The Johns Hopkins Melanoma Program treats between 250 – 300 cases of newly diagnosed melanoma per year. With a long history of conducting pivotal research and clinical innovations in melanoma care, Johns Hopkins faculty led randomized clinical trials to set the standards for melanoma surgical margins, wrote the definitive textbook on melanoma for health care professionals, and chair the committee that determines worldwide staging parameters. Surgical oncology faculty members have demonstrated expertise in melanoma among children, teenagers, and young adults, authoring several editorial articles and recently completing one of the largest review studies of the presentation and outcomes in young melanoma patients. In addition, surgical faculty in the Melanoma Program have specialized board certifications, received formal training in oncology, and are members of the Society for Surgical Oncology.
Surgery is the primary treatment for localized and regionally metastatic melanoma. The Johns Hopkins approach involves teams of specialists working together to deliver the entire scope of care, from initial biopsy to surgery and reconstruction. Our combined surgical expertise across many specialties, including surgical oncology, plastic and reconstructive surgery, otolaryngology, neurosurgery, and ophthalmology provides exceptional capability in managing some of the most complicated cases. Surgery can be combined with other therapies, such as biologics and radiation, to treat high-risk, resected primary and recurrent melanomas.
Staging with Sentinel Lymph Node Biopsy
Johns Hopkins faculty were some of the first to perform sentinel lymph node biopsies when the technique was introduced in the 1980’s. Sentinel lymph node biopsy is now well-established as a staging procedure for patients with newly diagnosed melanoma. Sentinel node biopsy results help us estimate a patient’s future risk of recurrence and often helps guide treatment choices. Areas of ongoing debate surrounding the procedure involve interpretation of whether residual microscopic disease has an impact on outcomes and whether all patients need complete lymph node dissections upon finding microscopic deposits of melanoma in sentinel lymph nodes.
Multicenter Selective Lymphadenectomy Trial II: Johns Hopkins will be participating in an international study called the Multicenter Selective Lymphadenectomy Trial II (MLSTII) to determine whether patients with melanoma in the sentinel node have better survival with complete node dissection as compared to patients who are observed without complete dissection. Patients enrolling in the trial will be randomly assigned to receive either complete dissection or close observation with follow-up ultrasound.
Surgical Management of Melanoma
The first-line or standard treatment for most melanomas is surgical excision. Small tumors generally can be removed during an outpatient surgery, with a centimeter (about a half-inch) of normal appearing skin surrounding the melanoma. Surgery cures the majority of people with early stages of melanoma when they have early, thin tumors that have not spread from the original site.
Surgery for melanomas that are not very thin may require a wider excision of two centimeters (about an inch) of skin around the melanoma. This is usually performed as an outpatient procedure. Simple surgical procedures can still allow for a primary closure of most wounds, but occasionally, a skin graft or more complex reconstruction is required to close the wound. In cases where the melanoma is known to have spread to the lymph nodes, the lymph nodes may also need to be surgically removed.
During surgery, your doctor will remove the tumor (or its biopsy site) along with an area of surrounding skin in order to lower the risk of a recurrence. How much skin is removed along with the tumor depends on the tumor’s thickness, which helps determine the stage of melanoma. Johns Hopkins surgical oncology faculty have led studies and chair international committees that have determined the following criteria for the margin of tissue removed during surgery and the classification of melanomas, depending on their size, into specific stages.
- In stage 0, also called melanoma in situ, the tumor is limited to the outer layer of skin cells. Your doctor will remove the lesion along with a half centimeter border of normal skin.
- For stage 1 melanomas that are no more than 1 millimeter thick, or tumors less than 2 millimeters with no ulceration, your doctor will remove the lesion along with a 1 centimeter border of normal skin or tissue.
- For stage 2 melanomas in which the tumor is between 1 and 2 millimeters thick and has ulceration, or the tumor is more than 2 millimeters, the surgeon will remove the lesion along with a 2-centimeter border.
- For thicker melanomas that are more then 4 millimeters, the surgeon will remove the lesion along with a minimum 2-centimeter border of skin, unless the tumor is on the face, where a 2-centimeter margin could result in cosmetic flaws or is located too close to the eyes, ears, nose or mouth.
Local recurrences of melanomas less than 2 millimeters thick are rare. Risk can be determined by the biology of the tumor as determined by location, thickness and whether ulceration is seen under a microscope.
Management of Local Recurrence of Melanoma
A re-growth of melanoma within 2 centimeters of the original tumor site is known as a local recurrence. Johns Hopkins surgical oncologists make every effort to prevent re-growth by removing the original melanoma along with a border of skin and underlying tissue.
Melanoma Recurrence Beyond the Original Site
Melanoma recurrences can also result when there is melanoma growth beyond the area originally removed by surgery, sometimes in nearby lymph nodes or other areas of tissue. Melanomas also can be spread by the bloodstream, resulting in new areas of re-growth. If a melanoma is going to recur, it will usually recur within the first two to five years after the original diagnosis and treatment. Patients having a local recurrence are strongly at risk of recurrence elsewhere in the body.
Factors that increase the risk of a recurrence are:
- Thicker original melanomas, especially if located on the head, neck, hands and feet.
- Presence of ulceration in the original melanoma
- Lymph nodes positive for melanoma
Because of the high prevalence of metastasis, patients with local or regional recurrences of melanoma should have a physical examination and and imaging scans of the chest, abdomen and pelvis. The scan will take detailed, cross-sectional images of tissue. The scanning can be with a high-quality CT scan or with a combined PET-CT scan. Johns Hopkins nuclear medicine specialists have studied the application of combined positron emission tomography (PET) scanning with CT scanning to detect recurrent melanoma.
Surgery remains the first-line treatment for local and regional recurrences. Lymph node metastasis detected by physical examination or scanning may be treated by complete surgical removal of regional lymph nodes (lymph node dissection, or lymphadenectomy).
Other treatments occasionally appropriate include:
- Hyperthermic isolated limb perfusion – This treatment can be used for a type of melanoma recurrence known as in transit metastases, in which several re-growths appear on a limb near an area where a melanoma tumor had been removed. It is an operation usually performed under general anesthesia in which the main artery and vein of the affected limb are connected to a bypass circuit, to completely isolate blood flow to and from the limb and treat that extremity with chemotherapeutics and heat.
- Intra-arterial infusion – With this method, which is simpler than the hyperthermic isolated limb perfusion to treat multiple melanoma recurrences in a limb, infusion of a chemotherapy drug is done through catheters inserted through the skin rather than with a surgical procedure.
- Local radiation therapy – Radiation therapy is usually not a substitute for surgery, but is sometimes useful to help reduce the risk of recurrence in a specific high-risk area or to provide symptom relief when a site cannot be removed surgically.