Cutaneous melanoma treatment options
Once diagnosed, there are a number of ways that melanoma is treated and managed. Beyond removing the tumor, there are additional actions your provider may take based on a number of factors to manage your disease.
Common treatment options
The primary treatment for all stages of melanoma.8 When surgery is not an option, the melanoma may be termed unresectable.i
- Wide excision. The invasiveness of the surgery depends on the thickness of the melanoma. Most melanomas are identified when less than 1.0mm thick, which means outpatient surgery is often the only treatment needed. The melanoma is removed along with some surrounding tissue (called a margin) to help ensure no cancer remains.1
- Lymphatic mapping and sentinel node biopsy. A dye and radioactive tracer are injected into the area of the melanoma to see if melanoma has spread to the lymph nodes, and, if so, which ones. Lymph nodes that take the dye and/or tracer are called sentinel lymph nodes. They are checked for melanoma to determine if the melanoma has spread. At this point a lymph node dissection may be discussed.
- Lymph node dissection. This is usually done after a positive sentinel lymph node. Historically, a complete lymph node dissection (CLND) to remove more lymph nodes was recommended. There is current debate about this because more recent data shows this does not affect how long a person with melanoma survives.1 If your doctor recommends this course of action, talk to them about your specific risks and benefits before taking action.1
Medications can be used to stop the growth of melanoma either by killing the melanoma cells or stopping them from dividing. When taken orally (by mouth) as pills or injected into a vein or muscle, the medications travel through the bloodstream and can reach cancer cells throughout the body. This means the medication can reach melanoma cells that have already spread.8
Chemotherapy medications tend to attack any quickly dividing cells, meaning the medications can also attack healthy cells. Chemotherapy is now more often used to treat advanced melanoma once other more effective treatments, such as immunotherapy and targeted therapies, have not worked.
Uses high-energy rays (eg, e-rays) or particles to kill melanoma cells or stop their growth.8,v This is usually done as external beam radiation therapy, where radiation given from outside the body is focused on the part of the body with cancer.5 It can also be used as palliative therapy for symptom relief and better quality of life.8
Works to treat skin cancer by enhancing and enlisting a patient’s immune system to fight melanoma.8 The medications used are called systemic drugs, which means they reach all parts of the body through the bloodstream.vi
Uses medications and other substances to identify and attack specific cancer cells. Usually causes less harm to normal cells than chemo or radiation.
Factors that determine outlook and treatment options
Melanoma diagnosed in its early [.text-color-brand-blue][#bottom-tooltip]stage[#bottom-tooltip][.text-color-brand-blue] with a small depth has higher survival rates.9 Coupled with surgical treatment at this early stage, progression is prevented in most cases.9
Tumor thickness or Breslow Depthviii
An important prognostic (outlook) factor. Helps predict if cancer will spread. The thicker the tumor, the higher likelihood it will spread and the poorer the prognosis.
Nodule melanoma has the lowest 5 and 10-year survival expectations than other subtypes of melanoma.9,S Superficial spreading or lentigo maligna has a better prognosis.9
If changes in the BRAFxii or KIT genes are present the prognosis is worse.8,1 NRAS changes happen in more than 20% of skin melanomasxiii and are associated with aggressive cancer and poor prognosis.
If melanoma spreads to nearby lymph nodes, the prognosis is poorer. Also, as the number of lymph nodes increase, the prognosis worsens. If the lymph nodes are enlarged and can be felt (doctors may say are palpable) or found during imaging test, there is a poorer prognosis than for only a small amount of melanoma (micrometastases) in the lymph nodes.10
Melanoma that has spread to other parts of the body, such as the lung, liver, or brain, has a poorer prognosis. If melanoma has spread to distant parts of the body, the 5-year-survival rate is about 30%.xiv Note that individual survival depends on a number of factors.
Mitotic rate, or how quickly the cells are dividing but also growing, is measured by the number of cells that divide (called mitosis) in a per millimeter squared (mm2) of melanoma tissue.10,13 The higher the number, the poorer the prognosis.10
When the tumor has broken the skin with an open wound. If this happens with the primary tumor, there is a less favorable prognosis. Ulceration increases the change the melanoma will spread and recur after treatment.10
For people with advance disease, survival may worsen as LDH rises,xv as poor response to treatment for patients whose melanoma has spread (metastatic disease).xvi
People with weakened immune systems are at a greater risk of dying from melanoma. Weakened immune systems can be due to health factors such as having an organ transplant, being infected with HIV17, cancer, or chemotherapy.xviii
Biological males tend to have a poorer prognosis than biological females. This may be explained by biological females more commonly developing melanoma in the extremities, while biological males more commonly develop melanoma in the trunk, head, or neck.10
Those younger than 35 years of age have a higher risk of melanoma spreading to nearby lymph nodes. However, overall, older people with melanoma with a poorer prognosis.10
Possible treatments for your melanoma stage
Note: For more information about specific procedures and medications that fall under each procedure,
the visit the Skin Cancer Foundation [.underline-move-left][.text-color-brand-dark-blue]here.[.text-color-brand-dark-blue][.underline-move-left]
| Stage 0 | Stage I (1) | Stage II (2) | Stage III (3) | Stage IV (4) | Stage IV, brain metastasis |
|---|---|---|---|---|---|
| Surgery | Surgery | Surgery | Surgery | Surgery | Radiation therapy: sterotactic surgery (SRS) |
| Sentinel lymph node biopsy (SLNB) | Mohs surgery | SLNB | Lymph node dissection | Radiation, for recurrence (skin or lymph nodes) or as palliative therapy | Cell |
| Mohs surgery | SLNB | Radiation | Immunotherapy, after surgery | Chemotherapy | Cell |
| Radiation therapy, if surgery cannot be done | Ultrasound | Immunotherapy, after surgery | Targeted therapy, for BRAF or C-KIT gene changes | Immunotherapy | Cell |
| Reflective confocal microscopy (RCM) | Immunotherapy, as adjuvant therapy to lower risk of recurrence | Targeted therapy, for a BRAF gene change | Radiation therapy | Targeted therapy | Cell |
| Cell | Targeted therapy, for a BRAF gene change | Prognostic gene expression profiling (lab test) | Chemotherapy | Vaccine therapy, when surgery cannot be performed | Cell |
| Cell | Prognostic gene expression profiling (lab test) | Ultrasound | Vaccine therapy, when surgery cannot be performed | Adoptive cell therapy | Cell |
| Cell | Vaccine therapy | Cell | Prognostic gene expression profiling (lab test) | May want to consider other clinical trials | Cell |
| Cell | Cell | Cell | Adoptive cell therapy | Cell | Cell |
| Cell | Cell | Cell | May want to consider other clinical trials | Cell | Cell |
Possible treatments if your melanoma recurs
| Local | In-transit | In nearby lymph nodes | Other body parts Note: Melanoma most often comes back in the lungs, bones, liver, or brain. |
|---|---|---|---|
| Surgery | Surgery | Lymph node dissection | Surgery |
| Sentinel lymph node biopsy (SLNB) | Immunotherapy | Radiation therapy | Radiation, for recurrence (skin or lymph nodes) or as palliative therapy |
| Additional options are person-specific, discuss with your cancer care team | SLNB | Radiation | Immunotherapy, after surgery |
| Cell | Chemotherapy or Isolated chemotherapy | Chemotherapy | Immunotherapy |
| Cell | Targeted therapy, for BRAF or C-KIT gene changes | Targeted therapy, for BRAF gene changes | Targeted therapy |
| Cell | Cell | Cell | Vaccine therapy, when surgery cannot be performed |
| Cell | Cell | Cell | Adoptive cell therapy |
| Cell | Cell | Cell | May want to consider other clinical trials |
| Cell | Cell | Cell | Radiation therapy: stereotactic surgery (SRS) |
