Melanoma
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Melanoma
Treatment for melanoma
Treatment for early melanoma
Melanoma that is found early (stages 0–2 or localised melanoma) can generally be treated successfully with surgery alone. If the melanoma has spread to nearby lymph nodes or tissues (stage 3 or regional melanoma), treatment may also include removal of lymph nodes and additional (adjuvant) treatments.
Surgery to remove the mole is the main treatment for early melanoma, and is often the only treatment you need. Even though the excision biopsy to diagnose melanoma may remove the melanoma, a doctor or surgeon will usually recommend a second procedure known as a wide local excision. This means removing more normal-looking skin from around the melanoma (wider margin).
Removing more skin around the melanoma reduces the risk of it coming back (recurring) at that site. The recommended margin is usually between 5 mm and 10 mm, depending on the type, thickness and site of the melanoma. For thicker tumours, a wider margin of up to 20 mm may be advised.
A wide local excision is often performed as a day procedure. This means you can go home soon after the surgery, provided there are no complications. People with a melanoma thicker than 1 mm will usually be offered a sentinel lymph node biopsy performed at the same time as the wide local excision.
After a wide local excision, the tissue removed from around the melanoma will be sent to a laboratory for testing. If the edge of the tissue sample doesn’t contain any cancer cells, it is called a clear margin. If the margins aren’t clear, you may need further surgery to remove more tissue.
Repairing the wound
Most people will be able to have the wound closed with stitches. You will have a scar but this will become less noticeable with time. If a large area of skin is removed, the wound may be too big to close with stitches. In this case, the surgeon may repair it using skin from another part of your body. This can be done in two ways:
Skin flap – Nearby skin and fatty tissue are lifted and moved over the wound from the edges and stitched.
Skin graft – A layer of skin is taken from another part of your body (most often the thigh or neck) and placed over the area where the melanoma was removed. The skin grows back quickly over a few weeks.
The decision about whether to do a skin flap or graft will depend on a number of factors, including:
- where the melanoma is
- how much tissue has been removed
- your general health.
In either case, the wound will be covered with a dressing. After several days, it will be checked to see if the wound is healing properly. If you had a skin graft, you will also have a dressing on any area that had skin removed for the graft.
What to expect after surgery
Pain relief – The area around the wide local excision may feel tight and tender for a few days. Your doctor will prescribe painkillers if necessary. If you have a skin graft, the area that had skin removed may look red and raw immediately after the operation. Over a few weeks, this area will heal and the redness will fade.
Wound care – Your medical team will tell you how to keep the wound clean to prevent it from becoming infected. Occasionally, the original skin flap or graft doesn’t heal. In this case, you will need to have another procedure to create a new flap or graft.
Recovery time – The time it takes to recover will vary depending on the thickness of the melanoma and the extent of the surgery required. Most people recover in a week or two. Ask your doctor how long you should wait before returning to your usual exercise activities.
When to seek advice – Talk to your doctor if you have any unexpected bleeding, bruising, infection, scarring or numbness after surgery.
Many people with early melanoma will not need to have any lymph nodes removed.
In some cases, you may have a sentinel lymph node biopsy at the same time as the wide local excision. This removes the first lymph node that melanoma may have spread to. If melanoma is found in the removed node, you will need to have regular imaging scans to check that the melanoma has not come back or spread. You may also be offered drug therapy to reduce the risk of the melanoma returning.
Occasionally, melanoma may spread to lymph nodes and cause lumps that your doctor can feel during a physical examination. If a fine needle biopsy confirms that a lymph node contains melanoma, that group of lymph nodes may be removed in an operation called a lymph node dissection or lymphadenectomy. This is performed under a general anaesthetic and requires a longer stay in hospital.
Side effects of lymph node removal
Having your lymph nodes removed can cause side effects. These are likely to be milder if you have only a few lymph nodes removed.
Wound pain – Most people will have some pain after the operation, which usually improves as the wound heals. For some people, the pain may be ongoing, especially if lymph nodes were removed from the neck. Talk to your medical team about how to manage your pain.
Neck/shoulder/hip stiffness and pain – These are the most common problems if lymph nodes in your neck, armpit or groin were removed. You may find that you cannot move the affected area as freely as you could before the surgery. It may help to do gentle exercises or ask your GP or cancer care team to refer you to a physiotherapist.
Seroma/lymphocele – This is a collection of fluid in the area where the lymph nodes have been removed. It is a common side effect and appears straight after surgery. It usually gets better after a few weeks, but sometimes your surgeon may drain the fluid with a needle.
Lymphoedema – This is a swelling of the neck, arm or leg that may appear after lymph node removal.
Managing lymphoedema
If treatment for melanoma removes or damages lymph nodes, your neck, arm or leg may later become swollen. This is called lymphoedema. It happens when lymph fluid builds up in the affected part of the body because the lymphatic system is not working as it should.
Your risk of developing lymphoedema following melanoma treatment depends on the extent of the surgery and whether you’ve had radiation therapy that has damaged the lymphatic system.
Lymphoedema can develop a few weeks, or even several years, after treatment. Although this condition may be permanent, it can usually be managed, especially if treated at the earliest sign of swelling or heaviness.
A lymphoedema practitioner can help you manage lymphoedema. To find a practitioner, visit the Australasian Lymphology Association or ask your doctor for a referral. You may need to wear a professionally fitted compression garment. Massage and regular exercise, such as swimming, cycling or yoga, can help the lymph fluid flow. It is also important to keep the skin healthy and unbroken to reduce the risk of infection.
If there’s a risk that the melanoma could come back (recur) after surgery, other treatments are sometimes used to reduce that risk. These are known as adjuvant (or additional) treatment. They may be used alone or together.
Some treatments use drugs that enter the bloodstream and travel throughout the body. This is known as systemic treatment.
The main systemic treatments for melanoma are:
immunotherapy – drugs that use the body’s own immune system to recognise and fight some types of cancer cells
targeted therapy – drugs that attack specific features within cancer cells known as molecular targets to stop the cancer growing and spreading.
Chemotherapy is another form of systemic drug treatment. It is used to treat many cancers, but it is rarely used for melanoma because immunotherapy and targeted therapy drugs usually work better.
In some cases, people with melanoma may be offered radiation therapy (also known as radiotherapy). This is the use of targeted radiation to damage or kill cancer cells in a particular area of the body.
Download our fact sheet ‘Understanding Immunotherapy’
Treatment for advanced melanoma
When melanoma has spread to distant lymph nodes or other internal organs or bones (stage 4), it is known as advanced or metastatic melanoma. Treatment may include surgery, immunotherapy, targeted therapy and radiation therapy. Palliative treatment may also be offered to help manage symptoms and improve quality of life. Since the development of more effective treatments, chemotherapy is rarely used to treat melanoma.
Treatment for advanced melanoma is complex, so it is best to have your treatment in a specialist melanoma unit. You will be offered a treatment plan based on factors such as the features of the melanoma, where it has spread and any symptoms you have. New developments are occurring all the time, and you may be able to access new treatments through clinical trials.
In some cases, surgery may be recommended for people with advanced melanoma. It is used to remove melanoma from the skin, lymph nodes, or other organs such as the lung or brain. Your suitability for surgery will be discussed at a multidisciplinary team meeting.
Even though the excision biopsy to diagnose melanoma may remove the melanoma, a doctor or surgeon will usually recommend a second procedure known as a wide local excision. This means removing more normal-looking skin from around the melanoma (wider margin). The recommended margin is usually between 5 mm and 10 mm, depending on the type, thickness and site of the melanoma. For thicker tumours, a wider margin of up to 20 mm may be advised.
A wide local excision is often performed as a day procedure. This means you can go home soon after the surgery, provided there are no complications. People with advanced melanoma will usually be offered a sentinel lymph node biopsy performed at the same time as the wide local excision.
After a wide local excision, the tissue removed from around the melanoma will be sent to a laboratory for testing. If the edge of the tissue sample doesn’t contain any cancer cells, it is called a clear margin. If the margins aren’t clear, you may need further surgery to remove more tissue.
Repairing the wound
Most people will be able to have the wound closed with stitches. You will have a scar but this will become less noticeable with time. If a large area of skin is removed, the wound may be too big to close with stitches. In this case, the surgeon may repair it using skin from another part of your body. This can be done in two ways:
Skin flap – Nearby skin and fatty tissue are lifted and moved over the wound from the edges and stitched.
Skin graft – A layer of skin is taken from another part of your body (most often the thigh or neck) and placed over the area where the melanoma was removed. The skin grows back quickly over a few weeks.
The decision about whether to do a skin flap or graft will depend on a number of factors, including:
- where the melanoma is
- how much tissue has been removed
- your general health.
In either case, the wound will be covered with a dressing. After several days, it will be checked to see if the wound is healing properly. If you had a skin graft, you will also have a dressing on any area that had skin removed for the graft.
What to expect after surgery
Pain relief – The area around the wide local excision may feel tight and tender for a few days. Your doctor will prescribe painkillers if necessary. If you have a skin graft, the area that had skin removed may look red and raw immediately after the operation. Over a few weeks, this area will heal and the redness will fade.
Wound care – Your medical team will tell you how to keep the wound clean to prevent it from becoming infected. Occasionally, the original skin flap or graft doesn’t heal. In this case, you will need to have another procedure to create a new flap or graft.
Recovery time – The time it takes to recover will vary depending on the thickness of the melanoma and the extent of the surgery required. Most people recover in a week or two. Ask your doctor how long you should wait before returning to your usual exercise activities.
When to seek advice – Talk to your doctor if you have any unexpected bleeding, bruising, infection, scarring or numbness after surgery.
Immunotherapy drugs called checkpoint inhibitors use the body’s own immune system to fight cancer. They have led to great progress in melanoma treatment. Checkpoint inhibitors used for advanced melanoma include ipilimumab, nivolumab and pembrolizumab.
You will usually have checkpoint immunotherapy as an outpatient, which means you visit the treatment centre for the day. In most cases, the drugs are given into a vein (intravenously). You may have treatment every 2–4 weeks in a repeating cycle for up to two years, but this depends on how the melanoma responds to the drugs and any side effects you have.
Checkpoint inhibitors do not work for everyone with advanced melanoma, but some people have had very encouraging results. Sometimes more than one drug is used, and different combinations work for different people. Treatments in this area are changing rapidly. Talk to your doctor about whether immunotherapy is an option for you.
Side effects of immunotherapy
The side effects of immunotherapy drugs will vary depending on which drugs you are given, and can be unpredictable. Immunotherapy can cause inflammation in any of the organs in the body, which can lead to side effects such as tiredness, joint pain, diarrhoea, and an itchy rash or other skin problems. The inflammation can lead to more serious side effects in some people, but this will be monitored closely and managed quickly.
You may have side effects within days of starting immunotherapy, but more often they occur many weeks or months later. It is important to discuss any side effects with your treatment team as soon as they appear so they can be managed appropriately. When side effects are treated early, they are likely to be less severe and last for a shorter time.
New types of drugs known as targeted therapy attack specific genetic mutations within cancer cells, while trying to limit harm to healthy cells. They are generally taken as tablets (orally) once or twice a day, often for many months or even years.
Several targeted therapy drugs are used for melanoma with the BRAF mutation. Different drugs may be given together to help reduce the growth of the melanoma and minimise side effects – for example, dabrafenib is often used with trametinib. Drugs for NRAS and C-KIT mutations may be available through clinical trials – talk to your doctor about whether one of these trials is right for you.
Cancer cells can become resistant to targeted therapy drugs over time. If this happens, your doctor may suggest trying another targeted therapy drug or another type of treatment.
Side effects of targeted therapy
The side effects of targeted therapy will vary depending on which drugs you are given. Common side effects include fever, tiredness, joint pain, rash and other skin problems, loss of appetite, nausea and diarrhoea.
It is important to let your doctor know immediately of any side effects from targeted therapy treatment. If left untreated, some side effects can become serious.
Ask your treatment team for advice about dealing with any side effects.
Also known as radiotherapy, radiation therapy is the use of targeted radiation, such as x-ray beams, to kill or damage cancer cells. Radiation therapy may be offered on its own or with other treatments. In rare cases, it is used after surgery to prevent melanoma coming back. It can also help relieve pain and other symptoms caused by melanoma that has spread to the brain or bone.
Before starting treatment, you will have a CT or MRI scan at a planning appointment. The technician may make some small permanent or temporary marks on your skin so that the same area is targeted during each treatment session.
Treatment sessions are usually given daily over 1–4 weeks. The number of sessions will depend on the size and location of the tumour, and your general health. For the treatment, you will lie on a table under a machine that aims radiation at the affected part of your body. Each session takes about 20–30 minutes and is painless.
In some cases, you may be offered a specialised type of treatment that delivers tightly focused beams of high-dose radiation onto the tumour from many different angles. This is called stereotactic radiosurgery (SRS) when used on the brain, and stereotactic body radiation therapy (SBRT) when used on other parts of the body. SBRT often involves four treatment sessions over a couple of weeks.
Side effects of radiation therapy
The side effects you experience will depend on the part of the body that receives radiation therapy and how long you have treatment. Many people will have temporary side effects, which may build up over time. Common side effects include tiredness and skin in the treatment area becoming red and sore during or immediately after radiation therapy. Ask your treatment team for advice about dealing with any side effects.
In some cases of advanced melanoma, the medical team may talk to you about palliative treatment. Palliative treatment aims to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It can be used at any stage of advanced cancer and does not mean giving up hope. Some people have palliative treatment as well as active treatment of the melanoma.
When used as palliative treatment, radiation therapy and medicines can help manage symptoms caused by advanced melanoma, such as pain, nausea and shortness of breath.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs. The team also supports families and carers.
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This information is reviewed by
This information was last reviewed January 2021 by the following expert content reviewers: A/Prof Robyn Saw, Surgical Oncologist, Melanoma Institute Australia, The University of Sydney and Royal Prince Alfred Hospital, NSW; Craig Brewer, Consumer; Prof Bryan Burmeister, Radiation Oncologist, GenesisCare Fraser Coast and Hervey Bay Hospital, QLD; Tamara Dawson, Consumer, Melanoma & Skin Cancer Advocacy Network; Prof Georgina Long, Co-Medical Director, Melanoma Institute Australia, and Chair, Melanoma Medical Oncology and Translational Research, Melanoma Institute Australia, The University of Sydney and Royal North Shore Hospital, NSW; A/Prof Alexander Menzies, Medical Oncologist, Melanoma Institute Australia, The University of Sydney, Royal North Shore and Mater Hospitals, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Paige Preston, Chair, Cancer Council’s National Skin Cancer Committee, Cancer Council Australia; Prof H Peter Soyer, Chair in Dermatology and Director, Dermatology Research Centre, The University of Queensland Diamantina Institute, and Director, Dermatology Department, Princess Alexandra Hospital, QLD; Julie Teraci, Clinical Nurse Consultant and Coordinator, WA Kirkbride Melanoma Advisory Service, WA.