Surgery for melanoma has two goals:
1. To remove all of the cancer with a margin of healthy tissue around it, known as wide excision
2. To determine if the melanoma has spread beyond the primary site to the adjacent lymph nodes
For years, the second goal was achieved by a lymph node dissection or total removal of the nodes nearest the melanoma. This procedure often led to short- and long-term problems for patients.
More recently, however, surgeons have begun to use a procedure in which they remove only the one or two lymph nodes closest to the tumor, the ones to which cancer cells are most likely to spread.
They identify these "sentinel" nodes as they are called by using special dyes as tracers. The dyes follow the same drainage paths as the cancer cells. If the cancer has not spread to the sentinel node, the chances are extremely high that it has not spread to any other nodes.
As Penn surgeon, Giorgos Karakousis, MD, noted, it is important to optimize the results for each patient while minimizing any negative consequences of the treatment.
For melanoma patients, this means tailoring the surgery to the individual patient's disease, using a wide range of factors that predict the risk that the cancer will spread. New technology, which is more accurate and sensitive, is also helping doctors to make individual decisions as to what surgery to do for various subsets of patients.
In general, patients with stage I and II disease will have wide excision of the melanoma. The decision as to whether to use the wide excision alone, add SNL or do the complete lymph node dissection depends on the thickness of the melanoma and those other factors such as whether there is evidence of active cell division, mitosis, in the tumor and whether the melanoma is ulcerated or not.
"In the past, we did a lot of complete lymphadenectomy, and many of our patients had problems either from the surgery itself or as a result of lymphedema,” says Dr. Karakousis. “We can avoid those negative outcomes for many of our patients today without compromising their overall treatment."
Dr. Karakousis also pointed to the increasing ability to surgically remove isolated metastases for patients with Stage IV melanomas, an approach that has had positive results for some patients. The decision as to whether or not to attempt to do this kind of surgery should be made by a multidisciplinary team.
Watch all of the presentations from the 2012 Focus On Melanoma Conference here.
Learn more about treatment for melanoma at Penn in Philadelphia.
