Treatment

Surgery is usually the main treatment for melanoma. Often this means your primary care doctor or dermatologist removes suspicious tissue, and has it checked for cancer (biopsied), before you ever see a specialist at SCCA. If your tumor is removed very early, you may not need any other treatment. 

Melanoma-specialized surgeons

Our skin cancer surgeon team includes experts in surgical oncology, reconstruction and head and neck surgery. This team specializes in the treatment of melanoma and you can feel confident knowing that the surgeon who cares for you is best-suited for your specific diagnosis.

Wide excision

If your melanoma is localized, meaning it is just on your skin, you may need only a simple excision (removing it by cutting it out).

• Your doctor removes the tumor, along with a margin of normal-looking skin around the tumor. If the melanoma is thicker, your surgeon will have to cut wider margins. This is important so that the melanoma does not grow back at the original location later. 
• If the doctor did not take wide margins during your original biopsy, you may need another excision to remove more skin, including very small lymph vessels near the tumor where cancer cells might have spread.
• Depending on where your melanoma is and how large the margins need to be, you might need only a local numbing medicine or you might have general anesthesia.

SCCA melanoma surgeons and plastic surgeons coordinate to treat tumors in sensitive locations, like the face or hand.

Sentinel lymph node mapping and biopsy 

Thicker melanomas tend to spread to nearby lymph nodes, which need to be checked for cancer and possibly removed.

A tracer substance and a dye are injected near your tumor to find the lymph node or nodes where your cancer would spread first (sentinel nodes). Your surgeon removes only the nodes where the substance appears, and a pathologist checks the nodes for cancer cells. 

• If cancer is found, your surgeon removes the lymph nodes in that area.
• If cancer is not found, the rest of your lymph nodes will be left in place.

SCCA's David R. Byrd, MD, brought this technique, sentinel lymph node mapping and biopsy, to the Northwest in the 1990s. 

Preventing and treating lymphedema

Lymphedema is not common, but it is a possible complication. So after any lymph node surgery, we refer our patients to physical therapists (PTs) with expertise in preventing, detecting and managing lymphedema.

We have several resources for lymphedema treatment, including PTs who provide complete decongestive therapy and specialized reconstructive surgeons who offer advanced surgical treatments, such as lymph vessel reconnection surgery and lymph-node transfer.

Immunotherapies harness your body’s immune system to fight your cancer. One type is called an immune checkpoint inhibitor. These medicines block proteins that normally keep your immune cells in check so that they do not become overactive.

Immune checkpoint inhibitors used for melanoma include:

• Pembrolizumab (Keytruda) and nivolumab (Opdivo) — These block the protein PD-1, taking the brakes off your T cells and allowing these immune cells to attack your cancer.
• Ipilimumab (Yervoy) — This medicine targets a different protein, CTLA-4. It is sometimes used in combination with pembrolizumab or nivolumab.

Other types of immunotherapy for melanoma include:

• T-VEC therapy — This is a genetically engineered virus that is injected into melanoma tumors. The virus kills the melanoma cells and triggers an immune response that helps in the clearance of cancer cells. T-VEC is also known as talimogene laherparepvec or Imlygic.
• Imiquimod (Aldara) — This is a cream you rub on your skin.

Learn More About Immunotherapy

Targeted therapies work selectively against cancer cells, rather than affecting all fast-growing cells, like standard chemotherapy does). Many of them target a gene or protein responsible for allowing cancer to grow.

Target therapies for melanoma include:

• BRAF inhibitors — Medicines that block the BRAF protein, such as vemurafenib (Zelboraf), dabrafenib (Tafinlar) and encorafenib (Braftovi).
• MEK inhibitors — Medicines that block the MEK protein, such as trametinib (Mekinist), cobimetinib (Cotellic) and binimetinib (Mektovi)

Your SCCA team will talk with you about the specific immunotherapies or targeted therapies we recommend for you, how you’ll receive them, your treatment schedule and what to expect. We’ll also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout SCCA.

Radiation therapy is often given to people with melanoma:

• After surgery to decrease the odds of cancer returning
• To prevent or relieve symptoms if cancer has spread to multiple parts of the body, especially the brain or bones

Radiation therapy is painless and noninvasive (similar to getting a CT scan), and each treatment lasts only minutes. Different types of radiation therapy are used for different situations.  A few examples are described below.

Radiosurgery

Radiosurgery is an advanced form of highly focused, high-dose radiation therapy that can kill tumors in fewer treatments than conventional radiation treatment — typically one to five session rather than daily sessions for several weeks. It has a greater than 95 percent chance of killing small tumors.

There are many names for this type of treatment, including:

• Stereotactic body radiation therapy (SBRT)
• Stereotactic ablative body radiotherapy (SABR)
• CyberKnife or GammaKnife, brand names

Gamma Knife is specifically designed for treating tumors in the brain. It is not a knife or scalpel in the usual sense of the word (neither is CyberKnife), and it doesn’t require opening the skull. Instead, it uses precisely focused beams of radiation. Patients are usually treated in one session.

Intensity-modulated image-guided radiotherapy (IMRT/IGRT)

In this form of radiation treatment, doctors use computed tomography (CT) to scan your tumor and create beams of radiation that closely conform to the tumor's shape. The beams vary in shape and intensity to deliver a higher dose of radiation to the tumor and lower doses to nearby healthy tissue.

IMRT/IGRT is generally used after surgery if there’s a high risk the cancer might recur, such as if multiple lymph nodes in the neck are involved.

Neutron therapy

Neutron therapy is a strong form of radiotherapy used for advanced melanomas that cannot be removed by surgery. It also helps with pain and other symptoms when melanoma is widespread.