Treatment of Melanoma

Malignant Melanoma is also epidemic worldwide and is the third most common form of skin cancer. There is a great deal of information already published about malignant melanoma on the internet. We will limit our discussion primarily to the treatment of primary melanoma which is done in the dermatologist’s office. Early detection of melanoma is critical and saves people’s lives because the prognosis or risk of spreading varies directly with its depth of invasion. Most melanomas start out early and are not very deep; if they are caught at that stage and removed completely they are not likely to spread.

The lowest risk form of melanoma is called in situ (MIS) which is on the surface of the skin similar to squamous cell carcinoma in situ. Those cancers should not spread at all although our statistics tell us that actual cure rates for MIS are not 100% as one might think. That is probably because some patients who have been diagnosed with MIS might have had areas of invasion that were missed under the microscope, since standard pathology misses a great deal of what is actually cut out by the dermatologic surgeon due to how the tissue is processed. This is not wrong; it is just how things are done in standard pathology which when compared to MOhs micrographic surgical pathology is much less thorough. The pathology partly dictates our treatment and the margin of normal skin around the melanoma. If the melanoma is in situ the standard recommendation is 5 mm margins, although research shows that that may not be adequate in many cases. Frequently melanomas are very ill-defined. We use a special light, a Wood’s light, to help delineate the size of a melanoma. This is a black light or UV light which illuminates brown spots and helps us determine the size of the melanoma which sometimes can be quite subtle and difficult to see with the naked eye. In situ melanoma on the central face in critical areas such as the eyelids, nose, ears, and lips can be treated with Mohs micrographic surgery, but the pathology is difficult requiring a special stain called an immunoperoxidase stain which labels melanoma cells to increase our sensitivity and our success rates. Despite that, this form of melanoma has a higher recurrence or persistence rate after Mohs or any form of treatment. When we do Mohs micrographic surgery on this type of melanoma on the face, we often have patients use Aldara or imiquimod cream to help clean up single cells that we may have left behind. Aldara or imiquimod cream has been use for in situ or superficial melanoma, although the research is quite limited and failure raters are substantia; thus we rarely if ever recommend it as what is called primary treatment. We sometimes do recommend it as mentioned above for what is called adjuvant treatment after surgery to possibly help improve our cure rates.