Innovative One Step Melanoma Surgical Approach (OSMS): Not a Myth-It’s a Reality! Case Related Analysis of a Patient with a Perfect Clinical Outcome Reported from the Bulgarian Society for Dermatologic Surgery (BULSDS)!

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BACKGROUND:One step melanoma surgery is a new surgical approach by which specific groups of patients with cutaneous melanoma may be operated only by or within a single surgical session. Until now, the Bulgarian Society for Dermatologic Surgery (BULSDS) has presented models of clinical behaviour, in which preoperative measurement of tumour thickness in combination with echographic measurement of the locoregional lymph nodes could lead to the conduct of the so-called one-step melanoma surgery. Although this one step surgery currently does not fit in the recommended guidelines, it ensures compliance of the recommended boundaries of operational security while saving patients a repeated excision and relieves the healthcare institutions or the patients themselves financially.CASE REPORT:We at this moment present another case from the Bulgarian Society for Dermatologic Surgery (BULSDS) of one step melanoma surgery with a perfect end result, where the tumour thickness was not preoperatively determined by high-frequency echography. Preoperative assessment of tumour thickness was performed based on the clinical picture and dermatoscopy. The histologically established tumour thickness was identical to the preoperative assessment, i.e. <1 mm. Removal of the melanocytic lesion was performed with operational security field of 1cm in all directions, where, as a rule, no further removal of the draining lymph nodes is required.CONCLUSION:One step melanoma surgery has two significant advantages: 1) it saves a re-excision in certain groups of patients, which in turn is 2) significantly more favourable from a financial point of view. Its applicability in the appropriate groups of patients and the postoperative (although in a limited number of patients) results achieved indicate the need to optimise the current algorithms and direct them individually to each patient. Guidelines may not and should not be unified or set strict limits given the fact that they show a significant level of variability themselves regarding some key moments in the initial surgical treatment of melanoma. More than 10% of the primary melanoma cases refer to thin melanomas, and dermatoscopy and clinics are a sufficient method of optimising the planned surgical excision.

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

One Step Melanoma Surgery (OSMS) Without Using Ultrasonography for Preoperative Tumour Thickness Measurement? - ʺA Question that Sometimes Drives Me Hazy: Am I or Are the Others Crazy! ʺ

Tchernev¹,

Temelkova²,

Stavrov³

2018

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“…In that case, if the therapeutic approach was based on the current guidelines, the treatment should start with a primary excision of the melanocytic lesion with a field of safety of 0.5 cm in all directions followed by postoperative measurement of the tumour thickness [ 4 ]. Depending on the histologically established thickness, during the so-called second stage, an assessment of the reexcision necessity with othe r without removal of the draining lymph nodes has to be performed [ 4 ]. In the case of our patient, the decision for only one initial excision of 1cm in all directions was taken by clinical experience and dermatoscopic data.…”

Section: Discussionmentioning

confidence: 99%

The Novel Surgical Margin for One Step Melanoma Surgery (OSMS) (Without Using Ultrasonography Preoperatively): The End of Conformity! ʺVivere militare est!ʺ

Tchernev¹,

Temelkova²

2018

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BACKGROUND:Innovations in medicine are often due to the simplicity of a certain activity, interaction, even counteraction, or a mistake leading to a subsequent final optimal outcome. Innovations could also be due to conclusions based on targeted clinical or sporadic, as well as completely random observations. The genius of an approach or statement is often based on the “iron logic”, which in turn is based on irrefutable data or facts. These are often observations or results from actions that happen right before our eyes and provide advantages or prerequisites for the better future development of things (in this case, disease) concerning certain groups of people (in these case-patients). When the clinical results achieved following an inevitable introduction of certain methods or innovations speak eloquently of a number of advantages in terms of 1) spearing effect on the patients, 2) better control or prevention of possible local and/or distant metastatic spread 3) better financial balance for the health institutions and patients, …, then even the “Gods of certain latitudes” should be silenced. We at this moment present a completely new method or approach for surgical treatment of cutaneous melanoma that once again proves the effectiveness of one-step melanoma surgery, which was successfully first officialised in the world literature again by the Bulgarian Society of Dermatologic Surgery, (BULSDS). In some cases, this method does not even require the preoperative use of a high-frequency ultrasound for determining the tumour thickness.CASE REPORT:In patients with advanced stage of cutaneous melanoma, removal of a primary draining lymph node and/or locoregional lymph nodes is often performed simultaneously. However, it remains unclear why in patients with early-stage (or intermediate, with moderately thick melanomas) disease high-frequency ultrasound is not applied as a routine method of determination of tumour thickness? Meanwhile, re-excision is required following histopathological verification? Is it necessary to have 2 surgical interventions? The two surgical interventions are a burden for the patients and create prerequisites for contradicting opinions, statements, and subsequent results, which ultimately slows down the patient’s staging and the introducing more precise treatments. Based on the logic (and further aided by the clinical picture and dermatoscopy), we decided to operate selected cases of patients with cutaneous melanomas with a field of surgical security of 1cm in all directions when clinical, and dermatoscopic data are indicative of melanoma in situ or thin melanomas (less than 1 cm). Optimal results were achieved, with one surgical intervention and subsequent rehospitalisation spared for the patient.CONCLUSIONS:An answer to the question whether it is better not to follow the guidelines strictly (since, as a rule, they are generally recommended and somewhat misleading in certain circles of specialists, and as we have already found, also lead to unjustified logical secondary excisions), or update t...

“…Based on the established guidelines, treatment begins with resection of the melanocytic lesion with a surgical margin of 0.4-0.5 cm in all directions, followed by re-excision (as in our patient) with or without parallel drainage lymph node (depending on the established postoperative tumor thickness), which however is not individualized and often leads to ambiguity and hesitation, and hence to difficulty in choosing a therapeutic approach, as in the patient we described. [ 30 ]. The role of SUNN (sentinel lymph node biopsy) continues to be studied, and its use is currently recommended for Stage IB and Stage II melanomas [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Multiple Primary Cutaneous Melanomas in a Bulgarian Patient: The Possible Role of One Step Melanoma Surgery (OSMS) As the Most Adequate Treatment Approach!

Tchernev¹,

Temelkova²

2018

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BACKGROUND:Simultaneous occurrence of multiple primary melanomas is a rare, however possible phenomenon, and it is believed that older, male, white, Atypical Mole Syndrome carriers (sporadic and familial) are part of the possible risk factors for its occurrence. In these patients, it is possible to observe involutional changes or (partial/complete) regression of melanocytic lesions, which are likely to be caused by the generation of a spontaneous immune reaction against specific tumour antigens.CASE REPORT:A 58-year-old male patient is presented with two melanocytic lesions located in the right clavicle (subclavicular area) and left the scapular area that meets clinically and dermatoscopically the requirements for malignant melanoma. The lesions were removed by a radical excision with 0.5 cm surgical safety margin in all directions. During the subsequent histological verification it was established it was melanoma with a tumour thickness of 1 mm that in one case, and the other 2 mm. A week later, according to the recommendations of the current guidelines, a re-excision was performed with a surgical safety margin of 1.5 cm in all directions. Considering the complications that are possible during the parallel removal of a draining lymph node recommended for these tumour thicknesses, the patient definitively refused its detection and removal.CONCLUSION:A rare case of a Bulgarian patient with multiple primary, however partially involutional melanomas existing for over 20 years, is described. The individual recommendations of dermato-oncologists for the patient (according to AJCC) were not in favour of radicality but of a more sparing, individualised approach, appropriate for that patient. Unfortunately, the approach we used, in this case, was inconsistent with the AJCC or OSMS guidelines. The reason for individualising the approach in the case we have described is due to the variability of the recommendations for surgical treatment of melanomas laid down in the AJCC.