Melanoma is the most aggressive form of skin cancer, but it is treatable when detected early, and during the metastatic stage, the revolution in immunotherapy and targeted therapy over the past decade has radically changed the prognosis. The Sourasky (Ichilov) Medical Center in Tel Aviv is one of the leading Israeli centers where melanoma is treated according to international NCCN and ESMO protocols, with full access to molecular tumor profiling, checkpoint inhibitors, combined targeted therapy, oncolytic virotherapy, and TIL-based cell immunotherapy. A patient arriving at the Ichilov oncology department undergoes staging according to the AJCC 8th edition, and if indicated, a sentinel lymph node biopsy (SLNB), wide excision of the tumor, and lymphadenectomy if regional nodes are affected, are performed. Each case is discussed at a multidisciplinary Tumor Board, where an oncological dermatologist, surgical oncologist, radiation therapist, pathomorphologist, molecular diagnostics specialist, and medical oncologist jointly make a decision about the plan. In this article, we detail how the patient journey with melanoma is structured at the Sourasky clinic—from the first appointment and biopsy to systemic therapy, monitoring, and relapse prevention.
What is this disease
Melanoma develops from the pigment-producing cells of the skin—melanocytes—and accounts for about 5% of all skin neoplasms, but it is responsible for the overwhelming majority of skin cancer mortality. In Israel, due to the high level of sun exposure and genetic characteristics of the population, the incidence of melanoma is among the highest in the world—and this is why Israeli oncology has historically accumulated significant clinical experience in this area. In the CIS countries, the registered incidence is lower, but patients often present at late stages due to low recognition of early signs.
Key risk factors include fair skin types I–II, a tendency to sunburn, multiple dysplastic nevi (more than 50), a family history of melanoma, hereditary mutations CDKN2A and BAP1, tanning bed use, and weakened immunity (including in transplant recipients and patients with HIV). Regular intense ultraviolet exposure with episodes of burning increases the risk more than uniform chronic exposure.
Clinical signs that require a visit to an oncological dermatologist fit into the ABCDE rule: A—asymmetry (asymmetry of the nevus), B—border (irregular border), C—color (heterogeneous color—brown, black, red, white, blue), D—diameter (greater than 6 mm), E—evolution (evolution—change in shape, color, size, appearance of itching or bleeding). Particular caution is warranted for "new" pigmented lesions that appear after age 40, as well as nodular forms—they often do not meet the ABCDE criteria but grow vertically and metastasize quickly. Acral lentiginous melanoma (on palms, soles, under nails) and lentigo melanoma of the face in the elderly are specifically highlighted—these forms require the expertise of a dermatologic oncologist, as they can be easily missed at an early stage. With early detection (Stage I according to AJCC), the 5-year survival rate exceeds 90%; with regional metastases (Stage III), it decreases, but modern adjuvant immunotherapy has significantly improved the prognosis.
Send your records — an Ichilov physician will reply within 1–2 days, free of charge.
Diagnosis at Ichilov Clinic
The diagnosis of melanoma at Ichilov Clinic begins with an appointment with a dermatologic oncologist and digital dermatoscopy—mapping the skin with photographic documentation of all suspicious elements, allowing for comparison of images over time during subsequent visits. A dermatoscope with polarized light allows for visualization of the internal structures of the nevus—asymmetry of the pigment network, "milk-red" zones, atypical vessels—which are invisible to the naked eye.
In the case of suspicious lesions, an excisional biopsy is performed—the lesion is completely removed with narrow margins and sent for histological examination. Shave or incisional biopsy of the central part of a suspicious nevus is not recommended, as it distorts the assessment of invasion depth (Breslow thickness). Histology at Ichilov provides a complete report: Breslow thickness in millimeters, presence of ulceration, mitotic index, level of invasion according to Clark, lymphovascular and perineural invasion, margin status. Based on this, the stage according to AJCC 8th edition (TNM) is established.
If the tumor thickness is greater than 0.8 mm or if ulceration is present, a sentinel lymph node biopsy (SLNB) is discussed—an intraoperative mapping of lymphatic drainage with a radioisotope and blue dye, removal, and pathomorphological examination of one or two "sentinel" nodes. The status of SLNB is a key prognostic marker and determines the strategy for adjuvant therapy.
A mandatory step is molecular tumor typing. At Ichilov, BRAF sequencing is performed (the V600E/V600K mutation is found in approximately 40–50% of patients and opens access to targeted therapy), NRAS, C-KIT (important for acral and mucosal melanomas), as well as determining PD-L1 expression as a predictive marker for immunotherapy. In metastatic disease—an extended NGS panel to search for rare drivers and potential clinical trials.
Staging of the extent includes PET-CT with 18F-FDG (detection of distant metastases), MRI of the brain with contrast (mandatory in stages III–IV, as melanoma is one of the "leaders" in cerebral metastases), ultrasound of regional lymph nodes, and laboratory monitoring of LDH (an important marker in stage IV). The complete diagnostic package—from the initial appointment to the Tumor Board—under a planned scenario takes 5–7 working days.
Treatment Methods
Surgical treatment is the foundation of radical treatment for early melanoma. At the Ichilov (Sourasky) clinic, wide local excision is performed with margins corresponding to the depth of the tumor according to Breslow: for in situ — 5 mm, for thickness up to 1 mm — 1 cm, for 1–2 mm — 1–2 cm, for more than 2 mm — 2 cm. For melanoma of the face and acral areas, Mohs surgery is used with intraoperative histological margin control. For melanoma under the nail plate, a conservative excision is performed, preserving finger function whenever possible.
Sentinel lymph node biopsy (SLNB) is performed simultaneously with wide excision and replaces total prophylactic lymphadenectomy. If the sentinel node is positive, the modern approach is dynamic ultrasound monitoring of the regional basin and adjuvant systemic therapy, rather than routine complete lymphadenectomy: studies MSLT-II and DeCOG-SLT have shown that total dissection in the presence of micrometastases does not improve overall survival but increases the risk of lymphedema. Complete lymph node dissection remains an option for clinically detectable macrometastases or in case of recurrence in the basin.
Adjuvant immunotherapy is recommended for stage IIB–IV after radical surgery. The main drugs are anti-PD-1 monoclonal antibodies: pembrolizumab and nivolumab, prescribed for 12 months. For patients with BRAF-positive melanoma, an alternative is adjuvant targeted therapy with the combination of dabrafenib + trametinib. The choice depends on the mutation status, comorbidities, and patient preferences after a detailed discussion of the toxicity profile.
Neoadjuvant immunotherapy is an actively developing area. In patients with macroscopically detectable regional metastases (clinical stage III), a short course of the combination of nivolumab + ipilimumab or monotherapy with pembrolizumab before surgery demonstrates a high percentage of pathomorphological response and improves recurrence-free survival. The Ichilov (Sourasky) clinic participates in international neoadjuvant therapy protocols and applies this approach in selected cases.
In metastatic disease (stage IV), the first line for patients without BRAF mutation is anti-PD-1 immunotherapy (pembrolizumab or nivolumab) in monotherapy, or the combination of nivolumab + ipilimumab in aggressive cases, with high tumor burden, and asymptomatic brain metastases. The combination yields a higher response rate but also significantly greater toxicity — colitis, hepatitis, endocrinopathies — and is therefore prescribed in a center experienced in managing immune-mediated adverse events.
For patients with BRAF V600 mutation, two approved combinations of targeted therapy are available: dabrafenib + trametinib and encorafenib + binimetinib. Both demonstrate high response rates and quickly control the tumor, which is important in symptomatic disease. Triple therapy (BRAF/MEK inhibitor + anti-PD-L1 atezolizumab) is an option in certain clinical scenarios. The strategy of sequential application (immunotherapy → targeted therapy or vice versa) is discussed individually at the Tumor Board.
For locally advanced or in-transit melanoma (in-transit metastases, satellite lesions), oncolytic virotherapy — talimogene laherparepvec (T-VEC) — is used. A modified herpes simplex virus is injected directly into tumor nodules, causing both local lysis of cells and a systemic immune response. T-VEC is particularly valuable for patients who are not candidates for extensive surgery and is well tolerated.
TIL therapy (lifileucel) is a breakthrough cell method for patients with melanoma that has progressed after immunotherapy and targeted therapy. Tumor-infiltrating lymphocytes are extracted from the tumor tissue, expanded in the laboratory to billions of cells, and reinfused into the patient after chemotherapeutic lymphodepletion and interleukin-2. The method was approved by the FDA in 2024 and is used in Israel in specialized centers like Ichilov for selected candidates.
Brain metastases are one of the most challenging situations, but the approach has significantly changed here as well. Stereotactic radiosurgery (Gamma Knife, LINAC-SRS) is used for a limited number of lesions, while whole brain radiation therapy (WBRT) is only used for multiple metastases. Anti-PD-1 immunotherapy or the combination of nivolumab + ipilimumab demonstrates intracranial responses, and the combination with SRS is often preferred over WBRT due to the preservation of cognitive function.
Metastases to the liver in melanoma are more difficult to control: options include systemic therapy, TACE (transarterial chemoembolization), radioembolization Y-90, and — for uveal melanoma — the targeted drug tebentafusp (bispecific antibody gp100×CD3), approved specifically for this rare subtype.
Treatment Program — Stages
The melanoma treatment program at Ichilov (Sourasky) is structured as a clear sequence of stages with fixed timelines. The first stage is a remote consultation: the patient sends medical records, slides, and blocks of histology, and images. The international department of the clinic provides a preliminary examination plan and an estimated budget within 2–3 business days.
The second stage involves arrival and an initial consultation with the leading oncologist specializing in melanoma. Blood tests, instrumental diagnostics (PET-CT, brain MRI as indicated), and a review of histology in the Ichilov pathomorphology laboratory are scheduled on the same day or the next day — this is critically important, as some initial conclusions from the CIS are clarified or revised based on the results of immunohistochemistry.
The third stage is molecular diagnostics: BRAF, NRAS, KIT, PD-L1, and, if indicated, an extended NGS panel. The report is prepared within 5–10 business days. Simultaneously, a multidisciplinary Tumor Board is organized: an oncological dermatologist, surgical oncologist, medical oncologist, radiation therapist, and neurosurgeon in cases of brain metastases.
The fourth stage is active treatment according to the Tumor Board protocol. The surgical stage (wide excision + SLNB) usually requires 1–2 days of hospitalization, with rehabilitation lasting 7–10 days. Immunotherapy and targeted therapy are conducted on an outpatient basis — the first cycles are monitored in Tel Aviv, and further management is possible at the place of residence with telemedicine oversight from the clinic.
The fifth stage is a follow-up examination 3, 6, and 12 months after the start of therapy: physical examination, dermatoscopy, ultrasound of regional basins, PET-CT, brain MRI — the intervals depend on the stage and type of therapy. Scheduled follow-up continues for at least 5 years.
Prices and Costs
The cost of treatment at the Sourasky clinic varies depending on the volume of diagnostics, stage, and chosen protocol. Below are approximate ranges for budget planning; the exact estimate is formed after the initial consultation.
The full diagnostic package (initial consultation with an oncological dermatologist, dermatoscopy, review of histology, PET-CT, brain MRI, laboratory tests) is approximately 6,000–9,000 USD. Molecular typing BRAF/NRAS/KIT/PD-L1 ranges from 1,500 to 3,500 USD depending on the panel size; extended NGS costs up to 5,000 USD.
Wide excision of primary melanoma with SLNB costs from 12,000 to 20,000 USD, including hospitalization, anesthesia, intraoperative mapping, and pathology of sentinel nodes. Complete lymphadenectomy (if indicated) costs 15,000–25,000 USD.
One cycle of immunotherapy (pembrolizumab, nivolumab) costs 6,000–10,000 USD depending on the drug and dosage; the combination of nivolumab + ipilimumab is significantly more expensive, up to 20,000 USD per cycle. Targeted therapy BRAF + MEK costs about 8,000–12,000 USD per month.
Stereotactic radiosurgery for brain metastases costs from 15,000 USD; T-VEC — the cost of the drug plus outpatient visits; TIL therapy (lifileucel) is the most resource-intensive option, requiring individual calculation and usually exceeds 500,000 USD, including hospitalization and accompanying therapy. The clinic provides patients from the CIS with a transparent estimate in advance, all invoices are official, and payment is possible under a contract with the international department.
Leading Doctors in the Field
The melanoma program at Ichilov (Sourasky) is a team project. The Tumor Board for each case includes the head of the oncological dermatology service, a leading surgical oncologist with experience in multi-organ operations and SLNB, a medical oncologist specializing in immunotherapy for solid tumors and cell therapy, the head of the radiation therapy service, a neurosurgeon (in cases of cerebral metastases), and a pathomorphologist with a subspecialization in melanocytic tumors, as well as a specialist in molecular diagnostics.
The personal composition of doctors is formed based on the results of the initial assessment: in stages I–II, the leading roles are held by the surgical oncologist and oncological dermatologist; in stage III, a medical oncologist is involved for adjuvant therapy; in stage IV, an interdisciplinary team with a leading role for the medical oncologist is formed, and in cases of cerebral metastases, joint management with the radiation therapist and neurosurgeon is conducted.
The international department of the clinic provides the specific names of leading doctors at the stage of program registration; if the patient wishes, a preliminary video call can be arranged for acquaintance and discussion of the plan before arriving in Tel Aviv.
FAQ
What language is used for communication with doctors?
The reception at Ichilov (Sourasky) clinic is conducted in English and Hebrew. For patients from the CIS, the international department provides a Russian-speaking medical coordinator who assists at all stages — from the initial consultation to the final conclusion. The translation of medical documents, conclusions, and prescriptions is performed by official translators of the clinic.
What documents should be brought from the CIS?
The optimal package includes complete extracts describing the diagnosis and treatment performed, histological slides and paraffin blocks (not just conclusions), and results of all imaging performed — PET-CT, MRI, ultrasound on disks in DICOM format. Slides and blocks are essential — they allow for a review and, if necessary, molecular typing in the Sourasky laboratory.
How many days will the program take?
The diagnostic stage and Tumor Board — 5–7 working days. Surgical treatment for stage I–II — 7–14 days with rehabilitation. Immunotherapy is conducted in cycles every 3 or 6 weeks — the first cycle in Tel Aviv, further management is possible at the place of residence with oversight from the clinic. The total duration of the first visit in a planned scenario is from 10 to 21 days.
Is an advance payment required?
Yes, after confirming the program, the international department issues an invoice for a deposit that covers the initial diagnosis and the first stage of treatment. The remainder is paid based on the actual services provided with transparent detailing. All payments are official, go directly to the Sourasky clinic, without intermediaries.
Is it possible to have a consultation with my treating physician at home?
Yes. Upon the patient's request, Ichilov (Sourasky) clinic organizes a video consultation with the treating oncologist in the home country — this allows for coordinating the plan, discussing further management after returning home, and ensuring continuity of therapy. All conclusions and prescriptions are issued with an official translation.
How can I obtain a second opinion without coming in?
The "second opinion" program is a remote service where histology, images, and clinical data are reviewed, and within 5–10 working days, a conclusion with recommendations from a leading melanoma oncologist is issued. Coming in is not required — all documents are accepted electronically.
Do you work with insurance?
The clinic accepts patients with international insurance — specific conditions depend on the policy and insurer. The international department agrees on coverage in advance, prepares invoices in the required format, and, if necessary, conducts direct settlements with the insurance company.
How is follow-up organized after returning home?
The clinic provides a complete follow-up protocol: timelines for check-ups, dermatoscopy, laboratory tests, PET-CT, and MRI. The patient gains access to telemedicine consultations with the treating physician at Ichilov (Sourasky), and interim results can be sent for evaluation without the need for a repeat visit. In case of signs of progression or immune-mediated adverse events — urgent consultation within 24–48 hours.
How to obtain a treatment program
The first step is to contact the international department of the Ichilov (Sourasky) clinic through the official contact: phone, form on the website, or email. You will need to gather a package of documents: recent discharge summaries, histological conclusions (preferably slides and blocks), PET-CT and MRI scans in DICOM format, if they were performed. Within 2–3 business days, the coordinator will provide a preliminary examination plan and an estimated budget. Arrival in Tel Aviv is possible within 1–2 weeks after the plan is agreed upon. The clinic assists with arranging an invitation, booking accommodation near the medical center, meets you at Ben Gurion Airport, and accompanies you at all stages of diagnosis and treatment. Submit a request through the form on this page — the coordinator will contact you within one business day.