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MELANOMA

How to treat
Melanoma

         Advancements in melanoma treatment, particularly for Stage III and IV cases, have transformed the landscape in the past decade. Previously limited and mostly ineffective, current treatment options have proven successful for many patients, with ongoing clinical trials offering even more possibilities. Treatment for melanoma is determined by factors like stage, cancer spread, location, overall health, melanoma type, gene mutations, and treatment goals.
         Surgery serves as the primary and often sufficient treatment for the majority of melanomas. Additional treatment approaches, depending on the stage, may include targeted therapies, immunotherapies, and participation in clinical trials. Radiation and vaccines can be viable options for certain patients as well.

This section provides general information about each of the different types of treatments available for melanoma.

Stages of Melanoma

What is Stage 0 (in situ)

In Stage 0 melanoma, the malignant tumor is still confined to the upper layer of the skin—the epidermis—which means the cancer cells are only in the outer layer of the skin and have not grown into the second layer of skin, called the dermis. Stage 0 melanoma is not considered invasive melanoma

Treatment: 

Surgery is the standard treatment for Stage 0 melanoma (in situ). The primary goal of the surgery is to eliminate any remaining cancer cells following the initial biopsy. This procedure, known as wide local excision, involves the removal of the tumor from the biopsy site, as well as a margin of normal-appearing skin surrounding it and the underlying subcutaneous tissue. The aim is to ensure complete removal of the entire tumor. In many cases, this procedure can be performed under local anesthesia in a doctor's office

What is Stage 1 

Stage I melanoma indicates the presence of cancer cells in both the epidermis and the dermis, which are the first and second layers of the skin, respectively. A melanoma tumor is classified as Stage I if its thickness is up to 2 mm, and it may or may not exhibit ulceration.

Treatment: 

The primary treatment for Stage I melanoma is wide local excision surgery. The objective of this surgical procedure is to eliminate any remaining cancer cells following the initial biopsy. Depending on the risk of tumor spread, your doctor may also recommend a sentinel lymph node biopsy. This procedure involves the examination and removal of the lymph nodes near the site of the melanoma to determine if the cancer has spread.

What is Stage II

Stage II melanoma indicates the presence of cancer cells in both the epidermis and the dermis, the first and second layers of the skin. This stage is considered higher risk compared to Stage I, often due to factors such as tumor depth or the presence of ulceration. However, there is no evidence of cancer spread to lymph nodes or distant sites (metastasis). Stage II melanoma is categorized as a local melanoma, indicating that it has not extended beyond the primary tumor.

Treatment: 

Treatment options for Stage II melanoma may include surgery, sentinel lymph node biopsy(SLNB), immunotherapy, and participation in clinical trials.

  • Surgery: This procedure aims to remove any remaining cancer cells after the initial biopsy. During a wide local excision, the surgeon removes the tumor, surrounding normal-appearing skin (known as the surgical margin), and underlying subcutaneous tissue to ensure complete removal of the tumor.

  • SLNB: To determine if cancer cells have spread to the sentinel node, the first lymph node that receives drainage from the primary tumor. This node is commonly the first site where melanomas metastasize. SLNB is recommended for all Stage II tumors, regardless of their size, to assess if the cancer has spread beyond the primary site.

  • Immunotherapy: Keytruda (pembrolizumab), an immunotherapy drug, has received approval for the treatment of melanoma patients aged 12 years and older who have undergone complete resection of the melanoma. This approval is based on the results of a Phase 3 clinical trial involving 976 newly diagnosed patients. The trial demonstrated that Keytruda significantly improved recurrence-free survival (RFS), reducing the risk of disease recurrence or death by 35% compared to placebo alone.

  • Clinical Trials: Vital research studies that evaluate new therapies and advance cancer care. They play a crucial role in driving progress in cancer prevention, diagnosis, and treatment. If you have melanoma, you may be eligible to participate in a clinical trial, offering you the chance to contribute to scientific advancements and potentially access innovative treatments.

What is Stage III

Stage III melanomas refer to tumors that have spread to regional lymph nodes or have developed in-transit deposits of disease, yet there is no indication of distant metastasis. In other words, Stage III melanoma is classified as regional melanoma as it has extended beyond the primary tumor to the nearby lymph nodes, but has not spread to distant locations.

Treatment: 

Stage III melanoma offers various treatment possibilities, including surgery (such as sentinel lymph node biopsy(SLNB) and potential completion lymph node dissection), neo-adjuvant therapy, adjuvant therapy, radiation therapy, and participation in clinical trials. Surgical oncologists typically handle surgery-related treatments, while medical oncologists specialize in drug-related treatments. If radiation therapy is required, a radiation oncologist will oversee the treatment.

  • Surgery:A surgery called wide local excision. The purpose of the surgery is to remove any cancer remaining after the biopsy of the primary tumor.In a wide local excision, the surgeon removes any remaining tumor from the biopsy site, the surgical margin (a surrounding area of normal-appearing skin), and the underlying subcutaneous tissue, to make certain the whole tumor has been removed.

  • SLNB:To evaluate the presence of cancer in the nearest lymph nodes to the primary tumor, which helps determine the stage of the tumor, specifically Stage III.

  • Lymph Node Dissection:If cancerous lymph nodes are detected through sentinel lymph node biopsy (SLNB), a follow-up procedure called completion lymph node dissection (CLND) may be advised to remove the remaining lymph nodes in the area. However, recent research involving over 1900 patients has indicated that CLND does not extend survival. Your doctor may discuss the option of CLND with you if SLNB reveals positive nodes.

  • Adjuvant Therapy:Treatment given after the primary surgery to remove melanoma. In Stage III melanoma, systemic therapy is commonly recommended as adjuvant treatment. This therapy can be administered through pills or infusions, targeting cancer cells throughout the body to eliminate any remaining cells.

  • Single Agent Immunotherapies:Yervoy (ipilimumab), Keytruda (pembrolizumab), and Opdivo (nivolumab) are immunotherapies that enhance the immune system's ability to combat the recurrence of melanoma.

What is Stage IV 

In Stage IV melanoma, the cancer has spread from the primary tumor to distant areas of the body. Common sites of metastasis include distant skin and lymph nodes, as well as the lungs, liver, brain, bone, and intestines.

Treatment: 

If you have advanced from an earlier stage diagnosis, your treatment would have typically involved wide local excision and possibly sentinel lymph node biopsy, among other treatments.

For Stage IV melanoma specifically, there are various treatment options available, including surgery, systemic therapies, radiation therapy, and participation in clinical trials. The FDA has approved several new drugs that have demonstrated improved survival outcomes. Additionally, there are ongoing investigations into experimental treatments that may be accessible through participation in clinical trials.

  • Surgery: Maybe considered in cases where there are a limited number of cancerous tumors or metastatic lymph nodes in other parts of the body, especially if they are causing symptoms. However, surgical options for patients with metastatic melanoma are usually restricted and need to be carefully evaluated in the context of the overall progression of the disease.

  • Systemic Therapies:Stage IV melanoma is typically treated with drug therapies. While one FDA-approved treatment, T-VEC, is delivered locally to specific lesions, the majority of treatments are systemic therapies that travel through the bloodstream to target and eliminate melanoma cells throughout the body. These treatments can be categorized into immunotherapies, targeted therapies, and chemotherapy.

  • Radiation Therapy:Is employed in certain cases to inhibit tumor growth or reduce the size of tumors in organs where surgery is not feasible or advisable. Additionally, it is utilized to alleviate symptoms arising from tumors, such as those occurring in the brain or bone.

  • Clinical Trials: A crucial research studies that assess new therapies and enhance cancer care. They have been instrumental in driving advancements in cancer prevention, diagnosis, and treatment. Clinical trials provide access to promising novel therapies that are not yet available outside of these studies because they are still under investigation. You might meet the eligibility criteria to participate in a clinical trial, offering you the opportunity to contribute to scientific progress and potentially access innovative treatments

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