Treatment of Melanoma Skin Cancer, by Stage

The type of treatment(s) your doctor recommends will depend on the stage and location of the melanoma and on your overall health. This section lists the options usually considered for each stage of melanoma.

Treating stage 0 melanoma

Stage 0 melanomas have not grown deeper than the top layer of the skin (the epidermis). They are usually treated by surgery (wide excision) to remove the melanoma and a small margin of normal skin around it. The removed sample is then sent to a lab to be looked at with a microscope. If cancer cells are seen at the edges of the sample, a repeat excision of the area may be done.

Some doctors may consider the use of imiquimod cream (Zyclara) or radiation therapy instead of surgery, although not all doctors agree with this.

For melanomas in sensitive areas on the face, some doctors may use Mohs surgery or even imiquimod cream if surgery might be disfiguring, although not all doctors agree with these uses.

Treating stage I melanoma

Stage I melanoma is treated by wide excision (surgery to remove the melanoma as well as a margin of normal skin around it). The margin of normal skin removed depends on the thickness and location of the melanoma.

Some doctors may recommend a sentinel lymph node biopsy, especially if the melanoma is stage IB or has other characteristics that make it more likely to have spread to the lymph nodes. You and your doctor should discuss this option.

If cancer cells are found on the sentinel lymph node biopsy, a lymph node dissection (removal of all lymph nodes near the cancer) is often recommended, but it’s not clear if this improves survival. Some doctors may recommend adjuvant (additional) treatment with interferon after the lymph node surgery. Other drugs or perhaps vaccines might be options as part of a clinical trial to try to lower the chance the melanoma will come back.

Treating stage II melanoma

Wide excision (surgery to remove the melanoma and a margin of normal skin around it) is the standard treatment for stage II melanoma. The amount of normal skin removed depends on the thickness and location of the melanoma.

Because the melanoma may have spread to lymph nodes near the melanoma, many doctors recommend a sentinel lymph node biopsy as well. This is an option that you and your doctor should discuss. If it is done and the sentinel node contains cancer cells, then a lymph node dissection (where all the lymph nodes in that area are surgically removed) will probably be done at a later date.

For some patients (such as those with lymph nodes containing cancer), doctors may advise treatment with interferon after surgery (adjuvant therapy). Other drugs or perhaps vaccines may also be recommended as part of a clinical trial to try to lower the chance the melanoma will come back.

Treating stage III melanoma

These cancers have already reached the lymph nodes when the melanoma is first diagnosed. Surgical treatment for stage III melanoma usually requires wide excision of the primary tumor as in earlier stages, along with lymph node dissection. Adjuvant therapy with interferon may help keep some melanomas from coming back longer. Other drugs or perhaps vaccines may also be recommended as part of a clinical trial to try to reduce the chance the melanoma will come back. Another option is to give radiation therapy to the areas where the lymph nodes were removed, especially if many of the nodes contain cancer.

If melanomas are found in nearby lymph vessels in or just under the skin (known as in-transit tumors), they should all be removed, if possible. Other options include injections of the T-VEC vaccine (Imlygic), Bacille Calmette-Guerin (BCG) vaccine, interferon, or interleukin-2 (IL-2) directly into the melanoma; radiation therapy; or applying imiquimod cream. For melanomas on an arm or leg, another option might be isolated limb perfusion (infusing the limb with a heated solution of chemotherapy). Other possible treatments might include targeted therapy, immunotherapy, chemotherapy, or a combination of immunotherapy and chemotherapy (biochemotherapy).

Some patients might benefit from newer treatments being tested in clinical trials. Many patients with stage III melanoma might not be cured with current treatments, so they may want to think about taking part in a clinical trial.

Treating stage IV melanoma

Stage IV melanomas are often hard to cure, as they have already spread to distant lymph nodes or other areas of the body. Skin tumors or enlarged lymph nodes causing symptoms can often be removed by surgery or treated with radiation therapy.

Metastases in internal organs are sometimes removed, depending on how many there are, where they are, and how likely they are to cause symptoms. Metastases that cause symptoms but cannot be removed may be treated with radiation, immunotherapy, targeted therapy, or chemotherapy.

The treatment of widespread melanomas has changed in recent years as newer forms of immunotherapy and targeted drugs have been shown to be more effective than chemotherapy.

Immunotherapy drugs called checkpoint inhibitors such as pembrolizumab (Keytruda), nivolumab (Opdivo), and ipilimumab (Yervoy) have been shown to help some people with advanced melanoma live longer. These drugs can sometimes have serious side effects, so patients who get them need to be watched closely. Other types of immunotherapy might also help, but these are only available through clinical trials.

In about half of all melanomas, the cancer cells have changes in the BRAF gene. If this gene change is found, treatment with newer targeted therapy drugs such as vemurafenib (Zelboraf), dabrafenib (Tafinlar), trametinib (Mekinist), and cobimetinib (Cotellic) might be helpful. They might be tried before or after the newer immunotherapy drugs, but they aren’t used at the same time. Like the checkpoint inhibitors, these drugs can help some people live longer, although they haven’t been shown to cure these melanomas.

A small portion of melanomas have changes in the C-KIT gene. These melanomas might be helped by targeted drugs such as imatinib (Gleevec) and nilotinib (Tasigna), although, again, these drugs aren’t known to cure these melanomas.

Immunotherapy using interferon or interleukin-2 can help a small number of people with stage IV melanoma live longer. Higher doses of these drugs seem to be more effective, but they can also have more severe side effects, so they might need to be given in the hospital.

Chemotherapy can help some people with stage IV melanoma, but other treatments are usually tried first. Dacarbazine (DTIC) and temozolomide (Temodar) are the chemo drugs used most often, either by themselves or combined with other drugs. Even when chemotherapy shrinks these cancers, the cancer usually starts growing again within several months.

Some doctors may recommend biochemotherapy, which is a combination of chemotherapy and either interleukin-2, interferon, or both. This can often shrink tumors, which might make patients feel better, although it has not been shown to help patients live longer.

It’s important to carefully consider the possible benefits and side effects of any recommended treatment before starting it.

Because stage IV melanoma is hard to cure with current treatments, patients may want to think about taking part in a clinical trial. Many studies are now looking at new targeted drugs, immunotherapies, chemotherapy drugs, and combinations of different types of treatments.

Even though stage IV melanoma is often hard to cure, a small portion of people respond very well to treatment and survive for many years after diagnosis.

Treating recurrent melanoma

Treatment of melanoma that comes back after initial treatment depends on the stage of the original melanoma, what treatments a person has already had, where the melanoma comes back, and other factors.

Melanoma might come back in the skin near the site of the original tumor, sometimes even in the scar from the surgery. In general, these local (skin) recurrences are treated with surgery similar to what would be recommended for a primary melanoma. This might include a sentinel lymph node biopsy. Depending on the thickness and location of the tumor, other treatments may be considered, such as isolated limb perfusion chemotherapy; radiation therapy; or local immunotherapy treatments such as tumor injection with the T-VEC vaccine (Imlygic), BCG vaccine, interferon, or interleukin-2. Systemic treatments such as immunotherapy, targeted therapy, or chemotherapy might also be options.

If nearby lymph nodes weren’t removed during the initial treatment, the melanoma might come back in these lymph nodes. Lymph node recurrence is treated by lymph node dissection if it can be done, sometimes followed by treatments such as interferon or radiation therapy. If surgery is not an option, radiation therapy or systemic treatment (immunotherapy, targeted therapy, or chemo) can be used.

Melanoma can also come back in distant parts of the body. Almost any organ can be affected. Most often, the melanoma will come back in the lungs, bones, liver, or brain. Treatment for these recurrences is generally the same as for stage IV melanoma (see above). Melanomas that recur on an arm or leg may be treated with isolated limb perfusion chemotherapy.

Melanoma that comes back in the brain can be hard to treat. Single tumors can sometimes be removed by surgery. Radiation therapy to the brain (stereotactic radiosurgery or whole brain radiation therapy) may help as well. Systemic treatments (immunotherapy, targeted therapy, or chemo) might also be tried.

As with other stages of melanoma, people with recurrent melanoma may want to think about taking part in a clinical trial.