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Treatment

How Is Melanoma Treated?

Several factors come into play when determining the best skin cancer treatment options. Factors include the type and stage of the cancer, the size of the tumor and where it is located, and the patient’s general health and medical history. The Melanoma Program at BMC provides coordinated, rapid access to treatment for all stages of melanoma.

The goal of treatment is to remove or destroy the cancer completely. Most melanomas are potentially curable if they are caught and treated early by removing them in their entirety. In these cases, no further treatment is necessary.

There are several treatment options available for patients with melanoma. These include:

Surgery

The most common treatment for melanoma is a surgical procedure called a wide local excision. During this procedure the melanoma is completely removed together with a margin of the surrounding healthy skin. How much healthy skin is removed depends on the depth of the growth. The margin is examined under a microscope for any remaining cancer cells. If no cancer cells are found, no further surgery is necessary. Many times, a wide local excision can cure early-stage melanoma.

Mohs Surgery

Mohs surgery removes less healthy tissue than excisional skin surgery. The Mohs surgeon cleans and numbs the area of skin to be operated on. Then he or she removes the visible portion of the tumor and a very small margin of healthy skin. The Mohs surgeon examines the tissue under a microscope for cancer cells. If part of the tumor is still present, the Mohs surgeon carefully maps out the area where the tumor remains and only removes additional skin in the area where the margin shows the tumor. The process is repeated until the tumor is completely removed. This type of surgery is typically reserved for melanomas on the face where it is beneficial to conserve as much healthy skin as possible during surgery.

Reconstructive Surgery for Melanoma

If the surgeon is required to remove a large piece of skin in order to remove the melanoma in its entirety, a reconstructive surgical procedure may be required to close up the skin. This may involve removing skin from another part of the body, such as the upper thigh, to cover the site where the skin cancer was removed. This is called a skin graft. Alternatively, the surgeon may rotate a portion of skin from a neighboring area to cover the site. This is called a skin flap.

Lymph Node Dissection

If the physician performs a sentinel lymph node biopsy, and cancer is found in the sentinel nodes, it is likely a lymph node dissection will be advised to remove the other lymph nodes in the area.

Treatment for Advanced Metastatic Disease

The term metastatic disease refers to disease that has spread from its original site to distant organs in the body. At this advanced stage of the disease, it is unlikely that surgery can be used to cure the cancer, although it may be used to improve a patient’s quality of life and help him or her live more comfortably.

Chemotherapy

Chemotherapy is a medication or combination of medications used to treat cancer. Chemotherapy can be given orally (as a pill) or injected intravenously (IV). When chemotherapy drugs enter the bloodstream, they destroy cancer cells. Chemotherapy is particularly useful for cancers that have metastasized, or spread. Chemotherapy attacks all quickly-dividing cells, regardless of whether they are cancerous which can cause a number of side effects, including hair loss, mouth sores, loss of appetite, nausea and vomiting, diarrhea, and low blood counts. Low blood counts can increase a patient’s risk of infection, bruising or bleeding, fatigue, and shortness of breath. The side effects of chemotherapy are generally temporary and often go away once treatment is completed. Chemotherapy regimens vary from patient to patient. They are generally repeated several times in cycles, with three to four weeks separating each cycle to allow damaged normal cells time to recover. After the first two or three sessions of chemotherapy, patients may have a CT or PET scan to see if the drug(s) is effective. If the drug(s) is not working, it may be switched out for a new drug(s).

Immunotherapy

For patients with advanced-stage melanoma, immunotherapy may improve the body’s natural immune response to cancer. Immunotherapy recruits the body’s own immune system and uses it to fight cancer all over the body, making it difficult for cancer cells to hide or develop defenses against it. Immunotherapy has the potential to keep working even after the patient has completed treatment.

Targeted Therapy

Targeted therapy is a type of cancer treatment that uses drugs or other substances to precisely identify and attack cancer cells. Usually, targeted therapy does less damage to normal cells than other cancer treatments.  

Drugs that target melanomas carrying BRAF gene mutations

BRAF is a human gene that makes a protein called B-Raf. When the BRAF gene mutates, it can lead to various types of cancer. BRAF mutations in melanomas cause the BRAF protein produced by the gene to be considerably more effective, which makes melanoma cells grow and divide more quickly and provides a survival advantage to the melanoma.

Drugs that target melanomas carrying C-KIT gene mutations

Mast/stem cell growth factor receptor (SCFR) is a protein in humans that is encoded by the KIT gene. Active mutations in this gene are associated with a small percentage of melanomas. C-KIT mutations also help the melanoma cells to grow and divide more quickly. The mutations are commonly found in melanomas that originate on the palms of the hands, the soles of the feet, or underneath the fingernails (called acral melanomas); inside the mouth or other mucosal (wet) areas; and on parts of the body chronically exposed to the sun.

Cytokines

Cytokines are proteins in the body that activate the immune system. Interferon and interleukin-2 (IL-2) are man-made versions of cytokines that are sometimes used to treat patients with advanced-stage melanoma. Interferon is injected intravenously or under the skin and can slow the growth of melanoma cells. It may be offered in addition to surgery for patients with melanoma that has spread to regional lymph nodes (Stage III disease) in order to help prevent further spread of the disease and help prolong survival.

Isolated Limb Perfusion

In rare cases, melanoma may spread as multiple deposits to the skin that are local to the original melanoma. Isolated limb perfusion is a localized form of chemotherapy used for treating these multiple metastatic melanomas that have spread to the skin on one arm or one leg. The treatment allows high doses of the chemo drug to be administered to the cancer site without endangering the rest of the body. It separates the blood flow of the limb with cancer from the rest of the body for a short period of time. During this period, high doses of the chemo drug are given into the limb.

Radiation Therapy

Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Radiation (also called radiotherapy, irradiation, or x-ray therapy) can be delivered internally through seed implantation or externally using linear accelerators (called external beam radiotherapy, or EBRT). Radiation may be used as a solitary treatment or with surgery and/or chemotherapy. The equipment used to deliver the radiation therapy is called a linear accelerator. The linear accelerator has a moveable arm, which enables the radiation to be focused on the part of your body where the cancer is located. Developments in EBRT equipment have enabled physicians to offer conformal radiation. With conformal radiation, computer software uses imaging scans to map the cancer three-dimensionally. The radiation beams are then shaped to conform, or match, the shape of the tumor.

Radiation works by breaking a portion of the DNA of a cancer cell, which prevents it from dividing and growing. Radiation therapy can be systemic, meaning it moves throughout your bloodstream. Systemic therapies are usually given as an injection into a blood vessel or are taken as a pill. Systemic treatments expose your entire body to cancer-fighting medication. Radiation therapy is typically given as a "local" treatment however, meaning it affects only the part of the body that needs therapy.

IMRT

Intensity-Modulated Radiation Therapy (IMRT) is a type of external beam radiation therapy that delivers beams of radiation customized to the shape and size of the tumor. Unlike 3D-CRT, which delivers the same amount of radiation to both the tumor and the surrounding tissue, the intensity of the beams can be adjusted (modulated) for IMRT, enabling the radiation oncologist to deliver different amounts of radiation to different areas of the tumor and the surrounding tissue. This allows the radiation oncologist to deliver the maximum amount of radiation to the tumor while sparing the surrounding healthy tissue.

CyberKnife

CyberKnife delivers highly targeted beams of radiation directly into tumors, in a pain-free, non-surgical way. Guided by specialized imaging software, we can track and continually adjust treatment at any point in the body, and without the need for the head frames and other equipment that are needed for some other forms of radiosurgery.

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