Information for patients with melanoma

Melanoma is a malignant skin tumor that develops from melanocytes—cells that produce the pigment melanin.

The diagnosis is established after performing an excisional biopsy (removal of the tumor with a small margin from the tumor edge) and histological examination, during which the thickness of the tumor is measured according to Breslow (the depth of penetration into the skin in mm). The Breslow thickness is the main parameter determining the stage of the disease, the plan for further examination, and treatment.

The plan for examination and surgical treatment depends on the Breslow thickness of the tumor.

Diagnosis and Treatment

If you have melanoma in situ (i.e., the tumor is located in the very surface layer of the skin—the epidermis) or the thickness of the tumor is less than 0.8 mm, you will be recommended to undergo an ultrasound of the lymph nodes and surgical intervention under local or general anesthesia involving wide excision of the post-biopsy scar with a margin of 5 mm to 1 cm from its edge.

If it is not possible to close the wound by bringing the edges together, you will undergo skin reconstruction using a free skin flap (skin graft from another site) or local tissues (closure of the wound defect through additional incisions and movement of skin flaps adjacent to the wound).

If the thickness of your tumor exceeds 0.8 mm, we will refer you for ultrasound of the lymph nodes and/or computed tomography (CT) of the thoracic organs, abdominal cavity, and pelvis with intravenous contrast.

The strategy for further treatment will depend on the results of these studies and will be approved by a multidisciplinary council, which includes specialists from various fields (surgical oncologist, clinical oncologist, pathomorphologist, radiodiagnostician, etc.).

In the absence of clinical signs of lymph node involvement (macrometastases) and internal organs, you will be offered surgical treatment under general anesthesia: wide excision of the post-biopsy scar with a margin from its edge of 1 to 2 cm, and if necessary, skin reconstruction and sentinel lymph node biopsy.

The sentinel lymph node is the first lymph node to which lymph from the area where the skin tumor was located drains. To locate it, a special dye (indocyanine green) is injected around the post-biopsy scar, which enters the lymphatic vessels and accumulates in the nearest (sentinel) lymph node. The node that accumulates the dye is completely removed and examined microscopically after special staining.

The biopsy of the sentinel lymph node is performed to clarify the stage: in the absence of tumor cells in the lymph node, stage I or II is established; in the presence of metastases in the sentinel lymph node (micrometastases), stage III is established.

If macrometastases are detected in the lymph nodes during palpation and/or ultrasound of the lymph nodes and/or CT of the internal organs, you will be recommended to undergo mandatory CT of the thoracic organs, abdominal cavity, and pelvis with intravenous contrast and MRI of the brain with intravenous contrast to assess the extent of the disease. If the disease has not spread to internal organs and the brain, you will be classified as having stage III disease and offered surgical intervention under general anesthesia, which involves the removal of all lymph nodes in the affected area along with surrounding adipose tissue.

For stages 0, IA, IB, and IIA, you will not require additional treatment, and you will be offered continued observation by an oncologist.

For stages IIB, IIC, and III, you will be offered adjuvant therapy, which you will receive for 12 months.

The need for adjuvant therapy depends on the stage of the disease.

In the treatment of melanoma, medications are divided into two groups:

1. Immunotherapy helps the patient's immune system cells (T-lymphocytes) recognize and destroy melanoma cells. In Ukraine, only one modern immunotherapy drug for melanoma treatment is registered—pembrolizumab (©Keytruda).

2. Targeted therapy destroys tumors that have specific properties—a mutation in the BRAF gene. To determine the BRAF mutation, which occurs in 50% of patients with skin melanoma, molecular genetic testing of the removed tumor is performed. Targeted drugs are always taken in combination. In Ukraine, two combinations are registered: dabrafenib (©Tafinlar) and trametinib (©Mekinist), vemurafenib (©Zelboraf) and cobimetinib (Cotellic).

For stages IIB and IIC of melanoma, immunotherapy with pembrolizumab (©Keytruda) may be offered as adjuvant therapy.

For stage III disease, either immunotherapy with pembrolizumab (©Keytruda) or targeted therapy with oral medications dabrafenib (©Tafinlar) and trametinib (©Mekinist) may be prescribed if the tumor has a mutation in the BRAF gene.

During adjuvant therapy, you will undergo CT of the thoracic organs, abdominal cavity, and pelvis with intravenous contrast and MRI of the brain with intravenous contrast every three months to assess the effectiveness of treatment.

In the case of tumor spread to internal organs or the brain, the main treatment method is systemic therapy.

If during examination it is determined that the tumor has spread to internal organs or the brain, you will be classified as having stage IV disease and recommended systemic therapy, meaning treatment with medications that will affect the entire body.

This may include either immunotherapy with pembrolizumab (©Keytruda) or targeted therapy if the tumor has a mutation in the BRAF gene. Targeted medications that may be used for stage IV melanoma include dabrafenib (©Tafinlar) and trametinib (©Mekinist), vemurafenib (©Zelboraf) and cobimetinib (Cotellic).

In most cases, regardless of BRAF mutation status, it is recommended to start treatment with immunotherapy; targeted therapy for patients with positive BRAF mutations is prescribed if immunotherapy proves ineffective.

Chemotherapy for skin melanoma is prescribed only if targeted and immunotherapy do not lead to the disappearance or reduction of metastases.

If melanoma metastases have spread to the brain, you may be offered radiation therapy. Stereotactic radiosurgery, i.e., focused radiation of the metastases with minimal impact on healthy brain tissue, is preferred.

To assess the effectiveness of treatment, you will undergo CT of the thoracic organs, abdominal cavity, and pelvis with intravenous contrast and MRI of the brain with intravenous contrast every three months. Unlike stage III melanoma, a definitive treatment timeline cannot be established for stage IV; this will depend on its effectiveness and the type of therapy.

Prevention

Regardless of the stage of the disease, after treatment, you will be offered follow-up with examinations and an oncologist's review: in the first year of follow-up, once every three months; in the second to third years, once every six months; and in the fourth to fifth years, once a year. The volume of examinations will depend on the stage of your disease.

The treatment of melanoma in the medical network "Dobrobut" is carried out according to modern Ukrainian and international guidelines:

• https://www.nccn.org/guidelines/guidelines-detail?category=patients&id=21 
• https://www.dec.gov.ua/mtd/melanoma/