Treatment

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.

It’s important to note that complete lymph node dissection is now performed less often, especially if only microscopic disease is present within the sentinel nodes, because it has not always been shown to improve survival. Instead, doctors may recommend close monitoring with imaging. But once lymph nodes become visibly or palpably enlarged, node dissection is typically required, and generally systemic (whole body) drug treatment is used as well. This can be recommended before or after lymph node surgery.

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 (postoperative) therapy may be recommended to try to decrease the risk of tumor recurrence. If the lymph nodes are enlarged, neoadjuvant (preoperative) therapy has been shown to be beneficial in adults with melanoma and therefore is also now frequently recommended for younger patients. 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.

Immunotherapy helps the body’s own immune system recognize and attack cancer cells. One of the first immunotherapies approved for melanoma was ipilimumab (Yervoy). In 2017, the FDA approved this treatment for patients ages 12 years and older with metastatic melanoma. Ipilimumab is known as a “checkpoint inhibitor”, a type of drug that blocks or removes barriers that can prevent the immune system from attacking cancer. Other checkpoint inhibitors, such as nivolumab (Opdivo) and pembrolizumab (Keytruda), are now more commonly used in adults especially after surgery (adjuvant therapy). While these drugs are not yet officially approved for children, they are sometimes used when appropriate, and studies have shown that children and teens respond similarly to adults. Side effects are also comparable, though some serious immune-related effects, like inflammation of the colon (colitis) appear to be less common in younger patients.

In 2025, the FDA approved new forms of Keytruda and Opdivo called Keytruda QLEX and Opdivo Qvantig, which can be given as an injection under the skin rather than through an IV. This new option is available for patients ages 12 and older and offers the same safety and effectiveness as IV forms of the same drug, but with a much shorter treatment time, the injection is given over a few minutes whereas the IV infusion is typically 30 minutes or so. This may make treatment easier and more flexible for families, as it can often be given in more convenient care settings.

Ongoing clinical trials continue to study how checkpoint inhibitors and other immunotherapies can best help children and teens with melanoma.

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.

Pediatric studies of BRAF and MEK inhibitors show that they can be effective and generally safe for children with BRAF-positive melanoma.

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.

Today, research shows that conventional pediatric melanomas often share the same genetic changes as adult melanomas. Because of this, many of the therapies developed for adults, including targeted therapies and immunotherapies, may also help children. Clinical trials remain one of the most important ways to make these treatments safer and more available for younger patients.