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MALIGNANT MELANOMA
( By JASCAP )

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Treatment

Treating thin melanoma (less than 1mm)

The only treatment needed for a thin melanoma is:

removing the whole mole
wide local excision (to make sure no melanoma cells are left behind).

After your whole mole has been removed (see diagnosis) and the results show that it is a melanoma, your specialist may ask you to have a wide local excision. If enough clear tissue was taken away when your melanoma was removed you might not need to have a wide local excision

Wide local excision
Change in appearance
Benefits and disadvantages of treatment

Wide local excision

The surgeon removes a small amount (margin) of normal-looking tissue all around the area where the melanoma was. This is to make sure that no melanoma cells have been left behind.

You will usually have this done under local anaesthetic in the day surgery unit in the same way as you had your mole removed. It may sometimes be done under general anaesthetic.

The surgeon usually removes at least 1cm of skin all around the melanoma. Your specialist nurse will give you information and advice about looking after the area. It will look red and sore at first, but this will gradually settle. Your stitches will be removed after 5Ė14 days. You will be left with a scar which is usually small and will eventually fade.

Very occasionally, a wider area of skin is removed and the surgeon may need to do a skin graft. Skin grafts are layers of skin taken from another part of the body and placed over the area where the melanoma has been removed. However, you donít usually need to have a skin graft if you have a thin melanoma removed.

Change in appearance

If the melanoma was on a visible part of your body (exposed), such as your face or neck, and its removal has changed your appearance, this may be difficult to come to terms with. Some skin clinics have a make-up specialist who will help you find the best way to cover up scars. There are also some organisations that provide camouflage make-up to cover up scars

Coping with a change in how you look can be difficult. Itís important to get support and many people find it helps to talk things through with someone close or a trained counsellor.

Benefits and disadvantages of treatment

Surgery has a very high chance of curing a thin melanoma. The surgery will leave a scar on the skin but this will fade and may not be noticeable, depending on where your melanoma was. Without surgery melanoma is likely to spread into the deeper layers of the skin and may then spread to other areas of the body.

If you have any questions, donít be afraid to ask your doctor or the nurses looking after you. It often helps to make a list of questions for your doctor and to take a close friend or relative to the discussion with you.

Treatment of stage 2 and 3 melanoma

Stage 2 is when the melanoma is more than 2mm thick, or more than 1mm thick and ulcerated (the skin is broken). Stage 3 is where melanoma cells are found in one or more lymph nodes.

After diagnosis and initial treatment you may have further tests to check if the cancer has spread to the lymph nodes and further treatment to try to reduce the risk of the melanoma coming back.

The lymph nodes
Further tests
Further treatment

The lymph nodes

The lymph nodes are part of the lymphatic system, which is part of the body's natural defence against infection. The lymph nodes (sometimes called glands) are situated throughout the body and are connected by very fine lymphatic vessels. Fluid drains from the tissues into the lymphatic system.

The lymphatic system

Sometimes melanoma cells can travel to the lymph nodes. If you have melanoma, your doctor may suggest further tests to see if it has spread.

Further tests

Fine needle aspiration (FNA)

Your doctor may suggest this if you have a swollen lymph node. The doctor uses a fine needle and syringe to take some cells from the swollen node. These are then examined in the laboratory.

Sentinel node biopsy

Your surgeon may suggest that during or after your operation you have a sentinel node biopsy to see if the melanoma cells have spread to the lymph nodes. The sentinel node is the one closest to the melanoma. To identify the sentinel node, two substances are injected into the area Ė one is mildly radioactive and the other is coloured blue. The surgeon removes the node which has taken up these liquids (the sentinel node), so it can be tested to see whether it contains melanoma cells.

The risk of problems following the sentinel node biopsy is very low. They include infection or having some fluid collect in the area. These can easily be treated.

Sentinel node biopsy is still being researched in trials, to see how effective it is.

If you have a sentinel node biopsy, you may not need to have any other lymph nodes removed. If melanoma cells are found in the sentinel node, your doctor will suggest another operation (lymph node dissection) to remove more of the lymph nodes in the area.

Lymph node dissection

This is an operation to remove all the lymph nodes in the area. It is sometimes called a block dissection and is done under a general anaesthetic. You will have some soreness for a few weeks after the operation, but hopefully it should not stop you doing any of your normal activities. Your doctor or nurse will give you detailed advice about what you can or canít do. Sometimes, the removal of lymph nodes may cause a gradual swelling in the limb where the glands were removed. This is called lymphoedema.

The following tests may be done either before or after you have a lymph node dissection.

Blood tests

To check your general health.

Chest x-ray

To check your general health and look for any signs of melanoma in the lungs.

Liver and abdominal ultrasound scan

This uses sound waves to make up a picture of a particular area of the body. Once you are lying comfortably on your back, a gel is spread on your abdomen. A small device like a microphone is then passed over the area. The echoes are converted into a picture by a computer.

CT scan (computerised tomography scan)

A series of x-rays is taken of the chest and abdomen. These are fed into a computer to build up a detailed picture of the body's organs and may show whether the melanoma has spread. The scan takes from 10 to 30 minutes. You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand. You will probably be able to go home as soon as the scan is over. Your doctor may also want you to have a CT scan of your brain.

Further treatment

Treatment is sometimes used after surgery to try to reduce the risk of the melanoma coming back. This is called adjuvant treatment. At the moment, there is no standard adjuvant treatment for stage 2 or 3 melanoma, although treatment with a drug called interferon is sometimes suggested.

Interferon is a substance produced by the body to fight viral infections such as flu. A man-made version is available. The aim is that interferon will help stimulate the bodyís own immune system to fight the melanoma. Interferon is given as an injection just under the skin (subcutaneously) usually three times a week. Interferon can cause side effects similar to flu symptoms (fever, chills, headache, tiredness). Although these can be troublesome, they gradually disappear once the treatment is over.

Treatment for advanced (stage 4) melanoma

Melanoma can spread to other areas in the body, including the lungs, liver, lymph nodes and the brain. It can also affect other areas of skin some distance from where it first started. Melanoma which has spread is called advanced or stage 4 melanoma. Doctors also use terms like secondary or metastatic cancer, which means cancer that has spread from its original site.

The treatment you have will depend on where the melanoma has spread to, your general health, and what treatment you have already had.

Further tests used to diagnose stage 4 melanoma
Treatment
Advantages and disadvantages of treatment
New treatments

Further tests used to diagnose stage 4 melanoma

You may have several different tests depending on the symptoms you have. These can include:

Blood tests

To check your general health.

Chest x-ray

To check your general health and look for any signs of melanoma in the lungs.

Liver and abdominal ultrasound scan

This uses sound waves to make up a picture of a particular area of the body. Once you are lying comfortably on your back, a gel is spread on your abdomen. A small device like a microphone is then passed over the area. The echoes are converted into a picture by a computer.

CT scan (computerised tomography scan)

A series of x-rays is taken of the chest and abdomen. These are fed into a computer to build up a detailed picture of the body organs and may show whether the melanoma has spread. The scan takes from 10 to 30 minutes. You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes this may make you feel hot all over. If you are allergic to iodine or have asthma, it is important to let your doctor know this beforehand, as you could have a serious reaction to the injection. You will probably be able to go home as soon as the scan is over. Your doctor may also want you to have a CT scan of your brain.

MRI scan (magnetic resonance imaging scan)

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. You will be asked to lie very still on a couch inside a long tube for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It is also noisy, but you will be given earplugs or headphones. Some people are given an injection of dye into a vein in the arm, but this usually does not cause any discomfort.

Treatment

Treatment for advanced melanoma aims to slow down the progress of the cancer. It can also help with some of the symptoms. You may want to discuss the aims of treatment with your doctors.

Surgery

If the melanoma is in the skin, the lymph nodes or in a single part of the brain, your doctors may suggest an operation to remove it. Surgery can also be used to help relieve symptoms of advanced melanoma.

Biological therapies

Biological therapies are based on substances naturally produced in the body. The main one used in melanoma treatment is interferon. Interferon is produced by the body to fight viral infections. A man-made version is available. The aim is that interferon will help stimulate the bodyís own immune system to fight the cancer.

Interferon is given as an injection just under the skin (subcutaneously) usually three times a week. It can cause side effects similar to flu symptoms (fever, chills, headache and tiredness). Although these can be troublesome, they gradually disappear once the treatment is over. Another type of biological therapy is interleukin. This is used more often in the USA. Interleukin tends to cause more side effects than interferon. There is no evidence that either drug is more effective than the other.

Chemotherapy

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. A drug called dacarbazine (DTIC) can be used to treat advanced melanoma. Sometimes it is used with other chemotherapy drugs. Most chemotherapy is given by an infusion (drip) into one of the veins in your arm (intravenously). It is usually given every three or four weeks. Another chemotherapy drug, temozolomide (Temodal®), is also being used in research trials for melanoma.

Isolated limb perfusion

If the secondary melanoma is confined to just an arm or a leg, your doctors may suggest isolated limb perfusion. This is a specialised procedure, only available at some hospitals, which allows chemotherapy to be given to just one limb. The side effects are reduced because the chemotherapy does not affect the rest of the body.

Radiotherapy

Radiotherapy uses high-energy rays to destroy cancer cells, while doing as little harm as possible to normal tissue. It may be used if, for example, cancer has spread to the bones, as it can help relieve pain. It may also be used to treat melanoma in the skin and brain.

Advantages and disadvantages of treatment

Treatment for advanced melanoma can only control the cancer and lead to an improvement in symptoms and quality of life. However, for some people the treatment will have very little effect on the cancer, and they will get the side effects without many of the benefits.

If a cure is not possible and the treatment is being given to control the cancer, you may want to consider whether you wish to have treatment. Making decisions in these circumstances is always difficult, and you may need to discuss your situation in more detail with your doctor. If you choose not to have treatment, you can still be given supportive care, (also known as palliative care) with medicines to control any symptoms.

New treatments

Cancer vaccines

Vaccines are being researched to see if they are useful to treat melanoma. It is hoped that cancer vaccines will help stimulate the bodyís own immune system to destroy the cancer cells.

Biochemotherapy

This treatment uses a biological treatment, such as interferon, in combination with chemotherapy to treat melanoma.

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