What treatments are available for melanoma that has spread to lymph nodes? 

When melanoma moves beyond the primary skin site and enters the lymphatic system, it is classified as Stage 3 melanoma. This progression represents a significant shift in the management of the disease, moving from local skin surgery to a more comprehensive approach that often involves systemic medical therapies. In the United Kingdom, the treatment pathway for Stage 3 melanoma has evolved rapidly over the last decade, with a focus on reducing the risk of recurrence and improving long-term survival through a combination of surgery and advanced drug treatments. 

What We’ll Discuss in This Article 

• The role of surgery in managing involved lymph nodes. 

• Why completion lymphadenectomy is no longer routine for most patients. 

• The use of adjuvant immunotherapy to boost the immune system. 

• How targeted therapy works for patients with specific genetic mutations. 

• Specialised treatments for melanoma spread within a limb. 

• The importance of regular ultrasound monitoring and surveillance. 

• When radiotherapy or chemotherapy may be considered in clinical care. 

Surgical management of involved lymph nodes 

Surgery remains a cornerstone of treatment for Stage 3 melanoma, but the extent of the operation depends on how the spread was identified. If the cancer was found through a sentinel lymph node biopsy, the primary treatment usually involves the wide local excision of the original skin site. However, if a patient has a clinically palpable or visible lump in a lymph node basin, a more extensive operation called a therapeutic lymph node dissection may be recommended. This involves the removal of all the lymph nodes in the affected area, such as the armpit or the groin, to achieve regional disease control. NHS clinical teams prioritise surgical removal of visible nodal disease to prevent the cancer from growing further within the lymphatic system. 

The shift away from routine completion lymphadenectomy 

In recent years, there has been a significant change in how UK surgeons manage microscopic spread found during a sentinel lymph node biopsy. Previously, it was standard practice to remove all remaining lymph nodes in that basin (completion lymphadenectomy) if the sentinel node was positive. However, major clinical trials have demonstrated that this extensive surgery does not improve overall survival for the majority of patients and can lead to long-term complications like lymphedema. As a result, many patients are now offered a choice between further surgery or close observation with regular ultrasound scans. This decision is made after a detailed discussion within a multidisciplinary team to weigh the risks and benefits for each individual. 

The role of adjuvant immunotherapy 

Adjuvant therapy refers to treatment given after surgery to kill any remaining microscopic cancer cells and reduce the chance of the melanoma returning. Immunotherapy has become a primary option for patients with Stage 3 melanoma in the UK. These medications, such as pembrolizumab and nivolumab, are checkpoint inhibitors that work by helping the body’s own immune system to recognise and attack melanoma cells. NICE recommends the use of immunotherapy as an adjuvant treatment for patients who have had their Stage 3 melanoma completely removed by surgery. These drugs are usually administered via an intravenous drip every few weeks for up to one year. 

Targeted therapy for BRAF-positive melanoma 

Approximately half of all melanoma patients have a specific mutation in a gene called BRAF, which helps the cancer cells grow. For these individuals, targeted therapy is an effective alternative or addition to immunotherapy. This treatment typically involves taking a combination of two oral medications, such as dabrafenib and trametinib, which work together to block the growth signals within the cancer cells. Targeted therapy is only effective for those with the BRAF V600 mutation, so a genetic test on the removed melanoma tissue is a mandatory step before this treatment can begin. Like immunotherapy, adjuvant targeted therapy is generally continued for twelve months following surgery. 

Treatments for in-transit and satellite spread 

Sometimes melanoma spreads to the area of skin or the lymphatic vessels between the original mole and the nearest lymph nodes. This is known as in-transit or satellite spread. If these areas cannot be easily removed with surgery, other specialised treatments are available. These include talimogene laherparepvec, which is an immunotherapy drug injected directly into the melanoma nodules. For melanoma spread that is confined to a single arm or leg, a procedure called isolated limb perfusion or infusion may be used. This involves delivering high doses of chemotherapy directly to the limb while its blood supply is temporarily isolated from the rest of the body, allowing for intense treatment with minimal systemic side effects. 

Surveillance and the role of ultrasound monitoring 

For patients who do not undergo a full lymph node clearance, regular monitoring is essential. This usually involves having a physical examination and an ultrasound scan of the lymph node basins every few months. Ultrasound is highly sensitive at detecting early changes in the size or shape of a lymph node that might suggest the cancer is returning. This proactive approach allows the medical team to intervene quickly with surgery or drug therapy if any new spread is identified. Surveillance is a lifelong commitment for many Stage 3 patients, ensuring that any recurrence is caught at the most treatable stage. 

The use of radiotherapy and chemotherapy 

Radiotherapy is sometimes used after surgery if there is a high risk that the melanoma will return in the same area or to help control symptoms if the cancer cannot be removed. It uses high-energy beams to target and destroy cancer cells. Chemotherapy, on the other hand, is rarely used as a primary treatment for Stage 3 melanoma in the UK today. While drugs like dacarbazine were once the standard, they have largely been replaced by more effective modern immunotherapies and targeted drugs. Chemotherapy is now generally reserved for situations where other treatments are not suitable or have stopped working, often as part of palliative care to manage symptoms. 

Conclusion 

Treatments for melanoma that has spread to the lymph nodes include a combination of specialised surgery and advanced systemic drug therapies. The introduction of adjuvant immunotherapy and targeted therapy has transformed the outlook for Stage 3 patients, significantly reducing the risk of the cancer returning. While surgery remains important, the trend is moving toward less invasive nodal management and more personalised medicine based on genetic testing. If you experience severe, sudden, or worsening symptoms, call 999 immediately. 

Authority Snapshot (E-E-A-T) 

This article is designed to provide clear and factual information regarding skin health for the general public. The content is written by the Medical Content Team and has been reviewed by Dr. Stefan Petrov. He is a UK-trained physician with an MBBS and postgraduate certifications including Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and the UK Medical Licensing Assessment (PLAB 1 & 2). He has hands-on experience in general medicine, surgery, anaesthesia, ophthalmology, and emergency care. Dr. Petrov has worked in both hospital wards and intensive care units, performing diagnostic and therapeutic procedures, and has contributed to medical education by creating patient-focused health content and teaching clinical skills to junior doctors.