Melanoma


Treatment for early melanoma

Tuesday 1 January, 2019

Melanoma that is found early (stages 0–II or localised melanoma) can generally be treated successfully with surgery.

If the melanoma has spread to nearby lymph nodes or tissues (stage III or regional melanoma), treatment may also include removing lymph nodes and additional (adjuvant) treatments.

Surgery

Surgery to remove the mole is the main treatment for early melanoma, and it can also be the only treatment you need.

Wide local excision

Even though the excision biopsy to diagnose melanoma often removes the melanoma, a doctor or surgeon may also do a procedure called wide local excision.

This means removing more normal-looking skin from around the melanoma (wider margin).

Removing more tissue around the melanoma reduces the risk of it coming back (recurring) at that site.

In the latest melanoma guidelines, it is recommended that the margin is usually between 5 mm and 1 cm, depending on the type, thickness and site of the melanoma.

For thicker tumours, a wider margin of up to 2 cm may be advised.1

A pathologist will check the tissue around the melanoma for cancer cells.

If the sample doesn't contain any cancer cells, it is called a clear margin. If the margins aren't clear, you may need further surgery.

A wide local excision is often performed as a day procedure using a local anaesthetic.

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 at the same time. See Understanding Surgery.

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 (usually 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 many factors, such as where the melanoma is, how much tissue has been removed and 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 dressings 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.

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.

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 and a new one is required.

When to seek advice

Talk to your doctor about any side effects such as bleeding, bruising, infection, scarring or numbness you may have after surgery.

Removing lymph nodes

If your doctor's examination, ultrasound or lymph node biopsy shows that the melanoma has spread to your lymph nodes (regional melanoma or stage III), you will have scans regularly and, in some cases, may be offered immunotherapy or targeted therapy (systemic treatment).

If melanoma has spread to lymph nodes and caused a lump, the lymph nodes will 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. Usually only the lymph nodes near the melanoma are removed.

Side effects of lymph node dissection

Having your lymph nodes removed can cause side effects, such as:

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 see a physiotherapist.

Seroma/lymphocele

This is a collection of fluid in the area where the lymph glands have been removed. It is a common side effect of lymph node surgery.

Sometimes this fluid is drained by having a needle inserted into the fluid-filled cavity after surgery.

Lymphoedema

If lymph nodes have been surgically removed, your neck, arm or leg may swell. 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.

The chance of developing lymphoedema following melanoma treatment depends on the extent of the surgery and whether you've had radiation therapy that has damaged the lymph nodes.

It can develop a few weeks, or even several years, after treatment.

Although lymphoedema may be permanent, it can usually be managed, especially if treated at the earliest sign of swelling or heaviness.

How to prevent and/or manage lymphoedema

  • Keep the skin healthy and unbroken to reduce the risk of infection.
  • Wear a professionally fitted compression garment if recommended by your doctor or lymphoedema practitioner.
  • Always wear gloves for gardening, outdoor work and housework.
  • Moisturise your skin daily to prevent dry, irritated skin.
  • Protect your skin from the sun
  • Don't pick or bite your nails, or cut your cuticles.
  • Try to avoid scratches from pets, insect bites, thorns, or pricking your fingers.
  • Do regular exercise to help the lymph fluid flow, such as swimming, bike riding or yoga.
  • Massage the affected area to help move lymph fluid.
  • Avoid having blood taken or blood pressure done on the arm on the affected side.
  • Visit lymphoedema.org.au to find a lymphoedema practitioner or ask your doctor for a referral.
  • If your skin feels swollen or hot, see your doctor as soon as possible as these may be signs of infection.
  • See Understanding Lymphoedema.

Pete's story

"I spent my childhood in the sun. Growing up I was always outside kicking the footy or hanging out at the beach.

In the 60s and 70s, using sunscreen was considered optional, and having a sunburnt nose and shoulders was mandatory.

This all changed in my early 20s. I realised through skin cancer ads that my fair skin and blue eyes meant I was more at risk.

I also have lots of moles, mostly on my arms and body. So I started covering up, using sunscreen and wearing a hat. And I now see my doctor for regular skin checks.

At one of these appointments, the doctor thought a spot on my arm looked suspicious and removed it.

The biopsy was pretty simple and didn't hurt. I had it done in his office during my lunchbreak.

The mole was sent to the pathologist for testing and within a few days the doctor called to ask me to come back in for further surgery.

I did suspect that it might be a melanoma but I was still shocked when this was confirmed.

The doctor said that we'd spotted the melanoma early and that it was likely the biopsy had removed it all, but that it would be good to take a 5 mm margin to be sure.

I had some local anaesthetic, he cut it out and then it was closed up with stitches.

The tissue was sent to pathology, and I was relieved when the doctor called to say it was fine and no further treatment was needed.

After the wide local excision, the wound looked red and was sore, but this improved within four weeks. I was given a cream to apply to my arm to help the scar heal.

I found the whole experience rattled me a bit. I'm thankful it was found early and the treatment was straightforward."

Tell your cancer story.

Adjuvant treatment

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 enter the bloodstream and travel throughout the body.

This is known as systemic treatment, and includes:

  • immunotherapy – drugs that help the body's 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.

In some cases, people may be offered radiation therapy (also known as radiotherapy). This is the use of targeted radiation to damage or kill cancer cells.

For further information about targeted therapy, immunotherapy and radiation therapy, see the Treatment for advanced melanoma section.

You may also be offered an opportunity to participate in a clinical trial.

Key points about treating early or localised melanoma

What it is

Melanoma is a type of skin cancer. Early or localised melanoma has not spread outside the primary site.

The main treatment

The main treatment is surgery to remove the suspicious area.

How surgery is done

Surgery for melanoma may include:

  • wide local excision – cuts out the melanoma and some skin around it (wider margin)
  • lymph node dissection or lymphadenectomy – removes lymph nodes if cancer has spread to nearby lymph nodes (regional melanoma or stage III).

Other treatment options

You may also have other types of treatment after surgery to reduce the risk of the melanoma coming back. This is called adjuvant treatment, and may include:

  • immunotherapy – drugs to help stimulate the body's immune system to recognise and fight melanoma
  • targeted therapy – drugs to attack specific features of cancer cells that allow cancer to grow and spread
  • radiation therapy – use of targeted radiation to damage cancer cells.

Expert content reviewers:

A/Prof Victoria Atkinson, Senior Staff Specialist, Princess Alexandra Hospital, Visiting Medical Oncologist, Greenslopes Private Hospital, and The University of Queensland Clinical School of Medicine, QLD; Adjunct Prof John Kelly AM, Consultant Dermatologist, Victorian Melanoma Service, and Department of Medicine at Alfred Health, Monash University, VIC; Dr Alex Chamberlain, Dermatologist, Glenferrie Dermatology, Victorian Melanoma Service and Monash Univeristy, VIC; Alison Button-Sloan, Melanoma Patients Australia; Peter Cagney, Consumer; Prof Brendon J Coventry, Associate Professor of Surgery, The University of Adelaide, Surgical Oncologist, Royal Adelaide Hospital, and Research Director, Australian Melanoma Research Foundation, SA; Dr David Gyorki, Consultant Surgical Oncologist, Peter MacCallum Cancer Centre, VIC; Liz King, Skin Cancer Prevention Manager, Cancer Council NSW; Shannon Jones, SunSmart Health Professionals Coordinator, Cancer Council Victoria; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Prof Richard Scolyer, Senior Staff Specialist, Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Co-Medical Director, Melanoma Institute Australia and Clinical Professor, The University of Sydney, NSW; Heather Walker, Chair, Cancer Council National Skin Cancer Committee, Cancer Council Australia.

Cancer Council Australia Melanoma Guidelines Working Party, Clinical practice guidelines for the diagnosis and management of melanoma, Cancer Council Australia, Sydney, 2018. [Cited 20 September 2018]. Available from: wiki.cancer.org.au/australia/Guidelines:Melanoma.

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