Surgery for Melanoma Skin Cancer

Surgery is the main treatment option for most melanomas, and it usually cures early-stage melanomas.

Wide excision

When melanoma is diagnosed by skin biopsy, more surgery will probably be needed to help make sure the cancer has been removed (excised) completely. This is known as a wide excision, and it will cure most thin melanomas.

Local anesthesia is injected into the area to numb it before the excision. The site of the tumor is then cut out, along with a small amount of normal skin around the edges, called the margins. The edges are usually stitched back together afterward. This will leave a scar.

The removed sample is then viewed under a microscope to make sure that no cancer cells were left behind at the edges of the skin that was removed.

Wide excision differs from an excisional biopsy. The margins are wider because the diagnosis is already known. The recommended margins vary, depending on:

• The thickness of the tumor. Thicker tumors need larger margins, both at the edges and in the depth of the excision.
• Where the melanoma is on the body. For example, if the melanoma is on the face, the margins might be smaller to avoid large scars or other problems.

Smaller margins might increase the risk of the cancer coming back, so be sure to discuss the options with your doctor.

Mohs surgery

Mohs surgery, also known as Mohs micrographic surgery or MMS, is done by a specially trained dermatologist or surgeon. It is not a standard treatment for melanoma, but it might be an option for some very early-stage melanomas that are in areas where a wide excision would be hard to do, such as the face or ears. This type of surgery is used more often for some other types of skin cancer.

In this procedure, the doctor removes a very thin layer of skin, including the melanoma. Then the layer is quickly frozen and looked at under a microscope. If cancer cells are seen, the doctor removes another layer of skin. This is repeated until a layer shows no signs of cancer. This is a slow process, often taking several hours, but it means that more normal skin near the tumor can be saved. This can help the area look better after surgery.

Amputation

In uncommon situations where the melanoma is on a finger or toe and has grown deeply, part or all of that digit might need to be amputated to help make sure that all of the melanoma has been removed.

Lymph node surgery

When melanoma spreads, it usually goes to nearby lymph nodes first. These lymph nodes might need to be removed.

In a lymph node dissection, the surgeon removes all the lymph nodes in the region near the primary melanoma tumor. For example, if the melanoma is on a leg, the surgeon would remove the nodes in the groin region on that side of the body, which is where melanoma cells would most likely travel to first.

When might a lymph node dissection be done?

Once the diagnosis of melanoma is made from the skin biopsy, the doctor will examine the lymph nodes near the melanoma. Depending on the thickness and location of the melanoma, this might be done by physical exam, or by imaging tests such as ultrasound or CT or PET scans.

If the nearby lymph nodes are abnormally hard or large, and a fine needle aspiration (FNA) biopsy or excisional biopsy finds melanoma in a node or nodes, a lymph node dissection is usually done.

If the lymph nodes are not enlarged, a sentinel lymph node biopsy (SLNB) might be done, particularly if the melanoma is thicker than 1 mm.

If an SLNB shows that the sentinel lymph node has cancer cells, a completion lymph node dissection might be advised to remove the remaining lymph nodes in that area, especially if there’s a high risk that more lymph nodes in the area contain melanoma. But more often, the lymph nodes are watched closely with exams and ultrasounds instead.

Possible side effects

A lymph node dissection can cause some long-term side effects, such as lymphedema.

Lymph nodes in the groin or under the arm normally help drain fluid from the limbs. If they are removed, fluid might build up. This can cause limb swelling, which might or might not go away.

If it’s severe enough, it can cause skin problems and an increased risk of infections in the limb. Elastic stockings or compression sleeves can help some people with this condition.

Lymphedema and the pain from the surgery are the main reasons why lymph node dissection is not done unless the doctor feels it is really necessary. An SLNB, however, is unlikely to have this effect. It’s important to discuss the risks of side effects with your doctor before having either of these procedures.

Surgery for metastatic melanoma

If melanoma has spread (metastasized) from the skin to other organs such as the lungs or brain, the cancer is very unlikely to be curable by surgery alone. Even when only 1 or 2 metastases (areas of spread) are found by imaging tests, there are likely to be others that are too small to be found by these scans.

Surgery is sometimes done in these circumstances, but the goal is usually to try to control the cancer rather than to cure it. If there are no more than a few metastases and they can be removed completely, surgery might help some people live longer. Removing metastases in some places, such as the brain, might also help prevent or relieve symptoms and improve a person’s quality of life.

Sometimes other treatments such as immunotherapy or targeted drugs might be given first to try to shrink the tumors and make surgery easier. This is known as neoadjuvant therapy.

These treatments might also sometimes be an option after surgery, to help lower the risk of the cancer returning. This is known as adjuvant therapy.

If you have metastatic melanoma and your doctor suggests surgery as a treatment option, be sure you understand what the goal of the surgery would be, as well as its possible benefits and risks.