Here’s What to Expect From the Surgical Management of Melanoma

Using excising for melanoma is an option that leads to less scarring and downtime.

Dr. Richard Geer, surgical oncologist at Sarah Cannon Cancer Center in Tennessee, discussed the surgical management of melanoma in detail during the CURE® Educated patient® Skin Cancer Summit, highlighting the benefits of excising as well as what patients can expect from scarring.

CURE® spoke with Geer to further discuss how quickly surgery is needed, the healing process, scarring and what’s on the horizon for advancements in the field.

CURE®: How quickly do you recommend surgery from diagnosis for patients with skin cancer?

Geer: All tumors have a certain time the moment you recognize them that you need to get them taken care of. … Most (tumors) we think double within about a two month period of time, some may have about 60 days. For the most part I like, from diagnosis to first treatment, not being any more than about 30 days.

What is the healing process like for patients after surgery?

What really most these patients go through is really pretty straightforward. ... Sometimes you can get some cutaneous nerves that bother patients where they have a numbness around the area. And that can be not really problematic, it's just different from how they feel with the lesion, but for the most part, within two weeks, they heal well and they feel good — the pain scores are down to minimal to nothing, and they can go on with their lives. ... I follow up (with) my patients, kind of every three to four months for the first two years, and then six months for the next five, and then make sure the dermatologist can change to see them along the way for not what I did, but for other lesions that could be on the body in terms that they could have an additional tumor. For the most part, they get back to whatever they want to do and do extremely well after these operations.

However, when we have patients that have skin grafts, skin grafts will take time to grow in, between probably eight to 12 weeks, to completely epithelialize. So oftentimes, we'll have a lot of scabbing that will be associated with the skin graft, (but) not necessarily discomfort because the nerves are kind of taken out. It's difficult for them to get back to normal routines because they have to almost wear a little bandage on it or protect it a little bit until the skin graft becomes completely mature. So (that’s) another reason to kind of avoid that. I would probably say in our practice, skin grafting is probably about 10% to 15% of patients.

What is important for patients to know about the scarring?

For the most part, you have to understand that when we're pulling skin together that much, there's a lot of tightness in there…it becomes very firm, but over time that will have a give to it. … To be honest with you, with the two centimeter margin, we can do this extremely well, cosmetically. Most of these stitches are completely buried under the skin, the skin incision heals well. Sometimes because of tension we have to put what are called retention sutures in that will live in for two to three weeks to make sure the wound doesn't pull apart and have a problem, but it's rare really to have someone that has an issue related to the wound in our practice at this point in time. So I think oftentimes, it's an education component up front, and when they understand it they kind of have a better understanding what to expect, post rapidly.

Do treatments differ depending on the subtype of melanoma?

Most melanoma pretty much are treated the same way. Now, there's a few that are a little bit different. ... One is in lentigo maligna. This is one that's generally a little bit more superficial, it's mainly in sun exposure, often of the face. ... They're harder to treat, because it's harder for us to get a margin around them. We try to do the best we can to get wide margins around all these tumors. Because our concern is that in the dermal lymphatic system, we can have these little satellite metastatic areas, and that's why this proponent of really wide surgical margins are important. However, in certain areas, it's just hard to do. The other was acral lentiginous that can be on the hands and the feet, those can be difficult to treat because oftentimes, in order to get a margin, you have to do an amputation of either the finger or the toe.

What are some advancements going on in surgical management of melanoma right now?

When we first started doing melanoma work, when we had high risk melanoma patients, we did elective lymph node dissections on all these patients. And elective lymph node sections whether it's in the axilla, groin or neck would involve removing anywhere from 15 to 20 lymph nodes, resulting in lymphedema of either the axilla, the upper extremity (or) lower extremity neck. Now we're just taking out really one or two lymph nodes that can give us the information we need about (whether or not the cancer has spread.) Beyond that, we now have a couple of clinical trials that have looked at when we just take out a lymph node or two and is positive, do we need to go back and continue to do additional dissection inside that lymph node base? And the answer that looks like it's going to be no. So I think we're getting better. I think our margins are kind of where they're going to be without any additional studies being done, and the only way to do the next study is really a randomized trial. … I think that we're, we're going to start to see more of these trials that we have done looking at longer term follow up to see (if patients) have additional benefit in the future.

This interview has been edited for clarity and conciseness.

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