Even as immunotherapies and targeted therapies continue to advance the treatment of cancer across the board, surgery still plays a vital — and promising — role in melanoma, according to Giorgos C. Karakousis, an assistant professor of surgery at the Perelman School of Medicine at the University of Pennsylvania. He emphasized this point during Abramson Cancer Center’s 14th “Focus on Melanoma” conference.
Surgery plays a crucial role for the management of early stage (stages 1 or 2), localized melanoma. Once the cancer is detected and measured, it can usually be excised. For early-stage melanoma that is deeper than 1 mm, physicians will often consider a sentinel lymph node (SLN) biopsy, in which dyes are injected into the lymph nodes, showing a “road map” of where the disease may spread.
“It gives us important information on the melanoma and how concerned we need to be about it,” Karakousis said.
If the SLN is positive for cancerous cells, the standard approach of treatment is a lymphadenectomy, though Karakousis mentioned that a clinical trial has just been completed to determine if a full removal of the lymph nodes is actually necessary. Results of the study have not yet been published.
Surgery is still a viable option for patients with stage 3 or 4 disease, such as the 6 to 10 percent of patients with stage 3 in-transit disease that has spread to nearby body parts. Isolated limb perfusion (ILP), which is surgical isolation of the blood vessels to the arm or leg with the in-transit melanoma to deliver higher doses of chemotherapy than the rest of the body could typically handle, is one option that Karakousis said usually has a “very dramatic and good response.”
Using surgery to treat distant-spread stage 4 melanoma gets even trickier.
“Generally, for this stage of disease, we don’t recommend surgery, since other therapies are now available, like immunotherapy and targeted therapies,” Karakousis said. “But occasionally, there may be a role for surgery in select patients with very limited disease.”
Karakousis emphasized that a multidisciplinary team-based approached must be used to determine if a patient is a good candidate for surgery.
Surgery will likely continue to be a mainstay in melanoma treatment as scientists and researchers at Penn keep developing new technologies, partially through their Precision Surgery Center which was launched this spring.
“To put it simply, we want to see areas in the tumor that we couldn’t see with our own naked eye,” Karakousis said.
Developments include a way to essentially make tumors “glow,” so they can be more easily identified at the time of surgery. Scientists are also working on a newer, more sensitive dye for SLN biopsies that will not only highlight nearby lymph nodes and sentinel nodes, but also tell if there is melanoma in it.
“It’s all about safer surgery,” Karakousis said. “Picking the right patients for surgery and doing it in a safer fashion.”