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.
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 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.
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.
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).
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).
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).
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).
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.