Once melanoma has been diagnosed by a skin biopsy, Mr Myles Smith will advise you on the type and extent of surgery you will require, depending on the stage of melanoma and where it is located.

Do I need a further excision of melanoma?

If you have been diagnosed with a melanoma, the next step is to perform a wide local excision of the scar.  This will reduce the risk of the melanoma coming back.

How wide is a wide local excision for melanoma?

How wide a further excision will be, is dependent on the Breslow Thickness (depth of invasion, measured in millimetres). Current British Association of Dermatology guidelines recommend a 0.5cm wide excision for a melanoma in situ (which hasn’t invaded), a 1cm wide excision for a melanoma that is 0.1-0.9mm thick, 1-2cm for a melanoma 1-2mm thick, and 2cm for a melanoma thicker than 2mm.

Will I need a sentinel node biopsy?

It is important to determine whether melanoma has spread to the lymph nodes in the region of the melanoma.

This can be determined by serial ultrasound surveillance or sentinel node biopsy.

A sentinel node biopsy may be considered at the same time as a wide excision. This is a procedure where you identify the lymph node that will drain the area of skin where a melanoma arises.

In other words, if a melanoma cell is spreading through the lymphatic system, this is the first node that it will reach. Generally, it is performed by injecting a small amount of radioisotope and blue dye, allows preoperative identification of the node with radioisotope scans, and at the time of surgery, identifying blue dye in the sentinel node, and confirming the presence of a radioactive signal with a gamma probe.  The amount of radioactivity is very small and safe for patients, and the incision made is small, usually less than 3cm.

The sentinel node (or nodes, with up to 3 removed) is then examined very thoroughly by pathologists to identify whether there is melanoma in the node.

If there is no melanoma (the majority of cases) you may be discharged back to the care of your dermatologist, for secondary skin surveillance, as melanoma patients have a risk of developing further melanomas and other skin cancers.

If there is melanoma present, you may be recommended to have further ultrasound surveillance, with a dissection of the remaining nodes only in very specific circumstances. You may be referred on for consideration of surveillance with CT and MRI scans, consideration of clinical trial, or for consideration of adjuvant treatment to reduce the risk of melanoma recurring.

Do I need a node dissection?

If you present with nodes that you can feel, that have confirmed melanoma by biopsy, you may be considered for a node dissection, where all of the nodes in that region (for example the inguinal region, or axilla/armpit) are removed. That will be to remove all melanoma in that site and can give symptomatic relief. You will be referred on for consideration of surveillance with CT and MRI scans, consideration of clinical trial, or for consideration of adjuvant treatment to reduce the risk of melanoma recurring.

In transit metastasis

In transit metastases are lesions that arise at least 2 cm away from the original tumour, and arise before the draining lymph node. For example, lesions which appeared on the arm, with a primary tumour on the hand.

They can be treated in many ways, which include surgical excision, surgery with laser to excise and vaporise, and isolated limb perfusion and infusion.  Injectable therapies such as T-VEC (Talimogene laherparepvec, Imlygic) may be helpful in treating areas not amenable to surgery.

Surgery for Stage IV melanoma

Surgery may have an important role for patients with metastatic melanoma.  All patients should be considered for effective systemic therapy (such as immunotherapy and small molecule inhibitors), however, in certain settings of small amounts of metastatic disease, symptomatic metastasis, or in combination with effective systemic therapy (either before or after surgery) within a multidisciplinary team.

Anorectal melanoma

Melanoma can occur in areas that are not sun exposed, such as the sole of the foot, and in mucosal membranes, such as the rectum.  It can be difficult to identify anorectal melanomas early, as they present in a very similar way to common anorectal problems, like haemorrhoids, or rectal cancers.  It is important to treat these cancers in centres with expertise in complex anorectal surgery and melanoma 

Relevant publications:

Mucosal melanoma guidelines (anorectal melanoma)

• Smith MJF, Smith HG, Joshi K, Gore M, Strauss DC, et al. The impact of effective systemic therapies on surgery for stage IV melanoma. Eur J Cancer. 2018 Nov;103:24-31. PubMed PMID: 30196107.
• Snow HA, Hofman MS, Mitchell CA, Gyorki DE, Smith MJF. Incidental Metastatic Melanoma Identified on 68Ga-Prostate-Specific Membrane Antigen PET/CT for Metastatic Prostate Cancer. Clin Nucl Med. 2018 Jul;43(7):509-511. PubMed PMID: 29742609.
• Arce Vargas F, Furness AJS, Litchfield K, Joshi K, Rosenthal R, et al. Fc Effector Function Contributes to the Activity of Human Anti-CTLA-4 Antibodies. Cancer Cell. 2018 Apr 9;33(4):649-663.e4. PubMed PMID: 29576375; PubMed Central PMCID: PMC5904288.

More publications

Patient information:

Melanoma Patient Decision Aid

For more information on the surgical procedures offered by Mr Myles Smith or to arrange a consultation, please either fill in the contact form or contact us via phone or email.

THE ROYAL MARSDEN HOSPITAL

E: Myles.smithPA@rmh.nhs.uk

T: 020 7811 8208

LISTER HOSPITAL

E: MylesSmith.Secretary@hcahealthcare.co.uk

T: 020 3770 5864

F: 020 7881 4094