Early and Advanced Melanoma Treatment
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How are melanomas classified?
Melanoma thickness is categorized as thin (1 mm or less), intermediate (1mm -4 mm) and thick (over 4mm). For those with thin melanomas, most patients are treated with wide excision only, meaning removal of the primary tumor with a rim of healthy tissue around it.
For a select few with thin melanomas (0.75mm-1mm) a sentinel node biopsy may be an option. The classic indication for sentinel node biopsy is a Breslow thickness (method used to determine the stage of cancer) of 1 mm and above. More and more studies demonstrate benefits to sentinel node biopsy in patients with thick melanomas as well.
What is the sentinel lymph node?
Melanoma cells travel via the lymphatic system at least in the initial stage of the process. Your lymphatic system consists of lymphatic channels and their junction points, called lymph nodes. A sentinel lymph node is the most likely regional lymph node to contain the melanoma if the cancerous cells have already traveled away from the primary tumor site. Of course, this varies based on the tumor’s primary location. Since the pattern of melanoma cells is predictable at this point, this is the basis for sentinel lymph node biopsy.
What is a sentinel lymph node biopsy?
Sentinel lymph node biopsy is a minimally invasive procedure that provides the most accurate information on the status of regional lymph nodes in those with invasive melanoma. On average, 2-3 lymph nodes are removed from the regional nodal basin from a one-inch skin incision. The biopsy is performed at the time of the wide excision of the primary tumor. Prior to surgery, another radiographic study called lymphoscintigram is done to aid the surgeon in identifying the true sentinel lymph node. Most surgeons use blue dye in addition to the lymphoscintigram to further enhance sentinel lymph node identification rates.
Once we remove the sentinel nodes, they undergo a specialized protocol by Stamford Health's dermatopathologist to identify potential tumor cells or larger melanoma deposits within the nodal tissue. Patients who test positive undergo further staging with MR, CT and PET scans as indicated as well as a medical oncology consultation with a specialist.
Treatment of advanced stage melanoma
Some patients with melanoma present with more advanced disease when a larger number of tumor cells have already traveled to regional nodes or distant sites. A non-surgical or surgical biopsy will determine the advancement of the disease. Our interventional radiologists perform most of these procedures.
Those with melanomas limited to just regional lymph nodes are still candidates for surgical interventions called regional lymph node dissections. Those who have other sites of metastatic melanomas can still undergo surgery based on the number and location of tumor sites. Patients with single or limited sites of melanoma benefit the most from surgery.
Most patients with sentinel node positive or stage 4 melanomas will be receiving adjuvant systemic therapy under the guidance of our dedicated medical oncologist. External beam radiation is also being used in well selected cases. Certain patients will receive systemic therapy prior to a surgical intervention. These are complex decisions made during discussions between patient and providers as well as tumor boards. For selected patients, clinical studies are also available. For those with stage 4 melanoma, symptoms like pain, bleeding and obstruction can be targeted to improve overall quality of life.
Melanoma surgeries our surgical oncologists perform
- Wide excisions with or without sentinel node biopsy
- Complete node dissections
- Skin grafting
- Resection of stage 4 melanomas in selected patients (lung, GI tract, skin)
Expectations for melanoma surgery
Before melanoma surgery, your surgical oncologist will discuss both the benefits and the risks. Most wide excisions and sentinel node biopsies are outpatient procedures done under some form of anesthesia. Resection of recurrent melanomas on the skin surface or in a regional nodal basin can be done on an outpatient or inpatient setting depending on the extent of surgery and your general condition. Sentinel node biopsies are done from small scars. Most primary tumor site resections result in a skin defect to achieve negative surgical margins. As a result, these wounds are under tension and closed in several layers. The top layer in the skin is usually nylon that needs to be removed weeks after surgery. All wounds are covered with waterproof dressings so you can shower right after surgery.
Expectations for after melanoma surgery
You may have some pain or soreness after surgery which you can control by medications your surgical oncologist will prescribe to you. If you have a complete node dissection, your drain insertion will require some simple care after leaving the hospital. If you have a skin graft, you'll get specific instructions on wound care. Range of motion exercises are a very important part of your recovery and specific instructions will be given after surgery or during your first follow-up visit.