The type of treatment(s) your doctor recommends will depend on the stage and location of the melanoma and on your overall health. This section lists the options usually considered for each stage of melanoma.
Stage 0
Stage 0 melanomas have not grown deeper than the epidermis. They are usually treated by surgery to remove the melanoma and a margin of about 1/2 cm (about 1/5 inch) of normal skin. For melanomas in sensitive areas on the face, some doctors may use a cream containing the drug imiquimod (Aldara) if surgery might be disfiguring, although not all doctors agree with this use.
Stage I
Stage I melanoma is treated by surgery to remove the melanoma as well as a margin of normal skin. The amount of normal skin removed depends on the thickness of the melanoma. When the thickness is less than 1 mm, wide excision with 1 cm (2/5 inch) margins is recommended. For stage I melanomas between 1 mm and 2 mm thick, the tumor and 1 cm to 2 cm (4/5 inch) of surrounding skin are removed. No more than 2 cm of normal skin needs to be removed from all sides of the melanoma in stage I. Wider margins make healing more difficult and have not been found to help people live longer.
Some doctors may recommend a sentinel lymph node biopsy, especially if the melanoma is stage IB or has other characteristics that make it more likely to have spread to the lymph nodes. This is an option that you and your doctor should discuss.
If the sentinel lymph node biopsy is positive, a lymph node dissection (removal of all lymph nodes near the cancer) is often recommended, but it's not clear if it can improve survival.
Stage II
Wide excision is the standard treatment for stage II melanoma. If the melanoma is between 1 mm and 2 mm thick, a margin of 1 to 2 cm of normal skin will be removed as well. If the melanoma is thicker than 2 mm, about 2 cm of normal skin will be removed from around the tumor site.
Because the melanoma may have spread to lymph nodes near the melanoma, many doctors recommend a sentinel lymph node biopsy as well. This is an option that you and your doctor should discuss. If it is done and the sentinel node contains cancer, then a lymph node dissection (where all the lymph nodes in that area are surgically removed) will be done at a later date.
In certain cases (such as if the tumor is found to be more than 4 mm thick or if lymph nodes contain cancer), some doctors may advise adjuvant therapy (additional treatment) with interferon after surgery. Other drugs or perhaps vaccines may also be recommended as part of a clinical trial to try to reduce the chance the melanoma will come back.
Stage III
These cancers have reached the lymph nodes at the time of diagnosis. Surgical treatment for stage III melanoma usually requires lymph node dissection, along with wide excision of the primary tumor as in stage II. Adjuvant therapy with interferon may help some patients with stage III melanomas fight off recurrence longer.
If several melanomas are present, they should all be removed. If this is not possible, injections of bacille Calmette-Guerin (BCG) vaccine or interleukin-2 directly into the melanoma or applying the topical immunotherapy imiquimod are treatment options. For melanomas on an arm or leg, another possible option is to isolated limb perfusion (infusing the limb with a heated solution of chemotherapy). In some cases, radiation therapy may be given as an adjuvant to surgery in the area where lymph nodes were removed, especially if many of the nodes were found to contain cancer. Other possible treatments include chemotherapy, immunotherapy with cytokines, or both combined (biochemotherapy).
Newer treatments being tested in clinical trials may benefit some patients. Many patients with stage III melanoma may not be cured with current treatments, so they may want to think about taking part in a clinical trial.
Stage IV
Stage IV melanomas are very hard to cure, as they have already spread to distant lymph nodes or other areas of the body. Skin tumors or lymph node metastases causing symptoms can often be removed by surgery. Metastases in internal organs are sometimes removed, depending on how many are present, where they are located, and how likely they are to cause symptoms. Metastases that cause symptoms but cannot be removed surgically may be treated with radiation, immunotherapy, or chemotherapy.
Ipilimumab (Yervoy), a newer immunotherapy drug, has been shown to help some people with advanced melanoma live longer. It is just now coming into use, but some doctors may prefer it over other treatment options, such as chemotherapy or other types of immunotherapy.
The chemotherapy drugs in use at this time are of limited value in most people with stage IV melanoma. Dacarbazine (DTIC) and temozolomide (Temodar) are the ones most often used, either by themselves or combined with other drugs. Even when chemotherapy can shrink these cancers, the effect is often only temporary, with an average time of about 3 to 6 months before the cancer starts growing again. In rare cases they are effective for longer periods of time, however.
Immunotherapy using interferon or interleukin-2 can help a small number of patients with stage IV melanoma live longer. Higher doses of these drugs seem to be more effective, but they also have more severe side effects.
Some doctors recommend biochemotherapy: a combination of chemotherapy and either interleukin-2, interferon, or both. For example, some doctors use interferon with temozolomide. The 2 drugs combined cause more tumor shrinkage, which may make patients feel better, although the combination has not been shown to help patients live longer. Another drug combination uses low doses of interferon, interleukin-2, and temozolomide. Each seems to benefit some patients. Patients should carefully consider the possible benefits and side effects of any recommended treatment before starting.
Because stage IV melanoma is very hard to treat with current therapies, patients may want to think about taking part in a clinical trial. Clinical trials of new chemotherapy drugs, targeted drugs, new methods of immunotherapy such as vaccines, and combinations of different types of treatments may benefit some patients.
Even though the outlook for patients with stage IV melanoma tends to be poor overall, a small number of patients have responded very well to treatment or have survived for many years after diagnosis.
Recurrent melanoma
Treatment of melanoma that comes back after initial treatment depends on the stage of the original melanoma, the prior treatment, and the site of recurrence.
Melanoma may come back in the skin near the site of the original tumor. In general, these local (skin) recurrences are treated with surgery similar to that recommended for a primary melanoma. This may include a sentinel lymph node biopsy. Depending on the thickness and location of the tumor, other treatments may be considered, such as isolated limb perfusion chemotherapy, systemic chemotherapy, immunotherapy, radiation therapy, or tumor injection with BCG vaccine or interferon.
If nearby lymph nodes weren't removed during the initial treatment, the melanoma may come back in these nearby lymph nodes. This may appear as a swelling or tumor mass. Lymph node recurrence is treated by lymph node dissection, and may include adjuvant therapy such as interferon or radiation therapy.
The cancer can also come back in distant sites. Almost any organ can be affected. Most often, the melanoma will come back in the lung, bone, liver, or brain. Treatment for these recurrences is generally the same as for stage IV melanoma (see above). Melanomas that recur on an arm or leg may be treated with isolated limb perfusion chemotherapy.
Melanoma that comes back in the brain can be hard to treat. Single sites of recurrence can sometimes be removed by surgery. Most chemotherapy drugs aren't able to reach the brain, although temozolomide may be useful. Radiation therapy to the brain may help as well.
As with other stages of melanoma, patients with recurrent melanoma may want to think about taking part in a clinical trial.
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