A funny-looking mole on your leg, nose, back, or elsewhere on your body could be the first sign of melanoma, a type of cancer that forms in the cells that produce skin color.
The cancer requires prompt treatment to remove the primary lesion, and track the cancer’s possible spread to the lymph nodes and other parts of the body.
“In 15 to 20 percent of patients with a positive sentinel node,” says James Clune, MD, a Yale Medicine surgeon, “there are additional nodes with melanoma.”
How is localized melanoma treated?
There are a variety of ways to treat melanoma, depending on the location, size and stage of the cancer as well as if it has spread (metastasized) to other areas of the body.
When surgery is needed to remove the melanoma, doctors perform a wide local excision, removing not only the melanoma but also a margin of 1 to 2 centimeters of what appears to be normal skin around the cancer, to ensure that all of the cancer is removed.
“Reconstruction of the area is usually undertaken at the time of excision,” says Dr. Clune. “We can usually avoid skin grafts by using a ‘flap.’” This allows for the same thickness and type of tissue to fill area after excision. This provides a natural contour to the area of the excision and improved cosmetic outcome.
How is melanoma detected in the lymph nodes?
Every patch of skin on your body drains to specific lymph nodes. If there’s a melanoma cell that has broken off the primary lesion and entered the lymphatic system, it winds up in this specific draining node. For patients who are clinically node negative—this means a physical exam hasn’t detected enlarged lymph nodes—but have a melanoma that is at least 1 millimeter thick, doctors recommend a procedure called a sentinel lymph node biopsy in order to detect any microscopic spread of the cancer to the draining lymph nodes.
The procedure involves the injection of a radioactive substance around the melanoma site. This is used to track the lymphatic drainage to the sentinel node. Images are obtained through a lymphoscintigraphy which help to show drainage patterns for a melanoma site. When the sentinel node is located, doctors make a separate incision at its location and remove it so a pathologist can determine if there’s any melanoma present. The sentinel lymph node biopsy procedure usually takes 1 to 2 hours in the operating room, which is in addition to the time for the wide local excision.
What is the treatment for melanoma in the lymph nodes?
If the sentinel node is positive for melanoma, a second surgery to remove the rest of the lymph nodes in that draining nodal basin is recommended in select cases. “If lymph nodes are palpable (can be felt) during the initial physical exam of the patient prior to the melanoma excision, a biopsy will be done in the office using a fine needle aspiration. If the palpable lymph node contains melanoma cells, we will discuss with the patient a combination of surgical and immunotherapy< treatments,” says Dr. Clune.
The surgery to remove the remaining nodes is called a lymph node dissection. This is a more extensive procedure, requiring admission to the hospital and recovery as an in-patient.
What is recovery from melanoma surgery like?
Wide local excision is generally well-tolerated and is performed as an outpatient procedure with local anesthesia and sedation, as needed. A sentinel node biopsy is more complex but is still done as an outpatient procedure. In most cases, the wounds are closed with internal, absorbable sutures that are not visible on the skin. “A single outer suture is used above the absorbable sutures which will be removed in the office. This allows the patient to shower the day after surgery,” Dr. Clune says.
How is a melanoma on a sensitive area, such as the face, treated?
While the surgical principles are the same, cosmetic and functional considerations become more prominent. “Removing the cancer is the goal of the operation; however, we can reach a cosmetically appealing outcome by taking advantage of natural resting skin tension lines,” says Dr. Clune. For example, when excising a melanoma from the cheek, we will perform an incision similar to a facelift to hide the scar in the hairline. The same principle is followed for the ears, eyelids and lips, he explains. Yale Medicine has an exceptional group of plastic surgeons who have expertise in treating melanomas, particularly those located in sensitive areas, such as the face, he says.
What should a patient know about follow-up to melanoma surgery?
Surgery is just the first step of treatment. Every patient with melanoma is placed in a surveillance program – he or she will go in for examinations every three to six months for the first five years and then annually after that to make sure that there is no evidence of recurrence of the melanoma. Doctors not only check the primary site and the lymph nodes, but also to see if melanoma has spread to other areas of the body. In addition, patients should follow up with a dermatologist regularly to check the entire body for any new melanomas that may develop.
What are examples of difficult melanoma cases that Yale Medicine treats?
Yale Medicine doctors are experienced in complex cases and are ahead of the curve in treating patients with advanced late stage melanoma. In select cases, we offer surgery for distant metastatic melanoma (when the cancer has spread to other organs) to remove any remaining cancer in patients who have a good response to systemic therapy and to remove tumors that appear resistant to systemic therapy in patients who have tumors regressing in other areas of the body.
“When appropriate, we are aggressive in our resection of residual disease (remaining cancer cells) that may not be responding to systemic therapy. In some cases, the residual tumor can be removed and genetic sequencing can be undertaken to evaluate it for targetable mutations. In other cases, the lymphocytes are harvested from the tumor and grown in the lab and then used to fight the patients’ residual tumors. This is called adoptive cell therapy,” Dr. Clune says.
What makes Yale Medicine’s approach to treating melanoma unique?
Yale Medicine has a multidisciplinary approach to treatment – surgeons, pathologists, medical oncologists, and radiation oncologists will meet to discuss how to optimize care for the patient.
“Every week our melanoma tumor board meets to discuss our challenging cases. As a group, we are able to present the patients with the best options available. I always tell our new patients that I happen to be the one that is meeting them that day, but we have another 30 doctors, nurses and technicians that will be weighing in on their case to make sure we think of every option available for them and their particular situation,” Dr. Clune says.
Yale Medicine helps patients to understand their disease, provides patients with all the treatment options, and discusses the risks and benefits of each option so that patients can feel comfortable with their care and make informed decisions on their treatment.