The treatment for melanoma depends on the general health of the person and the stage of the disease. Melanoma stage depends on the thickness of the melanoma (and whether the melanoma is ulcerated or not) and whether the melanoma has spread to the regional nodes. Most patients with melanoma are treated with a wide excision and sentinel lymph node Biopsy. If the nodes are without melanoma, that is all the treatment needed and the patient will be put in our follow up program.
Melanoma Surgery and Sentinel Lymph Node Biopsy
Surgical treatment of the skin melanoma involves a wide excision (WE) of the skin surrounding the biopsy site. The margin around the biopsy varies from 0.5 – 2 cm in all directions around the biopsy. Since circles do not close to a straight line, a flap is constructed to allow for skin closure (typically into a straight line). In addition to the WE, a lymph node biopsy performed to remove the lymph nodes that drain that patch of skin. These nodes are called sentinel nodes and will be carefully examined under the microscope by the pathologist. The procedure involves injecting a small amount of radioactive dye (or occasionally blue dye) around the melanoma. The radioactive dye drains like the melanoma could drain and makes the sentinel nodes slightly radioactive. This is done the morning of surgery of the afternoon before. In the operating room, a small hand-held Geiger counter is used to find the radioactive lymph nodes and they are removed. The amount of radiation is less than getting a chest x-ray. The entire procedure is usually performed as an outpatient procedure.
Adjuvant (additional) Therapy
If the sentinel node harbors melanoma, the patient now has stage 3 melanoma and needs additional therapy to increase their chances of cure. There is rarely a need to remove all the lymph nodes in the area nor is there any need for routine radiation. The additional therapy involves either targeted therapy for patients whose melanoma has a specific mutation called BRAF or NRAS or immunotherapy.
BRAF/NRAS Targeted Therapy
There are now several oral medications that target the BRAF/NRAS system for melanomas harboring these mutations. Since they are targeted to those mutations, the side effects are much less than other chemotherapy drugs. Treatment is typically given for one year.
Currently, most stage 3 (and stage 4) patients receive immunotherapy after surgery if their sentinel nodes harbor melanoma. This involves drugs called checkpoint inhibitors which will ‘rev up’ the patient’s immune system to identify and kill melanoma cells anywhere in the body. The 2 broad categories are PD1/PDL1 inhibitors and CTLA-4 inhibitor. The PD1 inhibitors currently approved (with more on the way) are nivolumab (Opdivo) and pembrolizumab (Keytruda). They are usually given every 3 weeks for 6+ months. The CTLA-4 inhibitor is ipilimumab and is given monthly for 1-3 years.