Melanoma: Diagnosis & Treatment of Skin Melanoma

Pictured: Nancy Eastman & Allan Halpern Chief of the Dermatology Service Allan Halpern, pictured here with nurse Nancy Eastman, has pioneered the use of whole-body photography for early detection and prevention of melanoma.

To confirm a diagnosis of melanoma, our expert pathologists examine a small sample of tissue under a microscope to determine whether melanoma cells are present.

The distinction of an atypical but ultimately benign mole from a true malignant melanoma is often subtle, and a diagnosis can sometimes be challenging to make. Memorial Sloan Kettering is one of the few hospitals in the United States with access to advanced diagnostic techniques that can help accurately evaluate these tumors.

For people with melanoma that has spread to other parts of the body (called metastatic), we perform extensive genetic tumor analysis and apply cutting-edge analytical tools that help us determine the most effective treatment approach.

Treating Local Melanoma

Because melanoma cells can spread (metastasize) to other parts of the body, it’s important to take steps to check whether this has happened when you undergo surgery. To make sure we’ve eliminated all of the affected cells, our surgeons remove the tumor as well as some of the normal skin around it, called the tumor margins.

The amount we remove depends primarily on the thickness of the tumor, where it is on the body, and how removing it might affect your appearance. Sometimes we recommend doing a skin graft, which involves removing a patch of skin from another part of the body to replace the lost tissue.

If we determine that the tumor poses a significant risk of spreading, we perform our most sensitive staging procedure — sentinel lymph node biopsy — at the same time that we remove the melanoma.

For this procedure, we assess which lymph node the cancer the cells are most likely to spread to first (the sentinel node) and remove it during surgery. Our pathologist examines the node very carefully to determine whether cancer cells are present. If they are, the surgeon may remove additional lymph nodes. If no cancer cells are present, no further surgery is needed.

In some instances, we recommend radiation therapy for the affected area. In fact, we’re the only center in North America participating in an international research study to determine if this approach helps prevent recurrence of melanoma in the head and neck area.

However, the decision to have radiation therapy can be complicated. For some people, this approach may reduce the chances that melanoma comes back in the area where surgery was done, but it does not guarantee that melanoma won’t recur in other parts of the body. 

Because radiation therapy can also produce side effects, our radiation oncologists are studying new ways of delivering it for people with melanoma, such as through intensity-modulated radiation therapy (or IMRT), a technique pioneered at MSK. By delivering radiation with this more precise and focused technique, it may be possible to avoid healthy, normal organs and prevent side effects from treatment.

Treating Metastatic Melanoma

The outlook for people with metastatic melanoma has changed dramatically since 2010, when therapies were introduced that significantly lengthened and enhanced the quality of life for patients with the disease. MSK researchers played a critical role in developing these therapies.

Targeted Therapy

One of the biggest advances was in understanding that almost all melanomas are driven by mutations, or genetic changes, that lead to the activation of a specific biochemical pathway. In almost half of melanomas, there is a mutation in the BRAF gene. Drugs that block this mutated gene — called RAF inhibitors — can lead to dramatic shrinkage of tumors.

In 2006, our investigators led the first clinical trial of the first RAF inhibitor (vemurafenib or Zelboraf®-), as well as the clinical trial resulting in the 2011 FDA approval of this agent for metastatic melanoma.  In 2010, we were the lead investigators in developing dabrafenib (Taflinar®), the second RAF inhibitor approved for BRAF-mutated melanomas.

We test all metastatic melanomas for BRAF mutations. In fact, we test most melanomas for mutations in more than 300 genes, which helps us learn more about patients’ specific melanomas and can tell us if they might benefit from participation in new clinical trials.

Immunotherapy

In 2004, MSK researchers were among the first to offer people an immunotherapy called ipilimumab (Yervoy™), a drug that activates the immune system to fight melanoma. We led studies showing that ipilimumab could prolong overall survival of people with metastatic melanoma, and the U.S. Food and Drug Administration (FDA) approved the drug for general use in 2011. Our patients had access to this drug seven years earlier.

In 2010, we were among the first places to offer patients pembrolizumab (Keytruda), another drug that activates the immune system to fight melanoma. The FDA approved this drug in 2014.

New and Investigational Therapies

As we continue to pursue new melanoma drugs, many of our patients still choose to enroll in clinical trials, in many cases allowing them to access drugs still unavailable at most other centers.

Many of our patients have had access to novel therapies years before the FDA approved them for general use.

Chemotherapy

Although it’s much less commonly used than it once was, chemotherapy remains the best treatment option for some patients. Some chemotherapies produce only mild side effects, but others can cause fatigue and loss of appetite that make it more difficult to carry on normal activities.

For people with melanoma confined to a single arm or leg, we can infuse chemotherapy medicines through the limb in a procedure called regional infusion therapy. This approach exposes the cancer to very high levels of chemotherapy while the rest of the body is spared, maximizing the drug’s effect while limiting its impact on the rest of your body. MSK doctors were among the first to use this technique, and through clinical trials we’re actively investigating ways to make it even more effective.

Radiation Therapy

With radiation therapy, we can provide focused treatment to areas difficult to reach by surgery or other means. For example, if you have melanoma that has spread to the brain, we may treat the tumor with stereotactic radiosurgery, a procedure that enables us to deliver a single high dose of radiation directly to the tumor. This approach can eliminate the tumor with few side effects.

We also pioneered the development of intensity-modulated radiation therapy (IMRT) at MSK, a technique for delivering radiation therapy with great precision while avoiding normal, healthy organs. IMRT can be also be combined with new image-guidance technology to precisely deliver radiation that’s more effective at controlling melanoma than other forms of radiation therapy.

Follow-up Care

After being treated for melanoma, you should continue being checked for the return of the disease, called recurrence, and the development of other skin cancers.

We’ll advise you on the best approach for protecting and monitoring your skin over time through such approaches as full-body photography screening.

Your Follow-Up Care Provider

Pictured: Kathleen Paisley Kathleen Paisley, PA I am a physician assistant with special training in melanoma survivorship issues. I graduated from Weill Cornell Medical College's Physician Assistant program and joined Memorial Sloan Kettering’s Melanoma and Sarcoma Service in 1997.