MelanomaTreatment
Melanoma treatment consist of five types of standard options.
The Skin Cancer Program developed
immunotherapies that are both
FDA-approved and in development,
including ipilimumab
for metastatic
melanoma patients
Surgery for Melanoma Treatment
Stanford surgeons have great expertise in melanoma treatment, from early disease to the most advanced. Dermatologic surgeons operate on patients with melanoma in situ and thinner tumors that do not require simultaneous staging with the sentinel lymph node biopsy procedure. Surgical Oncologists specialize in melanoma treatment for patients with head and neck tumors (Otolaryngology, Head & Neck Surgery) or for melanoma elsewhere on the body (General Surgery/Surgical Oncology) .
Stanford Melanoma Surgery
Stanford surgeons were among the first in northern California to perform sentinel node biopsy/dissection for melanoma treatment and have been utilizing this staging procedure since 1996. Our surgical, nuclear medicine, and pathology services offer exceptional expertise in this advanced procedure used to stage the regional node basin(s) for appropriate patients with invasive cutaneous melanoma and with Merkel cell carcinoma. The sentinel node biopsy examines the regional lymph nodes for possible microscopic spread of melanoma. This advanced procedure sequentially combines preoperative lymphoscintigraphy and intraoperative mapping to provide a highly reliable means of identifying the sentinel lymph node(s) and is generally used to stage cutaneous (skin) melanomas great than or equal to 1 mm depth and thinner melanomas with adverse histologic features
Significant advances in localizing sentinel lymph nodes have occurred over the years, and the Stanford melanoma surgeons work closely with the Stanford Division of Nuclear Medicine and Molecular Imaging during the preoperative assessment and lymphatic mapping. Newer imaging techniques, such as SPECT/CT, have dramatically improved our surgeons’ ability to assess the location of the sentinel lymph node in the setting of complex anatomy (SEE FIGURE of SPECT/CT). Novel devices to help facilitate the intraoperative localization of sentinel nodes are also being developed at Stanford and tested in conjunction with members of the Radiology and Engineering Departments. One such device that is currently under investigation is a handheld gamma camera, developed in the Molecular Imaging Program at Stanford, that allows for real-time spatial imaging of the sentinel lymph nodes containing the radioactive tracer.
In addition to providing the most comprehensive care for patients with melanoma, the improved understanding of the biology and clinical behavior of melanoma is an ever-present goal of the Melanoma Program. As such, Stanford Institutional Review Board-approved databases of sentinel lymph node biopsy data and outcomes are maintained and analyzed. In addition, our Stanford Melanoma Program clinicians work very closely with basic science laboratories within the Stanford Cancer Institute, that are studying tissue obtained from surgery to identify better prognostic markers and therapeutic targets. This has led to novel discoveries, and some of this work is now being applied to early preclinical studies to improve disease management.
Types of Surgery used for Melanoma Treatment:
Whenever possible, surgery to remove the tumor is the primary treatment of all stages of melanoma. The doctor may remove the tumor using the following operations:
- Wide Local excision
This involves surgical removal of the melanoma and some normal tissue around it. The amount of normal tissue taken (also called the clinical margin) depends on the thickness of the melanoma. Skin grafting (taking skin from another part of the body to replace the skin that is removed) or rotation flaps of skin from other sites may be used to cover the wound resulting from the wide local excision, but most cutaneous melanoma excisions can be closed without placement of a skin graft. - Wide local excision with Sentinel Lymph Node biopsy
The surgical removal of the melanoma with selective biopsy of the sentinel node(s) in the regional lymph node basin(s). This is typically performed for thicker skin melanomas (>1 mm) or thinner ones with adverse histologic features. - Sentinel lymph node biopsy
The removal of the sentinel lymph node (the first lymph node to which the cancer is likely to spread). A radioactive tracer and/or blue dye is injected near the tumor before surgery in a process called lymphatic mapping (or lymphoscintigraphy) The radioactive tracer or dye flows through the lymph channels in the skin to first draining lymph nodes in the region(s) around the melanoma. The injection of the radioactive tracer is performed in the Nuclear Medicine Department either the evening before surgery or several hours before surgery. A body scan is then performed to help the surgeon localize the sentinel lymph node before beginning the operation (SEE FIGURE of SPECT/CT). This first lymph node(s) to receive the tracer is removed for biopsy. A pathologist then views the tissue under a microscope to look for cancer cells and often uses additional tissue stains (immunostains) to determine whether microscopic evidence of melanoma is evident in the regional lymph nodes. If cancer cells are not found, no further surgery is necessary. - Lymphadenectomy
A surgical procedure in which a comprehensive removal of the draining lymph nodes is performed. This is often performed if the sentinel lymph node biopsy is positive for microscopic melanoma involvement and is termed a completion lymphadenectomy. Lymphadenectomy is also performed if a patient presents with palpable regional lymph nodes known to be involved by the melanoma. - Metastasectomy
Some melanoma that has spread to distant sites in the body (lung, liver, brain, gastrointestinal tract) may be amenable to surgical removal. The process of removing distant metastasis is called metastasectomy, and it has been associated with improved survival in select patients with limited sites of involvement.
Immunotherapy for Melanoma Treatment
Immunotherapy or other systemic therapy given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. This treatment uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment currently involves the use of adjuvant interferon, ipilimumab, and other immune activating agents, such as interleukin-2 (IL-2). Investigators at Stanford are leaders in understanding the interaction between cancer and the immune response and are developing new strategies for stimulating the immune system to fight cancer. Stanford is participating in an ECOG trial (E1609) to assess the use of adjuvant high-dose interferon vs. low- or high-dose ipilimumab in patients with surgically removed macroscopic regional lymph node disease, satellite or in-transit disease, or distant disease (limited to skin, subcutaneous tissue, lymph nodes, or lungs).
Interleukin-2 therapy
Interleukin-2 (Il-2) is a very potent stimulator of the immune system and as such, has been used in melanoma therapy for about 20 years. Select patients with advanced melanoma (stage IV) who are in good health may be offered treatment with high dose bolus Interleukin-2 therapy, which is administered as an inpatient by our melanoma oncologists at Stanford Hospital. Stanford. Interleukin-2 is the only FDA approved therapy that, in certain patients, can induce long term remissions in a small percentage of individuals with metastatic melanoma. The use of IL-2 requires stress testing prior to admission and involves 5 days of inpatient therapy every 2 weeks.
Chemotherapy for Melanoma Treatment
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It is used for advanced stage IV melanoma, but is not generally effective in destroying cancer cells by itself. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Targeted Therapy for Melanoma Treatment
Melanoma treatment has been greatly advanced through an understanding of specific genetic mutations in the tumor cells themselves that can be “targeted” for cell death, without affecting most normal tissues. New classes of targeted therapies have been FDA-approved for advanced melanoma and are also being studied in the adjuvant setting for surgically removed lymph node disease. Stanford offers standard therapy with the novel drug vemurafenib for patients whose melanoma harbors the BRAF mutation (which is assessed through testing of the tumor cells). The Stanford melanoma program is also investigating the use of a KIT mutation inhibitor as part of a national ECOG trial (E2607) for patients with locally advanced, or metastatic mucosal melanoma, acral (hands and feet) melanoma, vulvoginal melanoma, or melanoma arising from skin on sun damaged sites, that cannot be removed by surgery.
Radiation Therapy for Melanoma Treatment
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. The Stanford Melanoma Program is investigating the potential additive effects of radiation therapy in combination with the novel immunotherapy agent, ipilimumab, in patients with advanced (stage IV) melanoma.
CyberKnife (stereotactic radiosurgery) was developed by Stanford neurosurgeons nearly 20 year ago and is offered for brain metastases and selected other sites of disease. Multi Center Clinical Trials for Treatment of Stage III and Stage IV Melanoma
Trial Administration