It used to be customary to remove a large area, regardless of the stage of cancer. This potentially disfiguring approach has been abandoned because studies have shown that excising wider margins does not improve survival. Nevertheless, sometimes skin grafts may need to be taken from other body sites to help cover the wound.
Of note: recurrence rates are very high with lentigo maligna (LM) after conservative surgery. Although this is a very slowly progressive condition, LM can develop into melanoma. Most of these lesions appear on the face and neck, so extensive surgery can be disfiguring. Patients should discuss with their doctor carefully staged surgery to remove all diseased tissue with as little cosmetic harm as possible.
Lymph Node Removal. If there is evidence that melanoma has spread to nearby lymph nodes but has not spread beyond, removing them may reduce the chance of recurrence and help patients live longer.
Surgery for Metastatic Melanoma. In some cases, surgical removal of distant tumors may be possible and prolong survival, since often in melanoma the cancer spreads first only to a single site, such as the lung or the brain.
Cryosurgery. Cryosurgery freezes skin tissue and destroys it. This procedure is not useful for most melanomas, but it might have some value in specific situations. For example, it may be effective for smaller melanomas in the eye, a location that is difficult to treat with traditional surgery. It may be useful to eliminate residual cancer cells after standard surgery for lentigo maligna melanomas, an atypical form of melanoma that has a wide surface and is difficult to treat.
Chemotherapy
Chemotherapy is often used to treat recurrent or metastatic melanomas. The drugs are not intended as a cure but can prolong life and improve its quality.
Drugs Used. The following are some of the agents used to treat melanoma. They may be used alone or in combination under specific situations.
- Methylating agents, which impair the ability of cancer cells to divide, include dacarbazine (DTIC), temozolomide (TMZ), and procarbazine. To date, dacarbazine is the only drug approved for melanoma.
- Temozolomide, an oral drug, may be comparable and improve quality of life. Because it can cross the blood-brain barrier (unlike dacarbazine), temozolomide is showing promise in preventing metastasis to the brain. It may also have some benefits in treating cancers that have already spread to the brain.
- In a 2004 study, patients had a significantly higher response rate to fotemustine than to DTIC. Compared to DTIC, fotemustine was also associated with a slightly greater survival and longer time before brain metastases developed.
- Melphalan plus temozolomide are being given in combination with hepatic perfusion in a clinical trial of patients with ocular melanoma metastases to the liver. Temporarily separating the liver from the blood supply enables higher concentrations of melphalan to be otherwise tolerated. Phase I and II trials produced a positive response in 62% of patients.
- Nitrosoureas, which include carmustine (BCNU) and lomustine (CCNU) are often used.
- Taxanes, such as docetaxel (Taxotere) and paclitaxel (Taxol), are showing some low-level activity against melanoma. Docetaxel is being studied in combination with other drugs.
- Lenalidomide (Revlimid), a novel drug that inhibits the growth of new blood vessels to tumors. This drug is being studied for melanoma that occurs in the eye (ocular melanoma, the most common form of eye cancer) and has spread to other organs. No effective treatment for metastatic ocular melanoma is currently available.
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