Surgical Excision of Primary Melanoma

Melanoma skin cancer ---> primary melanoma ---> melanoma treatment ---> melanoma surgery

The primary purpose of a melanoma excision is to prevent local recurrence due to persistent disease. For melanoma in situ, excision margins of 0.5 to 1 cm are indicated. For invasive melanoma, wide excision of the primary tumor, with margins generally ranging from 1 to 2 cm, is indicated for local control. The optimal margin width remains somewhat controversial. The historical approach of excising all primary melanomas with a 3- to 5-cm margin is extinct. At least five randomized controlled trials failed to demonstrate a difference in overall survival or local recurrence with narrow (1 to 2 cm) versus wide (3 to 5 cm) margins. Of note, one trial demonstrated an increased risk of locoregional recurrence with 1 versus 3 cm margins for melanoma more than 2 mm thick.25 Hopefully, results from future randomized prospective trials will demonstrate how narrow a margin is truly safe and efficacious. Until more definitive data become available, current consensus guidelines recommend margins of 1 cm for melanoma of 1 mm or less thick, 1 to 2 cm for 1 to 2 mm thick, and at least 2 cm for greater than 2 mm thick.

Treatment of Regional Metastatic Melanoma

Melanoma skin cancer ---> metastatic melanoma ---> regional metastasis---> melanoma treatment

Surgical excision of metastases to regional lymph nodes is potentially curative therapy. The 5-year survival rate for patients who undergo lymphadenectomy for clinically positive involved nodes (AJCC stage III) ranges from 25% to 70%. In addition, for those patients not cured by lymphadenectomy, resection can avoid potential pain associated with tumor enlargement, skin breakdown, and tumor necrosis. Only 10% of patients who first present with the diagnosis of melanoma have clinical evidence of nodal metastases; approximately 85% have localized disease; the remaining 5% have distant metastases. In less than 3% of patients, a diagnosis of melanoma is made in the absence of a definable primary lesion.28 When patients present with isolated nodal disease from an unknown primary site, the results of lymphadenectomy are similar to those for patients with known primary tumors. For patients with melanoma 1.0 mm thick or greater who present with clinically negative nodes, SLNB should be considered to determine whether therapeutic lymphadenectomy is indicated.

Surgery for Metastatic Melanoma

Melanoma skin cancer ---> metastatic melanoma ---> melanoma treatment ---> melanoma surgery

Surgical excision of recurrent melanoma can be effective for palliation in patients with isolated recurrences in the skin, central nervous system, lung, or gastrointestinal tract. Surgical excision of solitary brain metastases has been shown to provide improved palliation and quality of life compared with brain irradiation. Resection of isolated pulmonary metastases or of subcutaneous recurrences is usually not considered curative but can result in significantly prolonged disease-free survival. Gastrointestinal lesions causing obstruction or bleeding should be considered for resection or bypass to relieve these symptoms.

Chemotherapy for Melanoma

Melanoma skin cancer ---> melanoma treatment ---> melanoma chemotherapy

Melanoma is responsive to few chemotherapeutic drugs. The best single agents for treatment of melanoma are DTIC, the nitrosoureas, vinca alkaloids, and cisplatin, which have objective response rates in the range of 10% to 20%. Conventionally, objective responses have included complete disappearance of all known tumor sites (complete response) and reduction of more than half in all assessable tumor (partial response). Complete responses are rare and nearly always of brief duration (<6months).
Radiation Therapy
Melanoma can respond to radiation therapy. Radiation therapy is commonly used for palliation of bone pain secondary to metastatic disease or brain metastasis. The average survival after brain irradiation for melanoma is approximately 4 months.

Immunotherapy for Melanoma

Melanoma skin cancer ---> melanoma treatment ---> melanoma immunotherapy

The rapid evolution of recombinant DNA technology has resulted in the availability of cytokines, such as the interferons and interleukins, that can be administered to modulate a patient's immune response. These biologic agents have been used in immunotherapeutic trials for metastatic melanoma and demonstrate that an anti-tumor immune response can be generated in selected patients.
The most significant advance in melanoma immunotherapy has been associated with the use of interleukin-2 (IL-2). IL-2 is a cytokine secreted by antigen-activated helper T cells and was initially discovered because it was a T-cell growth factor. Subsequently, it was found to have many other immunologic effects, and it appears to have an important role in the enhancement of immune responses. It has been discovered that the in vivo administration of IL-2 in preclinical animal models resulted in dramatic tumor regression. In clinical studies, the administration of IL-2 resulted in a 15% to 20% response rate in patients with advanced melanoma. Approximately 5% of patients have a complete response which has been durable for prolonged periods. This latter result prompted the FDA to approve IL-2 for the treatment of metastatic melanoma.
IL-2 has been used in combination with other forms of immunotherapy. One example of this is the use of anti-tumor reactive T cells as reagents to treat tumor that is called adoptive immunotherapy. One source of these T cells is from the tumor itself, known as tumor-infiltrating lymphocytes. It has been reported that patients with advanced melanoma treated with the combination of tumor-infiltrating lymphocytes, IL-2, and chemotherapy can result in response rates between 35% and 50%.
Vaccines derived from melanoma tumor cells or extracts of tumor cells have been an emerging field in the treatment of melanoma. The discovery of unique melanoma tumor associated antigens has opened the door for the development of highly specific reagents for tumor vaccines.

Biochemotherapy for Melanoma

Melanoma skin cancer ---> melanoma treatment ---> melanoma biochemotherapy

Combinations of IL-2 and/or IFN- with chemotherapy, known as biochemotherapy, have shown significant improved response rates compared with chemotherapy alone or cytokines alone. As might be expected, these regimens are more toxic than the component therapies by themselves. One of the biochemotherapy regimens that has demonstrated a significant response rate (i.e., 64%, including 21% complete and 43% partial) with moderate toxicity is a combination of cisplatin, vinblastine, dacarbazine, IL-2, and IFN- . A follow-up randomized trial comparing this biochemotherapy regimen to chemotherapy alone indicated that the addition of the cytokines significantly enhanced the anti-tumor activity of the chemotherapy. Biochemotherapy should be considered in patients with advanced melanoma who are thought to be able to tolerate the toxicities of the therapy.

Gene Therapy for Melanoma

Melanoma skin cancer ---> melanoma treatment ---> melanoma gene therapy

The technical feasibility of transfer of genetic material into somatic cells has established a new approach to the treatment of malignancies. Many of the gene therapy strategies for cancer have focused on modulating the host immune response by altering tumor cells to be more immunogenic. A variety of preclinical studies have demonstrated that genetic engineering of tumor cells to secrete or express immunoregulatory peptides (i.e., cytokines, costimulatory molecules, or adhesion molecules) increases the host immune response to these tumors Several clinical studies are evaluating the efficacy of genetic modification of melanoma tumor cells to secrete cytokines that can be administered to patients as tumor vaccines.

Treating Melanoma

Skin cancer awareness ---> skin cancer videos ---> melanoma skin cancer ---> melanoma treatment


If left untreated, melanoma can be fatal. Luckily, there are a host of options that can prevent this.