Treatment of melanoma skin cancer, by stage
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 melanomas have not grown deeper than the top layer of the skin (the epidermis). They are usually treated by surgery (wide excision) to remove the melanoma and a margin of about 1/2 cm (about 1/5 of an inch) of normal skin around it. If the edges of the removed sample are found to contain cancer cells, a repeat excision of the area may be done. Some doctors may consider the use of imiquimod cream (Zyclara) or radiation therapy, although not all doctors agree with this.
For melanomas in sensitive areas on the face, some doctors may use Mohs surgery or even imiquimod cream if surgery might be disfiguring, although not all doctors agree with these uses.
Stage I melanoma is treated by wide excision (surgery to remove the melanoma as well as a margin of normal skin around it). The amount of normal skin removed depends on the thickness and location of the melanoma, but no more than 2 cm (4/5 inch) of normal skin needs to be removed from all sides of the melanoma. 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 cancer cells are found on the sentinel lymph node biopsy, 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. Some doctors may recommend adjuvant (additional) treatment with interferon after the lymph node surgery as well.
Wide excision (surgery to remove the melanoma and a margin of normal skin around it) is the standard treatment for stage II melanoma. The amount of normal skin removed depends on the thickness and location of the melanoma, but it should be no more than 2 cm (4/5 inch) around all sides of the melanoma.
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 cells, then a lymph node dissection (where all the lymph nodes in that area are surgically removed) will probably be done at a later date.
For some patients (such as those with lymph nodes containing cancer), doctors may advise treatment with interferon after surgery (adjuvant therapy). 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.
These cancers have already reached the lymph nodes when the melanoma is first diagnosed. Surgical treatment for stage III melanoma usually requires wide excision of the primary tumor as in earlier stages, along with lymph node dissection. Adjuvant therapy with interferon may help keep some melanomas from coming back longer. 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. Another option is to give radiation therapy to the areas where the lymph nodes were removed, especially if many of the nodes contain cancer.
If melanomas are found in nearby lymph vessels in or just under the skin (known as in-transit tumors), they should all be removed, if possible. Other options include injections of Bacille Calmette-Guerin (BCG) vaccine, interferon, or interleukin-2 (IL-2) directly into the melanoma; radiation therapy; or applying imiquimod cream. For melanomas on an arm or leg, another option might be isolated limb perfusion (infusing the limb with a heated solution of chemotherapy). Other possible treatments might include targeted therapy, immunotherapy, chemotherapy, or a combination of immunotherapy and chemotherapy (biochemotherapy).
Some patients might benefit from newer treatments being tested in clinical trials. Many patients with stage III melanoma might not be cured with current treatments, so they may want to think about taking part in a clinical trial.
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 enlarged lymph nodes causing symptoms can often be removed by surgery or treated with radiation therapy. Metastases in internal organs are sometimes removed, depending on how many there are, where they are, and how likely they are to cause symptoms. Metastases that cause symptoms but cannot be removed may be treated with radiation, immunotherapy, targeted therapy, or chemotherapy.
The treatment of widespread melanomas has changed in recent years as newer forms of immunotherapy (known as immune checkpoint inhibitors) and targeted drugs have been shown to be more effective than chemotherapy.
Ipilimumab (Yervoy), a newer immunotherapy drug, has been shown to help some people with advanced melanoma live longer. It can sometimes have severe side effects, so patients who get it need to be watched closely. Other new immunotherapy drugs, including pembrolizumab (Keytruda) or nivolumab (Opdivo), might also be options. These drugs seem to be more likely to shrink tumors than ipilimumab and are less likely to cause severe side effects. Other types of immunotherapy might also help, but these are only available through clinical trials at this time.
In about half of all melanomas, the cancer cells have changes in the BRAF gene. If this gene change is found, treatment with newer targeted drugs such as vemurafenib (Zelboraf), dabrafenib (Tafinlar), trametinib (Mekinist), and cobimetinib (Cotellic) might be helpful. They might be tried before or after the newer immunotherapy drugs, but they are not used at the same time. Like ipilimumab, these drugs can help some people live longer, although they have not been shown to cure these melanomas.
A small portion of melanomas have changes in the C-KIT gene. These melanomas might be helped by targeted drugs such as imatinib (Gleevec) and nilotinib (Tasigna), although, again, these drugs are not known to cure these melanomas.
Immunotherapy using interferon or interleukin-2 can help a small number of people with stage IV melanoma live longer. Higher doses of these drugs seem to be more effective, but they can also have more severe side effects, so they might need to be given in the hospital.
Chemotherapy can help some people with stage IV melanoma, but other treatments are usually tried first. Dacarbazine (DTIC) and temozolomide (Temodar) are the chemo drugs used most often, either by themselves or combined with other drugs. Even when chemotherapy shrinks these cancers, the effect often lasts for an average of several months before the cancer starts growing again. In rare cases they work for longer periods of time.
Some doctors may 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 might 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. It’s important to carefully consider the possible benefits and side effects of any recommended treatment before starting it.
Because stage IV melanoma is hard to treat with current therapies, patients may want to think about taking part in a clinical trial. Many studies are now looking at new targeted drugs, immunotherapies, chemotherapy drugs, and combinations of different types of treatments.
Even though the outlook for people with stage IV melanoma tends to be poor overall, a small number of people respond very well to treatment and survive for many years after diagnosis.
Treatment of melanoma that comes back after initial treatment depends on the stage of the original melanoma, what treatments a person has already had, where the melanoma comes back, and other factors.
Melanoma might come back in the skin near the site of the original tumor, sometimes even in the scar from the surgery. In general, these local (skin) recurrences are treated with surgery similar to what would be recommended for a primary melanoma. This might 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; radiation therapy; tumor injection with BCG vaccine, interferon, or interleukin-2; or even systemic treatments such as immunotherapy, targeted therapy, or chemotherapy.
If nearby lymph nodes weren’t removed during the initial treatment, the melanoma might come back in these nearby lymph nodes. Lymph node recurrence is treated by lymph node dissection if it can be done, sometimes followed by treatments such as interferon or radiation therapy. If surgery is not an option, radiation therapy or systemic treatment (immunotherapy, targeted therapy, or chemo) can be used.
Melanoma can also come back in distant parts of the body. Almost any organ can be affected. Most often, the melanoma will come back in the lungs, bones, 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 tumors can sometimes be removed by surgery. Radiation therapy to the brain (stereotactic radiosurgery or whole brain radiation therapy) may help as well. Systemic treatments (immunotherapy, targeted therapy, or chemo) might also be tried.
As with other stages of melanoma, people with recurrent melanoma may want to think about taking part in a clinical trial.
Last Medical Review: 03/19/2015
Last Revised: 02/01/2016