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During your first visit to the Melanoma Program, we will thoroughly explain and discuss your diagnosis, including a review of your pathology report and/or x-rays. We also will review your treatment options and answer any questions or concerns you have. We want to understand your individual needs as a new patient so we can provide the best possible care. To do that, we will obtain a detailed medical history, perform a routine physical exam, and review other relevant medical information (prior labs and test results). We also will arrange for any additional tests, if necessary, and a follow-up appointment to discuss these additional test and treatment options. Diagnostic tests and services during your follow-up exam may include: You may need additional diagnostic tests to stage your cancer. These may include:
We also may refer you to other specialists, depending on your specific health needs. Our goal is to provide you efficient, individualized treatment, so that you can return to your normal activities as soon as possible.
Melanomas are staged based on several factors, including thickness, microscopic features, lymph-node involvement, and whether it has spread to distant areas. The staging of your melanoma will be reviewed in detail at your consultation, and will dictate what type and extent of treatment you will require.
NOTE: Many pathology reports will mention a “Clark’s level,” which is often misunderstood as the stage of the melanoma. Please be aware that Clark’s level is no longer used to stage melanoma and will not be used to determine your prognosis or treatment.
Treatment options for both non-melanoma and melanoma-aggressive skin cancers include surgery, chemotherapy, immunotherapy, and radiation therapy. Generally, melanomas are removed surgically, with chemotherapy and/or radiation often recommended later. The extent of treatment is determined by size of the lesion, depth of invasion, whether there is ulceration, whether there are satellite lesions, and whether there are lymph nodes involved.
Surgery may be performed to remove cancer that has spread to other parts of the body. This is done to relieve pain or discomfort associated with the growing cancer. The skin cancer and some surrounding tissue will be removed. How much skin is removed depends on how deep the melanoma has grown. If the cancer has spread to nearby lymph nodes, these lymph nodes also may be removed.
All melanomas require a wide local excision, the term used for removing the melanoma with a margin of normal tissue around it to minimize the chance of it recurring in the same area. The length of the margin is based on the thickness of your melanoma and its location, and can vary from 5 mm to 2 cm. A full thickness excision is performed, extending all the way down through the underlying fatty tissue to the bone or muscle, whichever is most superficial. This tissue is typically removed in the shape of an ellipse, or an elongated football shape. This allows us to close your skin in a straight line, which is more appealing cosmetically. The stitches used to close a wide local excision stay in about 1-3 weeks and will be removed in our office at your follow up appointment. Some melanomas on the face, scalp or other locations may require a skin graft or a specialized rotation flap closure by a plastic surgeon to close the defect after removal.
Based on the stage of your melanoma, we may recommend a sentinel lymph node biopsy. This is a procedure performed in the operating room at the same time as your wide local excision. The purpose of a sentinel lymph node biopsy is to sample the lymph nodes that are at greatest risk for spread, or metastasis, of the melanoma. The first step is a procedure called a lymphoscintigraphy, which involves an injection of a radioactive protein around the melanoma in the Nuclear Medicine department. The protein travels through the lymphatic channels and settles into the lymph nodes that drain the area of your skin where the melanoma is situated. A series of X-rays are performed, which helps us identify the location of the lymph nodes that need to be removed. A melanoma specialty doctor will meet with you in the pre-operative holding area and review the results of the lymphoscintigraphy with you prior to your surgery. Following your wide local excision, the sentinel lymph nodes are accessed through a small incision and sent to the pathologist for review under the microscope. The results will be available in about 7-10 business days and will either be called to you, or discussed at your post-operative visit. The operative procedure takes about 60-90 minutes to perform and no overnight stay is required.
Chemotherapy involves the use of medicine to kill cancer cells. More than half of all people diagnosed with cancer receive chemotherapy. The thought of having chemotherapy may be frightening, but for millions of people, this approach is effective and gets them back to enjoying full, productive lives. Many side effects once associated with chemotherapy can now be prevented or controlled, allowing people to go on with their normal activities during treatment. Chemotherapy may be administered intravenously, injected into a body cavity, or delivered orally in the form of a pill.
At Northside's Infusion Centers, chemotherapy is dispensed on an outpatient basis by registered nurses who are certified in chemotherapy administration. These nurses also provide ongoing physical assessments.
Medications such as interferon or interleukin help your immune system fight the cancer. They may be used along with chemotherapy and surgery.
Radiation is often used to treat both the site of disease and the draining lymph nodes which may be at risk. Northside Hospital Cancer Institute offers state-of-the-art radiation therapy techniques that expand patient options when dealing with aggressive skin cancer.
Before radiation therapy, a team of medical professionals will use CT, MRI, and/or PET imaging scans to accurately localize the area to be treated. Then, an advanced treatment planning process will allow us to spare normal tissue in proximity to the tumor. Two categories of radiation therapy are available: external beam radiation therapy (EBRT) and brachytherapy.
In EBRT, a sophisticated treatment machine (called a linear accelerator) produces high-energy X-rays that shape multiple beams or arcs of radiation, carefully conforming to the shape or volume of the tumor. This spares surrounding healthy tissues. EBRT may be delivered as stationary beams that match the tumor shape (3-D conformal radiation therapy) or as dynamic beams that intricately change shape to produce refined radiation fields that spare healthy tissues very close to the tumor. Each of these treatments is combined with leading-edge imaging technologies that help precisely match the radiation beams to the treatment area just before the x-ray beam is turned on, or even real-time during treatment. EBRT typically lasts for 10-20 minutes at each session, five sessions per week, and may be prescribed by your Radiation Oncologist for about three to six weeks in total.
If you have melanoma that is hard to treat, you might consider enrolling in a clinical trial. Ask your doctor for more information. Researchers continue to study new treatments.
As cancer is a moving target, cancer care is also an evolving process including clinical trials and molecularly-based precision medicine. Northside's Research Program is one of the largest community-based oncology/hematology programs in the nation. Our Sarcoma Program maintains ongoing access to promising National Cancer Institute (NCI) and industry-sponsored clinical trials, which include trials designed to determine the impact of multigene panel molecular tumor profiling in patient management as well as routine genetic mutational analysis for patients with early-stage melanoma. Learn more about Clinical Trials at Northside.