Surgery is the first step of treatment for the majority of melanomas.

• Wide local excision is the standard surgical procedure for melanoma in situ, Stage I, Stage II, and most Stage III melanomas, based on the results of multiple, large, randomized, controlled clinical trials. The surgeon removes the tumor, including the biopsy site, as well as a surgical margin, a surrounding area of normal-appearing skin and underlying subcutaneous tissue. The width of the margin taken depends upon the thickness of the primary tumor (how deeply the tumor has penetrated the skin). The goal of wide local excision is to remove any cancerous tissue that may remain after the biopsy.

  Recent advances in surgery allow surgeons to take narrower margins than ever before, so a much greater amount of normal skin is preserved. Most surgeons today follow the guidelines adopted and recommended by the National Institutes of Health (NIH) and the World Health Organization (WHO) Melanoma Program, based on large randomized, controlled trials:

  • 0.5 centimeter (cm) margin – less than 1/4 inch – for melanoma in situ (Stage 0)
  • 1 cm margin – about 3/8 inch – for tumors of 1 millimeter (mm) or less (Stage IA and primary tumors associated with Stage III disease, according to their thickness)
  • 2 cm margin – about 3/4 inch – for tumors between 1.1 mm and 3.99 mm (Stages IB, IIA, IIB, and primary tumors associated with Stage III disease, according to their thickness).
  • 2-4 cm margin – about 3/4 inch to 1 1/2 inch – for tumors greater than 4.0 mm (Stage IIC and primary tumors associated with Stage III disease, according to their thickness).

  Skin grafting is a procedure where skin from another part of the body is taken to cover the surgical excision. It is traditionally performed by a plastic surgeon. The skin is usually moved from areas that are normally or easily covered with clothing. Grafting may be required depending on the location of the primary tumor. However, given current surgical techniques, it can usually be avoided. In general, less than 10% of patients with primary melanoma require a skin graft.

• Sentinel lymph node dissection is a new surgical procedure in which only the sentinel lymph node(s) – the very first lymph node (or nodes) to receive drainage from an area – is removed for evaluation. Each area of skin in which a melanoma might arise has a corresponding sentinel node to which it drains. When lymph drains a patch of skin that contains melanoma, the sentinel lymph node is the one most likely to contain metastatic disease, if any lymph nodes are involved. Sentinel lymph node biopsy is often conducted in conjunction with lymphatic mapping, a procedure in which a blue dye is injected into the skin around the tumor, along with the small amount of radioactive substance used for lymphatic mapping. The dye gives the surgeon a visual reference for the process.

  More information about sentinel lymph node dissection is available in Lymph Node Evaluation.

• Therapeutic lymph node dissection (TLND) is surgery to remove all regional lymph nodes from the area where cancerous lymph nodes were found. It is the primary treatment for macrometastases. The goal of TLND is to prevent local symptoms from the regional disease, such as pain, and, theoretically, to interrupt the chain of progression to distant sites.

• Surgery for advanced disease may involve the removal of cancerous tumors or lymph nodes that have spread to other locations in the body. Excision may be performed on solitary masses or tumors of uncertain origin. The role of surgery in advanced melanoma is generally not to cure, but to relieve symptoms. It is also hoped that, in conjunction with newer medical treatments, removal of solitary sites of advanced disease may permit immunotherapy to prolong survival.