The first step in treating melanoma is often surgery. Today, physicians are able to remove far less tissue, achieving the same survival benefits while leaving the patient with a much smaller scar.
Thin melanomas are often removed in the physician’s office or as an outpatient procedure under local anesthesia.
If the melanoma is thicker, flaps can be made from skin near the tumor or with grafts of skin taken from another part of the body, insuring a good cosmetic result.
Mohs surgery is the single most effective technique for removing basal cell and squamous cell carcinomas and is now proving an effective way to remove melanoma in situ (contained skin cancers). This surgery spares the greatest amount of healthy tissue while achieving a cure rate of 98% or higher.
The procedure allows the surgeon to remove one thin layer of tissue at a time, checking it under a microscope for the presence of cancer cells. If the margins are cancer-free, the surgery is completed. If not, more tissue is removed from the margin until the sample is clear of cancer.
Surgery is the only treatment necessary for in situ melanomas—those that are contained on the surface layer of the skin.
It can also delay the need for systemic treatment for patients whose cancer has spread to one area or to a very limited degree. Finally, surgery can play an important role in eradicating any residual cancer in patients responding well to the therapies described below.
Immunotherapy is the prevention or treatment of disease with substances that stimulate the patient’s own immune response.
Several new immunotherapies have been approved over the past 10 years, including treatments that target immunological “checkpoints” including PD1, such as nivolumab and pembrolizumab, and CTLA-4, such as ipilimumab. By activating the immune systems within each patient such that the immune cells are better able to recognize and fight the melanoma cells, these treatments have resulted in significant improvements in the outcomes of individuals with melanoma. These drugs do have side effects and should be administered by a doctor with experience in its use.
There are other approved immunotherapies, including an oncolytic virus called TVEC, which is injected directly into melanoma tumors, as well as a number of very promising new immunotherapies which are being studied in ongoing clinical trials.
Researchers have identified several genetic mutations (changes in the sequence of DNA that can lead to cancer) associated with melanoma. These mutations can be specifically targeted with certain drugs, called targeted therapies.
Approximately one-half of melanoma patients have a mutation in the BRAF gene caused by overexposure to the sun’s UV rays. This mutation activates the MAPK pathway that has been related to many kinds of cancer. Inhibition of this MAPK pathway with a combination of pills that targets BRAF and MEK, such as dabrafenib and trametinib, vemurafeninib and binimetinib, and encorafenib and binimetinib, significantly increases overall survival of individuals with advanced melanoma harboring a BRAF mutation and is generally well tolerated.
Treatment with a KIT inhibitor (e.g., imatinib) may be considered for patients whose tumors contain a KIT mutation. These patients usually have melanomas that develop in areas where there is no or less sun exposure, such as with the oral cavity, the gastrointestinal tract, the nasal sinuses, or on the palms of the hands or the soles of the feet (acral melanomas).
Other rare mutations include mutations in a gene called N-RAS. MEK inhibitors may be active against this mutation either alone or in combination with other drugs. Your care team will discuss with you if targeted therapy may be an option for you.
With advanced radiation therapy techniques, doctors can better target tumors while reducing the radiation to nearby healthy tissues. Here at Columbia Cancer, our radiation oncology experts have the ability to provide state-of-the-art treatments for melanoma.
Your radiation oncologist will design the optimal treatment plan with you to ensure you achieve the best outcomes.
If radiation treatment is recommended, a radiation oncologist will work with our radiation oncology team to create a course of treatment. At Columbia University Irving Medical Center, treatment modalities available and most commonly used for melanoma are external beam radiation therapy, 3D conformal radiotherapy, image guided radiation therapy (IGRT), intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), and brachytherapy eye plaque.