Knowing your child’s stage of diagnosis is important so the best treatment plan can be put into place. It is important to know that you have choices when it comes to where to seek treatment for your child. Not all treatment centers follow the same protocol for treating pediatric melanoma. It is important that you gather all the facts and make your decision based on what is best for your family. To get you started use our Treatment Center Finder.
Surgery – a wide excision of the tumor – is the most common treatment for melanoma, especially in its earliest stages. The surgeon removes the melanoma along with a margin of surrounding tissue. The thickness of the melanoma will determine the margin of surrounding tissue removed. While local anesthesia may be used, younger children may need either sedation or general anesthesia to get through the procedure. The nature of the scar will depend on the size, depth and location of the tumor.
In many cases of melanoma, and even for some atypical tumors in children, your surgical oncologist will discuss sentinel lymph node biopsy to be done in addition to (and at the same time as) the wide excision of the tumor. Sentinel node biopsy almost always involves general anesthesia, but immediately before the surgery lymphatic mapping is carried out to identify where the sentinel node is located so the surgeon can remove it. This mapping procedure is done by injecting a radioactive tracer and obtaining scans in the Nuclear Medicine Department immediately before the operation. No sedation or anesthesia is typically used for lymphatic mapping, so young children may need to be coached through the process and encouraged to keep still to obtain useable results. Ask your surgeon if prescribing an anesthetic cream to numb the area before injection would be helpful.
The specimens removed during wide excision and sentinel node biopsy are evaluated by the pathologist after surgery, in a process that can take a week or longer. If the sentinel lymph node contains melanoma, your doctor may discuss further surgery and/or additional treatment.
Regional Lymph Node Metastasis
If melanoma has spread to the regional lymph nodes, a surgical procedure known as lymph node dissection is sometimes performed. This procedure consists of removal of all the lymph nodes related in the location where the tumor-containing lymph node was identified (for example, the armpit, groin or neck). Node dissection is performed under general anesthesia and sometimes involves an overnight hospital stay; one or more drain tubes are usually placed at the completion of surgery and may remain in place for several weeks.
Systemic Drug Treatment
Drug treatments are usually not required for early stage melanoma (stages I and II). If the melanoma has spread to the lymph nodes (stage III), adjuvant therapy may be recommended to try to decrease the risk of tumor recurrence. For metastatic melanoma (stage IV), drug treatments are routinely recommended. As pediatric melanoma is rare, generating knowledge, designing clinical trials and developing effective treatments is a challenge. To gain FDA approval, a treatment generally must first demonstrate efficacy in adults in an extensive series of clinical trials. In most cases, due to the rarity of pediatric melanoma, drugs approved in adults are used in children but without the same degree of extensive testing.
On July 24, 2017, the FDA approved the immunotherapy ipilimumab, also known as Yervoy, for patients ages 12 years and older with metastatic melanoma. Ipilimumab is a checkpoint inhibitor that was first approved in 2011 for the treatment of adults with melanoma in both the metastatic setting as well as for adjuvant therapy after complete removal of the tumor. Currently, anti-PD1 immunotherapy drugs (nivolumab [Opdivo] and pembrolizumab [Keytruda]) are more commonly used in adults, especially for adjuvant therapy, than ipilimumab. Even though these drugs are not yet approved for children, they are sometimes used.
About half of all pediatric melanoma tumors have a mutation in the key gene called BRAF. Tumors with this mutation are susceptible to treatment with targeted therapy pills like the combination of dabrafenib (Tafinlar) and trametinib (Mekinist). In adults, these pills are approved by the FDA for both adjuvant therapy and treatment of metastatic disease. Like with immunotherapy, even though these drugs are not yet approved for children, they are sometimes used. All these options should be discussed with your child’s oncologist.
Clinical trials are sometimes viewed as the best treatment option for adult melanoma patients. For children with melanoma, especially those with recurrent or Stage IV disease, clinical trials may be appropriate to consider. As with all treatment options, clinical trials should be discussed thoroughly with your child’s oncologist.
A 2014 study published in the Journal of Investigative Dermatology provided a comprehensive genomic analysis of pediatric melanoma – finding unique genomic features for each of the three subtypes of pediatric melanoma – and suggests compelling evidence that UV exposure may play more of a role than initially thought in this disease. The data from this study suggest that therapeutic targets for genotype-specific (such as BRAF) melanoma in adults might also be applicable to pediatric patients.
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Content last updated: May 20, 2020