Melanoma: Treatment

Melanoma may be treated by one or more of the following:

Surgery

The first step in treating melanoma is surgery. Today physicians are able to remove far less tissue, achieving the same survival benefits while leaving the patient with a much smaller scar. This type of surgery is called “resection.”

Thin melanomas are often removed in the physician’s office or as an outpatient procedure under local anesthesia.

If the melanoma is thicker, flaps can be made from skin near the tumor, or with grafts of skin taken from another part of the body, insuring a good cosmetic result.

Mohs surgery is the single most effective technique for removing basal cell and squamous cell carcinomas and is now proving an effective way to remove melanoma in situ (contained skin cancers). This surgery spares the greatest amount of healthy tissue while achieving a cure rate of 98 percent or higher.

The procedure allows the surgeon to remove one thin layer of tissue at a time, checking it under a microscope for the presence of cancer cells. If the margins are cancer-free, the surgery is completed. If not, more tissue is removed from the margin until the sample is clear of cancer.

Surgery is the only treatment necessary for in situ melanomas---those that are contained on the surface layer of the skin.
It can also delay the need for systemic treatment for patients whose cancer has spread to one area, or to a very limited degree. Finally, surgery can play an important role in eradicating any residual cancer in patients responding well to the therapies described below.

Immunotherapy

Immunotherapy is the prevention or treatment of disease with substances that stimulate the patient’s own immune response.

One of the immunotherapy agents used for the treatment of advanced melanoma is high-dose interleukin-2 (IL-2). Studies show that immunotherapy with high-dose interleukin-2 (IL-2) is associated with long-term disease-free survival in a very small minority of patients. It is also associated with significant toxicity and with the development of newer drug therapies is rarely used in the treatment of metastatic melanoma.

Another form of immunotherapy uses monoclonal antibodies—proteins made in a laboratory to bind with cancer cells and slow their rate of growth. Ipilimumab is a monoclonal antibody that targets a protein receptor called CTLA-4, causing the body to fight the tumor. This drug has been shown to significantly increase overall survival rates in patients with metastatic melanoma who cannot be cured by surgery. It is considered a break through drug in the treatment of patients with metastatic melanoma and is the first new drug to be approved for the treatment of melanoma in over 20 years. The drug does have side effects and should be administered by a doctor with experience in its use. There are several newer immunological agents being developed for patients with metasatic melanoma including drugs that target the protein PD-1. These drugs appear to have less toxicity since they are more cancer specific. It is anticipated that several drugs targeting PD-1 will soon be approved by the FDA. These drugs have also been shown to significantly prolong survival.

BRAF and KIT gene mutation

Approximately one-half of melanoma patients have a mutation in the BRAF gene caused by over-exposure to the sun’s UV rays.

This mutation activates the MAPK pathway that has been related to many kinds of cancer. Inhibition of BRAF with newly developed drugs (vemurafenib or dabrafenib) significantly increases overall survival of individuals with advanced melanoma and is generally well tolerated..

Treatment with an MEK inhibitor (trametinib) is yet another option for treating tumors containing a BRAF V600 mutation but usually this drug is given in combination with the BRAF inhibitors. Recent studies have shown that the drug combination prolongs the time on BRAF inhibitor before disease worsening and it also reduces some of the side effects associated with BRAF inhibitors.

Treatment with a KIT inhibitor (eg, imatinib) may be considered for patients whose tumors contain a KIT mutation. These patients though usually have melanomas that develop in areas where there is no or less sun exposure such as with the oral cavitiy, the gastrointestinal tract, the nasal sinuses, or on the palms of the hands or the soles of the feet (acral melanomas).

Other rare mutations include mutations in a gene called N-RAS. MEK inhibitors may be active against this mutation either alone or in combination with other drugs.

Radiation Therapy

With advanced radiation therapy techniques doctors can better target tumors while reducing the radiation to nearby healthy tissues. Here at HICCC our radiation oncology experts have the ability to provide “state of the art” treatments for Melanoma.

Your radiation oncologist will design the optimal treatment plan with you to ensure you achieve the best outcomes. Treatment delivery can be daily, weekly, every other day, and or single fraction.

If radiation treatment is recommended, a radiation oncologist will work with our radiation oncology team to create a course of treatment. At Columbia University Irving Medical Center treatment modalities available and most commonly used for this cancer are External Beam Radiation Therapy, 3D Conformal Radiotherapy, Image Guided Radiation Therapy (IGRT), Intensity modulated radiation therapy (IMRT), Stereotactic Body Radiotherapy (SBRT) and Brachytherapy Eye Plaque.

Chemotherapy

Chemotherapy

Chemotherapy drugs are designed to kill cancer cells. The medications can be given orally (by mouth), intramuscularly (injection into a muscle) or intravenously (through a vein).

Chemotherapy has not been shown to increase survival or to bring about a lasting remission from melanoma. For this reason, it is generally given only to patients who are not candidates for immunotherapy or targeted therapy, and for whom there is no appropriate clinical trial.