Treatment for Melanoma
If you are diagnosed with melanoma skin cancer, your doctor will discuss the best options to treat it. Your treatment for melanoma at MD Anderson will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
Surgery
The type of melanoma surgery your doctor uses depends on the thickness of the melanoma tumor and if it has spread.
Melanomas less than 1 millimeter thick
The most often-performed procedure is a wide excision of the primary tumor. The surgeon carefully cuts out the melanoma and a predetermined area around it. The amount of skin that is removed and the degree of scarring depend on the tumor thickness of the melanoma. Most patients usually do not need more treatment.
Depending on the size of the melanoma, the local excision may be an inpatient or outpatient procedure, often with local anesthesia. The area may require stitches, and recovery can take a few weeks. The severity of the scar depends on the size, depth and location of the melanoma.
Your surgeon may discuss a procedure called lymphatic mapping and sentinel lymph node biopsy (see illustration below). It is a minimally invasive surgical approach in which the regional lymph node(s) that receive lymph drainage from the primary tumor site is/are removed and carefully checked for cancer spread to the regional nodes. These "sentinel" lymph nodes represent the most likely nodes to contain spread, if any are involved. If the sentinel lymph node is cancer free, then the other lymph nodes do not need to be checked or removed. If the sentinel lymph node contains melanoma spread (metastasis), your doctor may discuss further surgery and other treatment.
Melanomas more than 1 millimeter thick
The principal procedure is a wide excision of the primary tumor. The surgeon carefully cuts out the melanoma and a predetermined area around it. The amount of skin that is removed and the degree of scarring depend on the tumor thickness of the melanoma. Most patients usually do not need more treatment.
If a large area of skin is removed during surgery, a skin graft may be done to reduce scarring. The surgeon numbs and removes a patch of healthy skin from another part of the body, such as the upper thigh, and then uses it to replace the skin that was removed. This is done at the same time as the skin cancer surgery. If you have a skin graft, you may have to take special care of the area until it heals.
In addition to a wide excision, your melanoma surgical oncologist will often discuss a procedure called lymphatic mapping and sentinel lymph node biopsy, a minimally invasive surgical approach in which the regional lymph node(s) that receive lymph drainage from the primary tumor site is/are removed and carefully checked for cancer spread to the regional nodes. These “sentinel” lymph nodes represent the most likely nodes to contain spread, if any are involved. If the sentinel lymph node is cancer-free, then the other lymph nodes do not need to be checked or removed. If the sentinel lymph node contains melanoma spread (metastasis), your doctor may discuss further surgery and other treatment.
Regional lymph node metastasis
If melanoma has spread to the regional lymph nodes, a surgical procedure known as lymph node dissection (also termed lymphadenectomy) is often performed. This procedure consists of removal of the “compartment” of lymph nodes related to the location of where the tumor-containing lymph node was identified. This procedure is performed under general anesthesia; one or more drain tubes are usually placed at the completion of surgery to facilitate recovery.
Depending on the extent of spread to the lymph nodes, radiation therapy may also be recommended to try to reduce the chance of the melanoma recurring in the regional nodes.
Metastatic melanoma (stage IV):
Surgery may sometimes be used to treat melanoma that has spread to distant parts of the body.
Radiation therapy
In collaboration with skilled radiation oncologists, cancer radiation therapy may be used as a component of your melanoma treatment plan. Radiation therapy may sometimes be combined with chemotherapy.
Targeted therapy
These innovative treatments, many of which were developed in part at MD Anderson, are designed to take advantage of a new understanding of the molecular alterations that sometimes occur within melanoma tumor cells. Treatment may include:
- B-RAF inhibitors
- KIT inhibitors
- Other treatments in clinical trials
Immunotherapy
These innovative treatments help the body’s natural immune response fight the cancer. Immunotherapy generally is used in advanced melanoma when the cancer has spread to other parts of the body. Treatment may include:
- Interferon-alpha
- Anti-CTLA-4
- Vaccines
- Interleukin 2
- T Cell therapy
- Biochemotherapy
In some cases, chemotherapy may be combined with interleukin 2, interferon and/or T-cell therapy.
Chemotherapy
MD Anderson offers the most up-to-date and effective chemotherapy options.
Follow-up after treatment
If you have had a melanoma, you are at higher risk of developing new melanomas than someone who has never had a melanoma. You may be at risk of the cancer coming back in nearby skin or in other parts of the body. The chance of recurrence is greater if the melanoma was thick or had spread to nearby tissue. Your family members also should have regular checks for melanoma.
To increase the chance of finding a new or recurrent melanoma as early as possible, follow your doctor's schedule for regular checkups. If you are at high-risk for recurrence, follow-up care may include X-rays, blood tests and imaging scans of the chest, liver, bones and brain; if you have very early stage melanoma, these tests are generally not performed unless specific situations arise.
Ommaya reservoir and its role in cancer care
An Ommaya reservoir is a plastic, dome-shaped device inserted underneath the skin on your scalp. The dome is connected to a catheter placed in the ventricle of your brain where the cerebrospinal fluid (CSF) circulates.
Doctors often use Ommaya reservoirs in patients with leptomeningeal disease (LMD), specifically solid tumor LMDs, such as breast cancer, lung cancer and melanoma.
To learn about Ommaya reservoirs and how they’re used in cancer treatment, we tapped the experts: neuro-oncologist Barbara O’Brien, M.D., and neurosurgeon Jeffrey Weinberg, M.D.
What is the purpose of an Ommaya reservoir?
Doctors can use an Ommaya reservoir to inject medicine into the fluid around your brain and spinal cord or aspirate the fluid for testing.
LMD occurs when cancer cells from primary tumors enter the CSF or leptomeninges, the inner lining of the brain and spinal cord. Cancer patients who develop LMD may receive intrathecal chemotherapy as part of their treatment.
“An Ommaya can be placed to allow the delivery of chemotherapy directly to the cerebrospinal space. Doing so allows us to bypass the blood-brain barrier,” says O’Brien. “It can be a more effective, direct way of delivering chemo to some patients with LMD.”
How is an Ommaya reservoir placed?
An Ommaya reservoir is placed by a neurosurgeon while you’re under general anesthesia.
“After the patient is asleep, we can use a stereotactic navigation system to select the location to guide the catheter into the patient’s ventricle,” says Weinberg.
The surgeon makes a large, C-shaped incision in the scalp and drills a small hole in the skull.
“We intentionally make the incision big because we cut all the nerves that bring pain to the flap overlying the dome,” explains Weinberg.
This means the patient will feel no pain any time chemotherapy is injected into the dome.
“We make a small nick in the brain tissue and then use the navigation system to guide the catheter through the hole we drilled and into the ventricle,” explains Weinberg. “Once it’s in the ventricle, we test to make sure we’re getting CSF flowing freely from the catheter.”
The Ommaya reservoir is secured with sutures to ensure it stays in place. The procedure typically takes 20 to 40 minutes.
Doctors will take a CT scan after the procedure to make sure the tip of the catheter is in the correct location and there’s no bleeding. Patients stay in the hospital overnight. If there are no issues, you can go home the following morning.
How do you care for an Ommaya reservoir after placement?
The most important thing is to make sure the wound heals properly.
“We don’t want the wound to get infected, so you must allow it to heal. That can take anywhere from 10 to 14 days,” says Weinberg. “Even then, the wound is still delicate, so make sure not to scratch or pick at it. You can exercise, but swimming is not recommended. It’s best to avoid contact sports for about a month following surgery.”
Check with your doctor to see when you can resume normal activities.
Are there any risks associated with an Ommaya reservoir?
Risks can include:
Wrong location
If the Ommaya reservoir is placed or ends up in the wrong location, you must see a neurosurgeon to get it repositioned.
Bleeding
If there’s a small amount of blood visible on a scan, your doctors may monitor for additional bleeding and do another CT scan. If bleeding is significant, you’ll need surgery to have the blood clot removed. This is extremely rare.
Infection
If the wound gets infected, you will need surgery to have the Ommaya reservoir removed.
How is an Ommaya reservoir used in leptomeningeal disease treatment?
MD Anderson’s Brain and Spine Center offers an Ommaya clinic for patients on Mondays and Thursdays. LMD patients with Ommaya reservoirs usually begin receiving chemotherapy twice a week.
When a patient visits the clinic, a neuro-oncology advanced practice provider (APP) cleans and sterilizes the area on the head. Then the provider inserts a needle into the reservoir and removes a small amount of fluid. This is known as an Ommaya reservoir tap.
“The fluid is sent to the lab for testing, and some of the fluid is earmarked for research if the patient has consented to a research study,” says O’Brien. “After the fluid is withdrawn, the provider injects chemo into the Ommaya reservoir.”
CSF cytology identifies cancerous cells in the fluid and helps doctors assess how well patients are responding to treatment. Research testing helps doctors learn more about the underlying biology of LMD, in part by assessing the molecular profile of the tumor.
Some patients may experience headaches, neck pain or nausea after the procedure. Doctors work with patients to manage these symptoms by adjusting the amount of fluid taken or prescribing steroids to reduce inflammation that may occur from injecting chemo.
“Patients typically follow up with their neuro-oncologist every four weeks while on treatment, and we reassess with imaging of the brain and spine every eight weeks to make sure the treatment is effective,” says O’Brien. “At eight weeks, if the treatment is working and all parameters look good, we consider decreasing the frequency of the Ommaya reservoir taps. It may go from twice a week to once a week or from once a week to every other week.”
Is an Ommaya reservoir the same as a shunt?
No. A shunt is commonly used in patients who have a blockage in their CSF pathway, causing fluid to accumulate in the brain.
“We will surgically place a shunt in the brain to help drain excess cerebrospinal fluid from the brain and transport it to another part of the body, where it gets reabsorbed back into the bloodstream,” says Weinberg. “The Ommaya reservoir – while we can attach a shunt to it, if necessary – is specifically placed to be used only when needed. There’s no continuous draining of fluid.”
How do you determine who is a good candidate for an Ommaya reservoir?
An LMD patient may have an Ommaya reservoir placed if doctors determine intrathecal chemotherapy is the best way to treat the disease. But it isn’t right for everyone.
“For instance, intrathecal chemotherapy only penetrates a few millimeters, so this therapy is not expected to help patients who have bulky or nodular LMD,” says O’Brien.
She carefully reviews the imaging to determine if the type of LMD the patient has can be appropriately treated by intrathecal chemo.
“If a patient functions well, doesn’t have any significant neurologic symptoms and has options to treat any active cancer outside of their leptomeninges, then they may be a good candidate for intrathecal chemotherapy via an Ommaya reservoir,” she says.
The goal of intrathecal chemo is to keep LMD under control, not manage symptoms. It’s important to have honest, realistic conversations with your doctors about your goals. Some patients want doctors to do whatever’s possible to help them make it to a special milestone in their lives. Other patients place more importance on quality of life and do not want to travel back and forth to a clinic twice a week to receive chemo.
“LMD can be tough to treat, so we must consider our options carefully,” says O’Brien. “A nice thing about intrathecal chemotherapy is it only treats the leptomeningeal compartment, so patients can often continue receiving systemic therapy without concerns of their treatments interfering with one another.”
Request an appointment at MD Anderson online or call 1-877-632-6789.