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Melanoma Treatment at Emory Winship

The Melanoma Clinic at Emory Winship Cancer Institute is a comprehensive, multidisciplinary treatment program. Each week the team meets for an interactive Melanoma Tumor Board to review and discuss patient cases and treatment plans. Participants from Dermatology, Surgical Oncology, Medical Oncology, Pathology and other support professionals all specialize in the diagnosis and treatment of melanomas and cancers of the skin.

Learn about current Melanoma Clinical Trials

The information that follows will answer some of the questions you may have regarding melanoma and treatment options. While the information within this website has been reviewed by a medical team, it should not take the place of a personal visit to your medical provider.

The information included here primarily applies to patients with melanoma that originates in the skin. Much of it also applies to the small number of patients with melanoma originating from mucosal sites such as the lining of the mouth or bowel. There is a separate section for patients with melanoma that starts in the eye.

Melanoma Frequently Asked Questions

What if your melanoma occurs in a place where it is very hard to bring the skin back together?
Although most wide-local excisions will be sutured closed, some patients will have lesions in areas such as the scalp, face, or on the ankle where the skin doesn't have a lot of mobility. Special techniques, including consultation with plastic surgeons, may be needed in order to appropriately repair this area. Your doctor will explain this to you specifically, if necessary. We will make every effort to obtain a cosmetically satisfactory scar without compromising our primary goal: curing you of your cancer.

What if my melanoma is in a difficult place like my face or close to my eye?
In some instances a specialized procedure known as Mohs' surgery may be indicated. This is also available here at Emory Winship.

How do we treat the lymph nodes?
If your melanoma is thicker than 1 mm, your doctor will generally recommend that you have your lymph nodes "checked." For patients with melanomas thinner than 1 mm, there are a number of characteristics in your pathology report which might indicate to your physician that there is a reason to check your lymph nodes. If you have evidence of a swollen lymph node on physical examination or by a radiographic test such as a CT scan, your doctor may choose to check the lymph node by a fine needle biopsy prior to any further planning. If not, lymph nodes are generally checked by a technique called "sentinel lymph node biopsy."

Sentinel lymph node biopsy is a technique which utilizes a relatively new process whereby patients receive a small dose of radioactivity around the area of their primary melanoma. A camera is then used to follow the radioactivity to see where the cells would go if they had spread from that melanoma via the lymphatic system. This is called the "sentinel lymph node." For melanomas of the limbs, this is usually straightforward, arm lesions usually go to the underarm, leg lesions usually go to the groin. It is important to understand that this radiologic test just provides your surgeon a map, it does not mean your melanoma has spread. With this map, your surgeon will then remove the node or nodes (usually between 1 and 5 nodes are removed) at the time of your surgery to treat the primary melanoma (the wide-local excision). This node (or nodes) is the first place that melanoma cells would spread if they had spread from your melanoma. For all patients undergoing this procedure only approximately 15% of patients will actually have melanoma cells in their sentinel lymph node.

What if I have a positive sentinel lymph node or a node that is positive based on physical examination and fine needle biopsy?
If you have a positive sentinel lymph node then when you meet with your doctor at your first post-operative visit, he will discuss this with you. In general, if you haven't had a "staging work up" (radiographic tests to check for spread to internal organs) many patients will be referred for this prior to any further surgery. After staging is complete, you will then be scheduled for what is called a "completion lymph node dissection," which will entail removing all of the remaining nodes from wherever your sentinel lymph node was. The specifics of this operation will be discussed with you by your doctor based on the site and the plan for your operation. Additionally, arrangements will be made for you to see the medical oncologist so that you can consider additional treatment after you have recovered from your operations. In some instances you may also see a radiation oncologist.

Some patients may be considered for a minimally invasive procedure to remove lymph nodes from the groin area. Typically, the standard way to remove all of the lymph nodes in the groin is by a large incision, approximately 8-10 inches in length. For patients who have this operation, there is a very high incidence of complications after surgery: as many as 50% as patients can have a problem after surgery. These problems range from a low grade skin infection needing oral antibiotics to deep infections requiring the wound to be opened and occasionally needing readmission to the hospital and antibiotics given via the vein.
 
With the advent of new technology and new equipment, the ability to perform this videoscopic procedure through small incisions away from the groin and further down the leg has become possible. Pioneered by Dr. Keith Delman and Dr. Viraj Master here at Winship Cancer Institute, the pair has since performed over 100 videoscopic procedures in this minimally invasive manner and has taught it to surgical oncologists from major academic centers in the United States and around the world.

How do we treat or prevent spread via the bloodstream?
This is also tailored to each patient and his/her specific medical condition and is guided by the medical oncologist. Using the staging system mentioned above, the medical oncologist will explain your risk of recurrence and what can be done to reduce that risk. The standard agent used in this situation is interferon-alpha2b. Your oncologist will also review any clinical trials that apply to your situation.

What will my recovery be like after surgery?
The incision for the sentinel lymph node biopsy will generally not be more than 1= inches long. This will be closed with absorbable sutures and steri strips and after 24 hours from surgery, can be showered. Soaking in a tub should be avoided. For all wounds, (sentinel node and wide-local excision both) some minimal redness is normal, but if the area gets progressively redder or begins to drain, this is a sign of infection and you should notify your doctor.

In contrast, the wide-local excision site will be much longer, and may be as long as 7 or 8 inches. This wound will require limits to activity, most importantly no heavy lifting and no aggressive activity. Lifting should be limited to approximately a 10 pound grocery bag. If you have young children, it may be best for you to have some assistance at home for at least the first week after surgery, if possible. Many of these incisions will be closed with absorbable sutures but some will be closed with nylon sutures which will need to be removed at your first post-operative visit. As mentioned above, in some cases, a special closure (such as a skin graft or plastic surgery closure) requiring specialized postoperative care may be needed.

If you do not require a special closure such as a skin graft, most patients will go home the day of surgery. In some instances, patients may stay in the hospital overnight. Your physician will discuss this with you prior to your operation.

If I am at high risk for recurrence of melanoma, how will I be followed?
In the past we used frequent scans to follow patients, but this has not been helpful to the patients. In addition, there is some risk of unnecessary procedures due to equivocal scan results, as well as some long term health risk from too much exposure to radiation. For these reasons patients' follow-up will consist primarily of history and physical examination, with some use of laboratory tests and routine x-rays. There are no blood tests specific for melanoma with any proven benefit to the patient.

What if there is distant spread of my melanoma?
Even if the cancer has spread to distant sites there is sometimes a role for surgery, and this will always be considered. Similarly there is sometimes a role for radiation therapy, including radiation focused on specific tumors, such as a small brain metastasis. At times the interventional radiologists can offer benefit to the patient with procedures such as radiofrequency ablation and embolization. All these will be considered before a decision is made about what treatment is best.

Often the best treatment is systemic treatment, which usually means chemotherapy or immunotherapy or, at times, combinations of the two. Which is best is a decision to be made by the patient and the medical oncologist after a careful discussion of the options. This discussion will include any clinical trials that may be available for you.

What if my melanoma started in my eye?
Patients with ocular melanomas start treatment with an ophthalmologist. It is important that this person be experienced in treatment of eye melanomas. Sometimes the eye can be preserved by local radiation (plaque therapy), although the vision may still be diminished. In other cases the eye must be removed. Patients can be told a prognosis, or risk of recurrence, based on characteristics of the tumor such as size, but the staging is different for the eye than for the skin. There are no treatments known to reduce the risk of recurrence of ocular melanoma. If the melanoma spreads to distant sites then many of the same treatments available to patients with skin melanoma can be offered. Unfortunately, many of the clinical trials available to patients with skin melanoma are not available to patients with eye melanomas.

Learn about current Melanoma Clinical Trials

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