what are the treatment options?

Your treatment will be planned by a team of doctors and other health care professionals.

They will take into account:

• the type of tumour you have
• how thick the tumour is, and where it is
• whether it has spread – and where to
• your age and general state of health
• your wishes

Your doctor and other specialists will tell you about the benefits, risks and side effects of the treatment being offered.

You will need to agree to the treatment before it can start. This is called giving your consent. Don’t be afraid to ask questions if there is anything you don’t understand.

The treatment for primary malignant melanoma is to cut out the cancer entirely with an operation (surgery). With successful surgery, the outlook can be very good, but there remains a risk that the cancer will return.

Sometimes surgery is combined with other treatments, listed below. Sometimes these treatments may be given instead of surgery.

Surgery
Before surgery, an excision biopsy will be done. For more information on this click here to go to the section on 'what tests will I have?'

Wide local excision
Some patients will have the suspected melanoma completely removed along with a narrow margin or normal skin (narrow margin excision). For most patients, it is standard practice to remove a wider area of skin around the site of the initial biopsy operation to make sure that no cancer cells have been left behind. This is called wide local excision. The operation will cure most patients.

The need for wide local excision, and the size of the margin of skin removed, is decided mainly by the thickness of the melanoma found on the original biopsy and the part of the body affected.

Occasionally, a wide local excision may be the only procedure performed, but in most cases, a narrow margin excision will have been performed first. It may seem a bad idea to have two operations rather than one, but there are two reasons. It is better for the patient as it means that wide excisions are not performed for moles that turn out to be harmless. It also gives the surgeon more information about the melanoma thickness and therefore the amount of skin removal that is required and any more tests that may be necessary.

You will meet a member of the surgical team face-to-face before your operation, so ask him or her to explain what will happen. She or he will also explain the possible complications that can happen following the chosen operation. You will find a link to a list of questions you might like to ask your surgeon by following the surgery link given below.

You may have the operation under a local or general anaesthetic. Afterwards, in most cases, the wound is stitched up directly. You may be able to go home the same day. If a larger area of skin needs to be removed, a skin graft or flap may be needed. This will be discussed with you beforehand.

Skin grafts and skin flaps
When large tumours are removed, a skin graft or a skin flap may be needed. A thin layer of healthy skin is taken from another part of the body (the donor site) to cover the wound. A flap is a slightly thicker layer of skin, including blood vessels, that is taken from an area close to the tumour. The operation is often performed by a plastic surgeon. You may need a general anaesthetic.

To get the best colour match, skin is usually taken from behind the ear for a face graft. For a graft for other areas of the body, skin is taken from somewhere that is usually hidden, such as the inner thigh.

The graft may be part of the operation, or it may be done the following day by the nursing staff.

You may have some discomfort for a few days afterwards, so painkillers will be prescribed for you.

With smaller operations you may be able to go home the same day. Usually, you will be able to go home 2-7days after surgery, depending on how well the graft and donor sites are healing.

The wounds will look unsightly to begin with, but evenually they will heal and fade, but will not disappear completely. The donor site will look like a large graze, and should heal within a few weeks. The graft will be much more delicate, and will need to be carefully protected from knocks and infection whilst the skin sticks together. Until it has healed, you will be checked regularly at the hospital.

Moh's micrographic surgery
Moh's is a specialised kind of surgery in which the tumour is removed piece by piece. This is done in order to conserve as much healthy tissue as possible, and so minimise damage. Each piece removed is then examined immediately under a microscope, to see whether there are still cancer cells present. If there are, further skin is removed.

This type of surgery is not often used in the treatment of melanoma. When it is, it is usually for lentigo maligna melanoma on the face. This is because the edges of this type of melanoma are often indistinct and the surgeon will want to remove all abnormal cells. At the same time, the amount of skin to be removed affects the cosmetic result, and the surgeon will not want to cut out more skin than necessary. It is also used for melanoma under nails, where surgery may have important effects on the function of a finger or toe.

It is usually done as day sugery, with a local anaesthetic. If you are having a skin graft or skin flap you will need to stay in hospital for up to four days whilst the skin graft knits and heals.

Surgery for larger melanomas
If the cancer is larger, or appears to have spread, the nearby lymph glands may also need to be removed. This is usually decided because you have lymph glands that are swollen, suggesting secondary tumours.

Removing lymph glands
Lymph glands are arranged in groups around the body, especially at the neck, armpits and groin. Your surgeon will remove the group closest to your tumour. This operation is called a lymphadenectomy.

You will usually be admitted to hospital the day before the operation, to allow for preparation. You will need a general anaesthetic, and will spend several days recovering in hospital afterwards. How long depends on how long the tube for draining the wound must be left in. You may have some pain, for which you will be given pain-killers.

There are common side-effects when lymph glands are removed. They include swelling, stiffness, and sometimes pain, in the limb closest to the site of the operation. Your medical team will tell you how the side-effects can be controlled, and refer you to a Lymphoedema Nurse Specialist for assessment and treatment.

Additional surgery for later stage melanoma
If the melanoma has spread to another part of your body, it is called seconday cancer. In some cases surgery may be used to remove small numbers of secondary tumours in places such as the lungs, gut or brain.

We have more general information about surgery in the treatments section of this website.

Radiotherapy
Radiotherapy uses radiation to kill cancer cells. It is given using a machine called a linear accelerator that carefully targets high-energy rays at the cancer cells.

Melanoma does not respond to radiotherapy in a predictable way. For this reason it is rarely used for treating primary melanoma but it is very occasionally used when surgery is not suitable.

It is used to treat the pre-cancerous condition lentigo maligna (also called in situ Lentigo Maligna Melanoma). It is used to treat secondary tumours, including brain tumours. There are short-term and long-term side-effects from radiotherapy. The 'treatments' section of this website can give you more infomation about radiotherapy.

Chemotherapy
Chemotherapy uses special drugs to kill cancer cells. They are normally given by injection or through a tube directly into a vein. Some drugs can be taken by mouth as tablets.

It may be used to treat melanoma that has come back near to where it started (local recurrence), to relieve the symptoms of secondary melanoma in another part of the body, or as a way to prevent the cancer from returning.

Sometimes chemotherapy is given only in one arm or leg. This is called isolated limb perfusion or adjuvant limb perfusion. It is only used to treat secondary melanoma that has come back near to where it started.

The 'treatments' section of this website can give you more infomation about chemotherapy.

Palliative care
Palliative treatment is care for the control of your symptoms, rather than the treatment of the disease itself. It may include palliative chemotherapy, radiotherapy or surgery.

Palliative treatments may be used to remove skin nodules (small tumours) caused by the spread of melanoma, or to deal with painful nodules in the skin or other sites such as the bone, or to heal skin nodules that have a raw surface (ulceration).

Most of the methods used as curative treatment can also be used to help palliative care. The most common are surgery or laser treatment for skin nodules, and radiotherapy for internal nodules (such as those causing bone pain).

For more information on palliative care, click here.