinel Node Biopsy

This type of surgery is performed  when a higher risk primary melanoma has been diagnosed after and initial biopsy. It determines whether the melanoma has spread to the surrounding lymph nodes. Knowing whether the melanoma has spread to lymph nodes also provides a estimate of the risk of potential spread to other parts of the body.

The process of Sentinel node biopsy starts with lymphatic mapping. Dye is injected into the skin around a melanoma where it passes into the lymphatic system. Lymphatic mapping identifies the first “downstream” node - the sentinel node. 

The sentinel node is removed and sent to a pathologist who assesses whether malignant cells are present. Malignant cells are an indicator of the risk that melanoma may have spread to other parts of the body. CT and/or MRI scans may be appropriate.

Lymph Node Dissection

Melanoma that has spread to sentinel nodes in the regional node groups in the armpit, neck or groin may linger before spreading to organs. In these cases melanoma can sometimes be cured with surgery called a regional lymph node clearance that removes all the lymph nodes in the invaded area. There are three types of regional lymph node clearance: axillary (armpit), neck and groin.

Axillary Dissection (armpit)

An axillary lymph node clearance  removes all the lymph nodes and possible tumour-containing tissue from the armpit region.

It’s performed under a general anaesthetic so you will not be awake during the procedure. Once you are asleep local anaesthetic is injected into the area of surgery to help ease discomfort after the operation.

There are several important arteries, veins and nerves that run through the axilla. The operation is planned and performed to remove all the lymph nodes and malignant tissue without causing damage to these important structures.

Minor underarm nerves – intercostobrachial nerves – are removed as part of the operation. This causes numbness in the armpit and down the inside of the arm that is often permanent.

The operation generally takes 60 to 90 minutes. Any large wound produces fluid – like in a blister – so a surgical drain is inserted to collect the fluid while the wound heals. The drain is a soft, flexible silicone tube that is connected to a suction bottle and will be checked frequently by the nursing staff. The drain will be in place for several days up to several weeks after the operation.

Lymphatic Regions

A. Cerivical Nodes (neck)
B. Axillary Nodes (armpit)
C. Inguinal Nodes (groin)

The tissue that’s removed out is sent to a pathologist whose analysis guides the next stage of treatment.

To learn more about axillary lymph node clearance download a detailed information brochure (PDF).

Groin Dissection

Melanoma that has spread to the groin area requires surgery in the form of either an inguinal lymph node clearance (removal of nodes from the groin) or ilio-inguinal lymph node clearance (removal of nodes from both the groin and pelvis).Both these procedures are significant surgery that require a general anaesthetic. 

A surgical drain is inserted as the wound is being closed to remove excess fluid that may accumulate in the days after this operation. Thehe drain is removedremoved after the risk of a lymph collection in the wound has been minimised. 

Recovery from this procedure requires  5 - 7 days of bed rest after your operation. Because this is significant surgery you  may have some discomfort. Medication is provided to control any pain.

Ilio-inguinal node clearance is a somewhat more extensive lymph node removal that includes pelvic lymph nodes

To learn more about inguinal and ilio-inguinal node clearance download a detailed information brochure (PDF).

Neck Dissection

Known as a cervical lymph node clearance, this type of surgery removes affected lymph nodes in the neck region. The lymph nodes in the neck run from the ear down either side of the neck to the clavicle and also under the jaw.

The extent of the node clearance will be determined by the location of the original melanoma and how far it’s metastasised. The neck is a complex anatomy part of the body. Some structures surrounding the lymph nodes may also need to be removed to adequately remove all the tumour.

A few minor skin nerves need to be removed for the surgeon to have access to the lymph nodes. This results in numbness on that side of the neck, ears and upper chest and back that is often permanent.

This is a significant surgery and will require a general anaesthetic. Local anaesthetic is also injected to the site of the surgery to help ease discomfort after the operation.

Some cases might require a parotidectomy to clear malignant tissue from the parotid gland, a salivary gland just in front of each ear. There is also an important facial nerve that runs through the parotid gland. When the nerve can be spared it will usually function normally soon after surgery. But if melanoma involves the facial nerve directly it might have to be partially or totally divided. This results in lack of movement in some or all of the muscles on that side of the face.

As the wound is closed two soft surgical drains are inserted to drain away the fluid that’s produced by large wounds as they heal. Once the fluid subsides the drains are removed.

The tissue that’s cut out is sent to a pathologist whose analysis guides the next stage of treatment.

To learn more about cervical node clearance download a detailed information brochure (PDF).

Cervical Lymph Nodes
Approximate locations of neck lymph nodes represented in green.

Lymphoedema

A common side effect of lymph node dissection surgery is lymphoedema. This is the swelling of limbs caused by blockages in the lymphatic drainage system post surgery. Because the lymph fluid cannot drain as readily as it used to the limb swells, feels tight and may be difficult to use as it once was.

The frequency and severity of lymphoedema depends on a few factors, like how extensive your surgery (or radiotherapy) was, your body weight before treatment and whether you have a natural resistance to lymphedema.

Early treatment is important to manage and reverse the swelling. If left untreated the fluid can be more difficult to move, making the limb feel hard and thick.

Minimal cases of lymphoedema can usually be controlled with compression stockings or sleeves. More severe swelling can require physical therapy, like massage and exercise, to get the fluid moving, good skin care to keep the tight skin healthy and compression techniques to manage swelling.

It’s important to note that swelling that appears shortly after surgery is usually not lymphoedema, but instead the body’s natural inflammatory reaction to injury.

To learn more about lymphoedema download a detailed information brochure (PDF).

Lymphodema
Enlarged left lower leg and ankle indicative lymphoedema.

Reconstructive Surgery

One of the side effects associated with some melanoma surgery is significant scarring of the skin or even altered bodily function e.g. damaged nerves or loss of movement.

That’s why Melanoma Institute Australia offers reconstructive surgery to ensure our patients look and feel their best post treatment. Our specialist plastic surgeons are highly skilled in performing reconstructive surgery techniques, including skin grafts and flap repairs.

Skin grafts  – this technique is used when the Wide Local Excision leaves a wound area too big for stitches. Skin is taken from another part of the body (usually the thigh or buttocks), and used to cover the wound. Split skin grafts only use the top layers of the skin for less invasive results, whereas full thickness skin grafts use the tissue under the skin as well for a more complete, aesthetically pleasing result e.g. on the face.

Flap repairs – also known as rotation, transposition or advancement flaps, flap repairs involve adjacent skin being lifted and moved over the wound without being fully cut away from the body e.g. skin from the forehead used to repair a wound on the nose. The advantage of this procedure is the match in colour and texture of the skin, plus the wound heals more quickly thanks to the blood supply remaining intact.

What is radiation therapy?

After surgery your doctors may recommend radiation therapy to help improve your outcome.

Radiation therapy uses x-rays to kill cancer cells by damaging their DNA. Normal cells can repair damage to their DNA, but cancer cells  are less able to do this  and therefore die. The dead cancer cells are then broken down and eliminated by the body’s natural processes. 

Since radiation therapy damages normal cells as well as cancer cells, treatment must be carefully planned to allow the normal cells to repair themselves and minimise side effects.

The total dose of radiation and the number of treatments you need will depend on the size and location of your melanoma, your general health and other medical treatments you’re receiving.

The radiation used for cancer treatment can come from a machine outside your body or it might come from radioactive material placed in your body near the cancer cells.

Types of radiation therapy

These are three of types of radiation therapy used at Melanoma Institute Australia:

Stereotactic Radiosurgery/Radiotherapy

  • Uses an extremely accurate beam to deliver a high-dose of radiation to a small area of cancer without excess damage to surrounding normal tissue.
  • Can only be used to treat small cancers with well-defined edges.
  • Most commonly used in the treatment of cancer in the brain, liver and lungs.
  • Requires an immobilisation device to ensure treatment is delivered accurately.

Volumetric Modulated Arc Therapy

  • Uses three-dimensional volume imaging to maximise the dose the tumour receives while minimising exposure of the surrounding healthy tissue.
  • Takes much less time to deliver treatment.
  • A new radiotherapy method first performed in the Sydney at Mater Hospital, North Sydney.

Brachytherapy

  • Uses radioactive sources placed inside the body.
  • Requires an operation with anaesthesia.
  • May require a hospital stay.
  • Can deliver treatment to otherwise inaccessible areas.

Side Effects

  • Temporary or permanent loss of hair in the area being treated
  • Skin irritation
  • Temporary change in skin colour in the treated area
  • tiredness

Other side effects might be experienced depending on the area of the body treated. Your radiation oncologist will discuss these with you.

External radiation therapy does not cause your body to become radioactive. There’s no need to avoid being with other people because you are undergoing treatment. Even hugging, kissing or having sex create no risk of radiation exposure.

What are targeted therapies?

A targeted therapy is a drug that blocks the growth of cancer by interfering with specific molecules involved in tumour growth. This is different to non-specific treatments like chemotherapy that simply aim to kill rapidly dividing cells. 

This new generation of drugs has resulted in a big improvement in melanoma treatment for patients with the spread of the disease to other organs.

Researchers have identified some of the key genetic mutations that drive the growth of melanoma in patients. These discoveries are opening new avenues for treatment options using drugs that selectively block activity of these driving mutations, known as ‘targeted therapy’.

The genetic mutations involved in melanoma development that have been discovered so far have interesting names. They include:

  • BRAF (“BEE-raff”)
  • NRAS (“EN-rass")
  • C-KIT (“SEE-kit”)

More mutations are continuing to be discovered.

How do they work?

Messages are sent inside the cell by a series of molecules that tell the cell how to grow and divide. This process is called a ‘signalling pathway.’

Mutations, or abnormalities, in these signalling pathways can cause cells to rapidly divide and replicate out of control, resulting in tumour formation. The mutated signalling pathways in melanoma cells are the targets for therapy.

Not all melanomas have the same driving mutations. By identifying which molecules are mutated in different forms of the disease patients can be categorised and treated based on their specific mutation. Identifying all of these molecular mutations is what molecular oncology researchers around the world are working on.

Who are they for?

Not every patient has mutations in their melanoma that are affected by the drugs that are currently available or in trial. Part of treatment at Melanoma Institute Australia includes being tested for these mutations and pairing you with the best option for your situation.

Some of the drugs are still under investigation in clinical trial testing. That means that even though you might have the mutation that correlates to a drug, the trial’s inclusion criteria could still prevent you from qualifying. Take a look at the Clinical Trials section of this site to learn more about how trials work.

Side Effects

Common side effects of targeted therapies include:

  • Development of squamous cell carcinomas.
  • Appearance of minor skin disruptions similar to acne or warts.
  • Hair follicle changes e.g. hair loss, curly hair, grey hair etc.
  • Sensitivity to light.

What is immunotherapy?

Immunotherapy are treatments that work to trigger the body’s own immune system to fight melanoma.

This idea was inspired by the fact melanoma sometimes shows signs of regression (getting smaller) on its own without treatment. This is attributed to the body’s immune system attempting to fight the cancer cells. Sometimes primary melanomas may even disappear from the skin entirely, but not before tumour cells have spread to other parts of the body. These distant tumour are called occult melanoma or melanoma with unknown primary tumour.

Researchers have used knowledge that the body can sometimes mount an attack on melanoma with two general strategies – activating an immune response with checkpoint inhibitors or “training” an immune response with vaccines.

How do immunotherapies work?

Checkpoint Inhibitor Approach

Cancer grows in our bodies by tricking the immune system into ignoring it. Checkpoint inhibitor drugs  stimulate the immune system to recognise and destroy melanoma cells.

Checkpoint inhibitor drugs are showing exciting promise for the future outcomes of melanoma patients. Several drugs are in different phases of development. The immunotherapy drugs getting the most attention for melanoma patients are nivolumab and Ipilimumab.

Right now MIA is leading a clinical trial using nivolumab and Ipilimumab together to test their effectiveness in patients with metastatic, stage 4 brain metastases.

Vaccine Approach

This approach is based on the concept of using immunisation to treat disease rather than prevent it as it is used in childhood vaccines. The idea is to prepare an antigen made from melanoma tumour cells that enables the immune system to identify and destroy the disease more readily.

Though vaccines for other diseases are highly effective, melanoma vaccines have so far not been found to be consistently effective, although research continues.

Side Effects

Reported side effects include:

  • fatigue
  • joint pain
  • inflammation of major organs including intestines, lungs and liver

There may be other side effects that your doctor will discuss with you.

Chemotherapy

Conventional chemotherapy treatment using anti-cancer drugs has had a major role in many cancers including breast, colon and lung cancer. The goal is to slow the growth of tumour cells that have spread to internal organs. Chemotherapy also sometimes helps relieve symptoms caused by the growth of the cancer. Generally chemotherapy drugs have not been particularly effective in treating melanoma.

During the last few years new targeted therapies that are focused on the genes of melanoma cells have been found to be a much more effective treatment in recent years chemotherapy has become a less-considered option. But in some cases chemotherapy may be the best recommended option.

Side effects

Chemotherapy can cause the following side effects:

  • nausea
  • vomiting
  • depression
  • tiredness
  • hair loss

These side effects are temporary and steps can be taken to prevent or reduce them.