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Melanoma: Treatment by Stages

Stage Information
Stage 0 Stage 0 melanomas have not spread beyond the epidermis. They are usually treated with surgical removal of the melanoma and a margin of about 1/2 cm (about 1/5 inch) of normal skin. For melanomas on the face, some doctors may instead use a cream containing the drug imiquimod (Aldara). This is mainly used when surgery would create a cosmetic problem. The cream is applied anywhere from once a day to 2 times a week for around 3 months.
Stage I Treatment of stage I melanoma consists of surgical removal of the melanoma and removal of a margin of normal skin. The amount of normal skin removed depends on the thickness of the melanoma. When the thickness is less than 1 mm, wide excision with 1 cm (2/5 inch) margins is recommended. For stage I melanomas between 1 mm and 2 mm thick, the tumor and 1 cm to 2 cm (4/5 inch) of surrounding normal-appearing tissue are removed. No more than 2 cm of normal skin needs to be removed from all sides of the melanoma in stage I. In the past, wider margins were used but healing was more difficult and the wider margins were not found to help people live longer.

Routine lymph node dissection (removal of lymph nodes near the cancer) has not been shown to improve survival in patients with stage I melanoma. Some doctors recommend sentinel lymph node mapping and biopsy if the melanoma is stage IB or has other characteristics that makes spread to the lymph nodes more likely.
Stage II Wide excision is the standard treatment for stage II melanoma. If the melanoma is between 1 mm and 2 mm thick, a margin 1 to 2 cm of normal skin will be removed as well. If it is thicker than 2 mm, about 2 cm of normal skin will be removed from around the tumor site.

Because the melanoma may have spread to lymph nodes near the melanoma, some doctors may recommend a sentinel lymph node biopsy as well. This is an option that you and your doctor should discuss. If the sentinel node(s) is found, then it will be biopsied along with removing the melanoma. If the sentinel node contains cancer, then a lymph node dissection (where all the lymph nodes in that area are surgically removed) will be done at a later date.

In certain cases (such as if the tumor is found to be more than 4 mm thick or if lymph nodes contain cancer), some doctors may advise adjuvant therapy (additional treatment after surgery) with interferon. Other drugs or perhaps vaccines may also be recommended as part of a clinical trial to try to reduce the chance the melanoma will come back.
Stage III In addition to wide excision of the primary tumor as in stage II, surgical treatment for stage III melanoma usually requires lymph node dissection. Adjuvant therapy with interferon may help some patients with stage III melanomas fight off recurrence longer. If several melanomas are present, they should all be removed. If this is not possible, injections of bacille Calmette-Guerin (BCG) vaccine or interleukin-2 directly into the melanoma is a treatment option. For melanomas on an arm or leg, another possible option is to infuse the limb with a heated solution of the chemotherapy drug melphalan. In some cases, radiation therapy may be given as an adjuvant to surgery in the area where lymph nodes were removed, especially if many of the nodes were found to contain cancer. Other possible treatments include chemotherapy, immunotherapy with cytokines, or both combined (biochemotherapy). Newer treatments being tested in clinical trials may benefit some patients. Many patients will not be cured with current treatments for stage III melanoma, so they may want to think about being in a clinical trial.
Stage IV These melanomas are very hard to treat as they have already spread to distant lymph nodes or other areas of the body. Skin tumors or lymph node metastases causing symptoms can often be removed by surgery. Metastases to internal organs are sometimes removed, depending on how many are present, their location, and how likely they are to cause symptoms. Metastases that cause symptoms but cannot be removed surgically may be treated with radiation or chemotherapy.

The chemotherapy drugs in use at this time are of limited value in most people with stage IV melanoma. Dacarbazine (DTIC) and temozolomide (Temodar) are the ones most often used, either by themselves or combined with other drugs. Even when chemotherapy can shrink these cancers, the effect is often only temporary, with an average time of 3 to 6 months before the cancer starts growing again. In rare cases they are effective for longer periods of time.

Immunotherapy using interferon or interleukin-2 can help a small number of patients with stage IV melanoma live longer. Higher doses of these drugs seem to be more effective, but they also have more severe side effects.

Many doctors recommend biochemotherapy -- a combination of chemotherapy and either interleukin-2, interferon, or both. For example, some doctors are combining interferon with temozolomide. The two drugs combined cause more tumor shrinkage, which may make patients feel better, although the combination has not been shown to help patients live longer. Another drug combination uses low doses of interferon, interleukin and temozolomide. Each seems to benefit some patients. Patients should carefully consider the possible benefits and side effects of any recommended treatment before starting.

Because stage IV melanoma is very hard to treat with current therapies, patients may want to think about taking part in a clinical trial. Clinical trials of new chemotherapy drugs, new methods of immunotherapy or vaccine therapy, and combinations of different types of treatments may benefit some patients.

Even though the outlook for patients with stage IV melanoma tends to be poor overall, a small number of patients have responded extraordinarily well to treatment or have survived for many years after diagnosis.