Malignant Melanoma Removal in Southeast Michigan

Melanoma is a type of skin cancer that begins in melanocytes, the cells that give skin its pigment. It is less common than other skin cancers but more likely to spread if not detected early. 

• There are 2 layers of skin separated by basement membranes
  • Epidermis  
  • Dermis
• If melanoma cancer cells are in the epidermis only then its melanoma in-situ and  if the cancer cells have gone deeper in to the dermis through the basement membrane, then it’s called invasive melanoma 

Melanoma develops when DNA in melanocytes becomes damaged. Contributing factors can include ultraviolet (UV) light exposure from the sun or tanning beds, genetics, and certain skin types. Not all melanomas are related to sun exposure. 

Many melanomas follow the ABCDE rule: 

• Asymmetry: one half doesn’t match the other 
• Border: edges are irregular or blurred 
• Color: multiple colors or uneven color 
• Diameter: larger than a pencil eraser (though they can be smaller) 
• Evolving: any change in size, shape, color, or symptoms 

New or changing moles, or lesions that itch, bleed, or don’t heal, should be evaluated. 

• Superficial Spreading Melanoma
• Nodular Melanoma
• Acral Lentiginous Melanoma
• Lentigo Maligna Melanoma

Risk increases with: 

• A history of sunburns or significant UV exposure 
• Fair skin, light eyes, or red/blond hair 
• A large number of moles or atypical moles 
• A personal or family history of melanoma 
• A weakened immune system 

Melanoma can occur in anyone, including people with darker skin tones. 

Diagnosis typically involves: 

• A comprehensive skin exam by your dermatologist 
• A biopsy of the suspicious skin lesion 
• The biopsy determines the type of melanoma and how deep it goes into the skin. 
• Additional imaging if needed  
• Lymph node evaluation by sentinel lymph node biopsy 

• Staging describes how advanced the melanoma is. It considers: 
  • Tumor thickness 
  • Ulceration 
  • Lymph node involvement 
  • Spread to other organs or metastatic disease 
• Early-stage melanoma is often highly treatable. 

• You might need imaging based on biopsy results 
• Usually, PET Scan and MRI of brain 
• Sentinel Lymph node Biopsy at the time of removal of melanoma to assess the lymph node status 
• Not everyone meets the criteria for imaging for staging. 

Treatment depends on the stage and may include: 

• Surgical removal of the melanoma called Wide Local Excision (WLE) 
• Sentinel lymph node biopsy (SLNB) 
• Local advancement Flaps for covering the defect created by surgical removal of melanoma 
• Skin graft or Skin Graft Substitute followed by Skin graft 
• Immunotherapy 
• Radiation therapy 
• TILS (Tumor Infiltrating Lymphocytes) 

Early detection usually means surgery alone is sufficient. 

• The CASTLE test generally refers to the DecisionDx‑Melanoma test developed by Castle Biosciences—often informally called the “Castle test.” It is a gene expression profile (GEP) test used for patients with Stage I–III cutaneous melanoma. The test analyzes the activity of 31 genes within a melanoma tumor to help predict: 
  • Risk of melanoma recurrence 
  • Risk of metastasis 
  • Likelihood of sentinel lymph node (SLN) positivity 
• This helps clinicians tailor follow‑up, imaging, and sentinel lymph node biopsy decisions.  

Predicts Sentinel Lymph Node Positivity 

• The test integrates tumor biology with clinical features to estimate whether a patient is likely to have cancer in the sentinel lymph node.  

Stratifies Recurrence Risk 

• It classifies patients into risk groups (low, intermediate, high) to guide surveillance intensity and imaging. 

Helps Personalize Management 

• By combining genetic data with traditional pathology, it supports more individualized decisions about: 
  • Whether to perform SLNB 
  • How often to follow up
  • Whether to increase surveillance imaging

Why It’s Used 

• This helps clinicians tailor follow‑up, imaging, and sentinel lymph node biopsy decisions.  

Patients with Stage I–III melanoma, especially when: 

• SLNB decision is uncertain 
• Additional prognostic information would change management 
• There is interest in personalized risk assessment 

• A sentinel (First) lymph node biopsy is a surgical procedure used to determine melanoma (can be done for some other cancers) has spread beyond the primary site to the lymph nodes.  
• Procedure helps identify and target the sentinel lymph nodes and then surgeon removes lymph node(s) (“sentinel nodes”) that drain the area of the tumor for microscopic histopathological analysis by the pathologist. 

Why It’s Done 

• To check if cancer has spread to nearby lymph nodes as not all cancer has gone to Lymph nodes and no imaging modality can tell if the lymph nodes have microscopic cancer. 
• To help determine cancer stage and guide treatment decisions. 
• To avoid removing many lymph nodes unnecessarily—if the sentinel nodes are cancer‑free, further node removal is usually not needed. 

How It Works 

• Radiologist use radiotracer injection near the tumor before the surgery to remove the melanoma (usually same day). 
• These substances travel to the sentinel lymph node(s)—the first nodes that would receive cancer cells if the spread has occurred. 
• A trained radiologist injects (near the tumor) a radioactive tracer (emitting very small amount of radiation) in nuclear medicine department of the hospital and take images of your body using a gamma camera. This process will generate images of the location of the lymph node (s). Radiologist then speak to the surgeon about location (s) of the lymph node (s). Then surgeon usually bring (in preoperative area) a device radiation counter (Like Geiger Counter) that makes noise on detection of small amount of radiation emitted from the targeted lymph nodes. After that confirmation (that we have a target), you are taken to operating room for Surgical removal of the lymph node (s). 
• In the OR, in addition, blue dye is injected in the skin near the tumor when you are under anesthesia to help see the sentinel lymph nodes by turning them blue. 
• The surgeon uses a detector or visual dye to locate the nodes. 
• The sentinel nodes are removed through a small incision. 
• A pathologist examines them under a microscope for cancer cells. 

Wide Local Excision is removal of full thickness skin and subcutaneous tissue all the way to muscle around the skin with melanoma with normal margin of skin measured with tape measure 

• Clinical margin is defined by a margin of normal of skin around the melanoma marked with ruler precisely 
• Margin is decided based on the thickness of melanoma

Pathological margin is defined by a margin of normal of skin around the melanoma measured by the pathologist after melanoma has been s=removed from body and sent for histopathologic analysis to pathology 

A local advancement flap is created by lifting a section of skin and subcutaneous tissue adjacent to a surgical defect and advancing it forward—without rotating or pivoting—to cover the area. The flap remains attached at one side, preserving its blood supply. 

• The defect is too large for simple stitches 
• A skin graft would not match well or would heal poorly 
• The surrounding skin has enough laxity to move safely 
• Maintaining cosmetic and functional outcomes is important (e.g., face, scalp, extremities) 

• A skin graft is a surgical procedure where healthy skin is taken from one part of the body (the donor site) and transplanted to another area where skin is missing or damaged. 
• This helps wounds heal, restores function, and improves appearance. 
• Skin grafts are commonly used after skin cancer surgery. 

• Integra Dermal Regeneration Template (DRT) is a bioengineered, two‑layer skin substitute that helps the body regenerate a new dermal layer.  
• It is commonly used for Reconstruction after skin cancer removal 
• It provides a scaffold that allows the patient’s own cells to grow into it and form new tissue. 

Integra has two layers, each with a specific purpose: 

• Dermal Layer (Bottom Layer) 
  • Made of bovine collagen and glycosaminoglycan (GAG) 
  • Acts as a scaffold for new dermal tissue to grow 
  • Encourages blood vessels to form (neovascularization) 
• Silicone Layer (Top Layer) 
  • Functions as a temporary epidermis 
  • Protects the wound from bacteria and fluid loss 
  • Removed later once the dermal layer has regenerated 

• Stage 1: Apply Integra 
  • The wound is cleaned and prepared. 
  • The Integra template is placed over the wound. 
  • The silicone layer protects the area while the dermal layer grows underneath. 
  • Over 2–3 weeks, the body forms a new vascularized dermis.
• Stage 2: Skin Grafting 
  • Once the dermal layer is ready, the silicone layer is removed. 
  • A thin split‑thickness skin graft is placed on top. 
  • Because the dermis is already formed, the graft “takes” more easily. 

• Bolster is dressing made of various dressing components that are put together to apply pressure at the site of integra/skin graft to help integration at the surgical site.
• It's sutured and/or stapled in place.
• Surgeon will advise you not to wet the bolster. 
• It is taken off in 7-10 days. 

• Immunotherapy is a type of cancer treatment that helps your immune system recognize and attack cancer cells more effectively.  
• It uses substances made by the body or created in a lab to boost, direct, or restore the body’s natural defenses against cancer. 
• Cancer often hides from the immune system or suppresses it; immunotherapy works by removing those “brakes” or strengthening the immune response.You will need discussion with medical oncologist who will go over the nuances of the therapy in detail (including their side effects and effectiveness) with you
• Not everyone with melanoma need immunotherapy. 

• These drugs block proteins (like PD‑1, PD‑L1, CTLA‑4) that normally keep immune responses from getting too strong. 
• Blocking them allows T‑cells to attack cancer more aggressively. 

• Radiation therapy is a type of cancer treatment that uses high‑energy beams—usually X‑rays, but sometimes protons or other particles—to kill cancer cells or stop them from growing. It works by damaging the DNA inside cancer cells so they can no longer divide. Over time, the cancer shrinks or disappears. 
• Radiation can be used alone or combined with surgery, chemotherapy, or immunotherapy depending on the cancer type. 
• You will see a radiation oncologist who will go over the details of radiation therapy. 
• Radiation oncology is a separate entity from medical oncology 
• Not everyone with melanoma needs radiation therapy 

• Tumor Infiltrating Lymphocytes 
• TIL therapy is an advanced form of immunotherapy that uses your own immune cells—specifically lymphocytes that have naturally entered a tumor—to fight cancer.  
• These cells are collected from the tumor (surgically), multiplied in a lab into billions of cancer‑fighting cells, and then infused back into the patient. 
• It is FDA‑approved for advanced melanoma that cannot be removed surgically or has spread, especially when other treatments have not worked. 

• Yes—when caught early, melanoma is often curable with surgery.  
• Treatment options for Advanced melanoma have also improved significantly, offering better outcomes than in the past.

• Melanoma can recur, especially if it was thicker or involved lymph nodes at the time of diagnosis.  
• Regular follow‑up visits and skin checks are important for early detection of recurrence or new melanomas. 

• Use broad‑spectrum sunscreen daily 
• Avoid tanning beds 
• Wear protective clothing and seek shade 
• Perform monthly skin self‑exams 
• See a dermatologist for routine skin checks 

• Short answer is NO 
• Most moles are harmless.  
• Although there are Moles that require evaluation  
  • Mole that changes 
  • Mole that looks different from others  
  • Mole that causes symptoms 

• Merkel Cell Carcinoma
• Advanced Cutaneous Squamous Cell Carcinoma
• Advanced Basal Cell Carcinoma

• https://www.cancer.gov/types/skin/patient/melanoma-treatment-pdq
• https://www.uptodate.com/contents/melanoma-treatment-localized-melanoma-beyond-the-basics
• https://patient.info/cancer/skin-cancer-types/melanoma-skin-cancer
• https://medlineplus.gov/melanoma.html
• https://www.skincancer.org/skin-cancer-information/melanoma/
• https://rarediseases.org/rare-diseases/merkel-cell-carcinoma/