Melanoma Surgery

What is Melanoma Surgery?

Melanoma surgery is the primary treatment modality for melanoma, which is the most serious type of skin cancer. This surgical intervention aims to remove melanoma cells from the skin, thereby reducing the risk of the cancer spreading to other body parts. The scope and complexity of the surgery depend on the stage of the melanoma at diagnosis.

Who is Suitable for Melanoma Surgery?

The suitability for melanoma surgery generally depends on several factors:

Stage of the Melanoma:
Early-stage melanomas (Stage I and II): Patients with melanomas confined to the site of origin without spreading to lymph nodes or distant sites are ideal candidates for surgical removal of the tumour.
Stage III melanomas: If the cancer has spread to nearby lymph nodes, both the primary tumour and the affected lymph nodes may be surgically removed.
Stage IV melanomas: Surgery is less commonly a primary treatment at this stage but may be used to remove tumours causing symptoms or complications.
Health and Age of the Patient: Patients must be in suitable health to undergo surgery, especially if extensive lymph node removal or reconstructive surgery is involved.
Location and Size of the Melanoma: It is also crucial to determine the feasibility of completely removing the melanoma with adequate margins. Melanomas in certain places (like the face or fingers) may require specialised surgical techniques.
Biopsy Results: Information from a biopsy, including the depth and thickness of the melanoma (Breslow depth), can influence decisions about the type of surgery and the need for lymph node assessment.

Benefits of Melanoma Surgery

The primary benefits of melanoma surgery include:

Complete Removal of Cancer: Surgery aims to completely remove the melanoma from the skin, offering the best chance for a cure, especially in early-stage melanoma.
Prevention of Spread: By removing the primary tumour, surgery helps prevent the spread of melanoma to other parts of the body.
Accurate Staging: Surgical procedures like sentinel node biopsy help accurately stage the cancer, which is crucial for determining the prognosis and planning further treatment.
Symptom Relief: In advanced cases, surgery can help alleviate symptoms caused by large tumours or metastases.
Improved Cosmetic Outcome: For melanomas in visible areas, specialised surgical techniques can minimise scarring and maintain the appearance as much as possible.

Types of Melanoma Surgery

Excisional Surgery: This involves removing the tumour along with a margin of healthy tissue around it. The size of the margin depends on the thickness of the melanoma.
Sentinel Lymph Node Biopsy: This is performed to determine if the melanoma has spread to nearby lymph nodes. It involves removing the first few lymph nodes that drain the area of the tumour.
Lymph Node Dissection (Lymphadenectomy): If melanoma cells are found in the sentinel lymph nodes, further surgery may be required to remove additional lymph nodes in the region.
Mohs Micrographic Surgery: This technique is used primarily for melanomas in cosmetically sensitive areas, such as the face. It allows for preserving more normal tissue by examining each layer of skin removed during surgery.
Wide Local Excision: Typically used for thicker melanomas, this surgery removes more extensive margins around the tumour.
Amputation: In rare cases, if the melanoma is located on a digit like a finger or toe, amputation might be necessary.

Alternative Options to Melanoma Surgery

While surgery is the primary treatment for melanoma, alternative or additional therapies might be considered, especially in cases where surgery isn't feasible, or the melanoma is at an advanced stage:

Immunotherapy: Drugs that help the immune system recognise and attack cancer cells are a cornerstone of advanced melanoma treatment.
Targeted Therapy: These drugs target specific genes and proteins involved in the growth and survival of cancer cells. They are typically used for patients whose melanoma has specific genetic mutations.
Chemotherapy: Although less commonly used today for melanoma due to the effectiveness of targeted and immunotherapies, chemotherapy can be used for melanomas that are resistant to other treatments.
Radiation Therapy: This may be used to relieve symptoms in advanced melanoma or in situations where surgery isn’t possible. It's also sometimes used after surgery to help prevent recurrence.
Clinical Trials: Patients might consider participating in clinical trials that provide access to new treatments not yet available on the market.

Preparation Before Melanoma Surgery

Preparing for melanoma surgery involves several important steps:

Preoperative Evaluation: This includes a thorough physical examination and possibly a series of tests (such as blood tests and imaging studies) to ensure you are fit for surgery and to understand the extent of the melanoma.
Medication Review: Discuss your current medications with your doctor. Some drugs, like blood thinners, may need to be stopped temporarily.
Skin Preparation: Follow instructions about bathing and possibly using antiseptic soap to reduce the risk of infection.
Fasting: You may be instructed to fast, typically from midnight the day before the surgery, especially if you're undergoing general anaesthesia.
Arranging Transportation: Arrange for someone to drive you home after the surgery, as you may be under the influence of anaesthesia.
Mental Preparation: Understanding the procedure and its possible outcomes can help reduce anxiety. Consider discussing any concerns with your doctor or a counsellor.

Melanoma Surgery Procedure

The specifics of melanoma surgery vary based on the type of surgery being performed:

Excisional Surgery: The surgeon cuts out the melanoma along with a margin of healthy skin. The size of the margin is based on the thickness of the melanoma.
Sentinel Lymph Node Biopsy: A dye or radioactive substance is injected near the tumour to locate the sentinel lymph nodes, which are then removed and tested for cancer cells.
Lymphadenectomy: If cancer is found in the sentinel nodes, additional lymph nodes may be removed during a more extensive procedure.
Mohs Surgery: This is a layer-by-layer removal process where each layer is examined under a microscope until no cancer cells are detected.

What to Expect After Melanoma Surgery?

Some pain and discomfort are normal, and pain medication may be prescribed.
Instructions will be given on how to care for the surgical site to prevent infection and promote healing.
Depending on the extent of the surgery, activities might be limited for several days to weeks. Heavy lifting and vigorous exercise might also be restricted.
Follow-up Appointments are crucial for monitoring recovery and detecting any recurrence of melanoma. Based on pathology results, further treatment may be planned.

Melanoma Surgery Recovery Plan

Wound Care: Proper care of the surgical site is crucial. This includes keeping the area clean and dry and applying or changing dressings as instructed.
Pain Management: Use prescribed pain relievers as directed. Over-the-counter pain relief may also be recommended.
Physical Activity: Follow your doctor's advice to gradually increase your activity level. Avoid strenuous activities until your surgeon clears them.
Monitoring for Complications: Watch for signs of infection, such as increased redness, swelling, or drainage from the incision site. If lymph nodes were removed, monitor for signs of lymphedema.
Regular Follow-ups: Attend all follow-up appointments for wound checks, stitches removal, and to discuss the pathology report results. Regular skin checks are important for monitoring for new signs of melanoma.

Melanoma Surgery Prognosis

The prognosis after melanoma surgery depends significantly on the stage of the melanoma at diagnosis. Early detection and treatment typically offer the best prognosis.

Early-Stage Melanoma (Stage I and II): The prognosis is generally very good, with high survival rates. Patients with very thin melanomas (less than 1 mm thick) have a 5-year survival rate that can exceed 90%.
Intermediate-Stage Melanoma (Stage III): The prognosis varies based on the extent of lymph node involvement and other factors. Treatments have improved significantly, and targeted therapies and immunotherapies have enhanced outcomes.
Advanced Melanoma (Stage IV): Although historically associated with a poor prognosis, advances in treatment have improved survival even in this stage, especially with new systemic therapies.

Continuous follow-up is crucial to monitor for recurrence or the appearance of new melanomas, as previous melanoma patients are at higher risk of recurrence.

Melanoma Surgery Risks

Infection: This is a risk with any surgical procedure, and signs include redness, swelling, and pus.
Scarring: Any surgery involving cutting the skin will result in some scarring, although techniques to minimise and manage scars are improving.
Nerve Damage: There may be temporary or permanent sensation changes, especially in areas where nerves are close to the surgical site.
Lymphedema: Particularly after lymph node removal, lymphedema, or swelling due to fluid retention, can occur in some patients.
Bleeding and Bruising: These are common after surgery but usually resolve independently.

What if Melanoma Surgery is Delayed?

Delaying melanoma surgery can have serious implications:

Progression of Cancer
Reduced Treatment Options
Increased Risk of Recurrence
Worse Cosmetic Outcomes

Due to its aggressive nature and potential to spread quickly, melanoma requires immediate consultation and timely management. Early surgical intervention remains the cornerstone for the best outcomes in melanoma treatment, emphasising the importance of early detection and prompt action.