Surgery to remove the tumor is the primary treatment of all stages of melanoma.
When a diagnosis of melanoma is made by skin biopsy, "excisional biopsy", the site will probably need to be excised again to help make sure the cancer has been removed completely. This fairly minor surgery will cure most thin melanomas.
If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas.
Wide excision differs from excisional biopsy. The margins are wider because the diagnosis is already known. The recommended margins vary depending on the thickness of the tumor and how deeply it as invaded the skin. Thicker tumors call for larger margins.
If the melanoma is thick, the doctor may need to remove a larger margin of tissue. If a large area of tissue is removed and requires more extensive surgery, a better cosmetic appearance can be obtained with flaps made from skin near the tumor, or with grafts of skin taken from another part of the body. For grafting, the skin is removed from areas that are normally or easily covered with clothing.
The following two procedures are used to evaluate/remove lymph nodes:
Sentinel Lymph Node Biopsy
If the lymph nodes are not enlarged, a sentinel lymph node biopsy may be done, particularly if the melanoma is thicker than 1mm. The sentinel lymph node is the first lymph node the cancer is likely to spread to, from the tumor.
A sentinel lymph node biopsy is performed after the biopsy of the melanoma, but before or in conjunction with the wider excision of the tumor. A radioactive substance and sometimes a blue dye are injected near the melanoma. The surgeon follows the movement of the substance radiographically with a hand-held probe. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping. The surgeon removes the sentinel node(s). A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. If the sentinel lymph node contains cancer cells, removing the remaining lymph nodes in that area with a lymph node dissection is usually advised. This is called a completion lymph node dissection.
Therapeutic Lymph Node Dissection
The surgeon removes all the lymph nodes in the area of the melanoma. Therapy may be given after surgery, even if the doctor removes all the melanoma that can be seen at the time of the operation. Some patients may be offered chemotherapy after surgery to kill any cancer cells that remain in the body. Chemotherapy given after surgery to lower the risk of the cancer returning is called adjuvant therapy.
Surgery for Metastatic Disease
Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. However, surgery is sometimes done in these circumstances to try to control the cancer rather than to cure it. If one or even a few metastases are present and can be removed completely, surgery may help some people live longer. Removing metastases in some places, such as the brain, might also relieve symptoms and help improve the person's quality of life. Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered systemic therapy after surgery to kill any cancer cells that are left. In such cases, doctors may use other methods of treatment, such as chemotherapy, immunotherapy, targeted therapy, radiation therapy, or a combination of these methods.