Update and Review on the Surgical Management of Primary Cutaneous Melanoma

Leilabadi, Solmaz N.; Chen, Amie; Tsai, Shirley C.; Soundararajan, Vinaya; Silberman, Howard; Wong, Alex K.

doi:10.3390/healthcare2020234

Cited by 13 publications

(16 citation statements)

References 60 publications

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“…Current National Comprehensive Cancer Network guidelines for MIS recommend a 5-mm surgical margin of resection, but this margin is frequently insufficient to prevent recurrence. 6 A large study by Kunishige et al 7 in 2012 suggested that MIS should be treated similarly to early invasive melanoma, with surgical margins of at least 9 mm. A further study by Akhtar et al 8 suggested that narrow margin excisions are unlikely to lead to recurrence and that wide margins may be unnecessary.…”

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confidence: 99%

An Assessment of Histological Margins and Recurrence of Melanoma In Situ

Joyce

Jones

et al. 2015

Plastic and Reconstructive Surgery Global Open

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Background:Melanoma in situ (MIS) accounts for up to 27% of all melanomas. MIS has no metastatic potential and the aim should be to excise the lesion completely with a clear histological margin, although margin clearance remains undefined. We aimed to assess the relation of histological excision margins of MIS to recurrence and progression to invasive disease.Methods:We analyzed all patients with MIS excised by wide local excision or staged excision in our institution over a 5-year period from December 2008 to January 2014 using a prospectively maintained database. Clinicopathologic details included patient demographics, anatomical site of lesion, melanoma subtype, histological excision margin, and recurrence.Results:A total of 410 patients had MIS excised during this time, the majority of which were lentigo maligna subtype (79%). The average histological excision margin was 3.7 mm. The rate of recurrence was 2.2% (9/410), with a median follow-up of 23 months. Lentigo maligna had a similar rate of recurrence to non-lentigo MIS (2.3% vs 1.2%) (P = 0.69). The mean excision margin of those that recurred was 1.9 mm compared with an average of 3.8 mm in those that did not. The rate of recurrence of MIS with histological excision margin ≤3.00 mm was 3.8% compared with 0.5% in those with a histological margin >3.00 mm (P = 0.03). One case of MIS recurred as invasive disease.Conclusion:At institutions using wide local excision or staged excision for MIS, a histological margin of >3.0 mm is required to achieve a low recurrence rate.

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confidence: 99%

An Assessment of Histological Margins and Recurrence of Melanoma In Situ

Joyce

Jones

et al. 2015

Plastic and Reconstructive Surgery Global Open

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“…Two cm is also the recommended area for treatment of melanomas with a thickness of 2.01-4 mm [ 1 ] [ 5 ]. For melanomas with thickness over 4 mm, resection areas of more than 2 cm in all directions are not recommended [ 5 ].…”

Section: Discussionmentioning

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

Open Access Maced J Med Sci

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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.

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“…The approach adopted for treatment of malignant melanoma includes surgical resection with adequate excision margins, with or without lymph node biopsy [ 28 ]. At this stage, a large proportion of dermatologists follow the recommendations of the American Joint Committee on Cancer, according to which primary melanoma surgery is based on Breslow tumour thickness and includes resection of 0.5 cm for MIS, 1.0 cm for melanomas ≤ 1.0 mm thick, 1-2 cm for melanoma thickness of 1.01-2 mm, 2 cm margins for melanoma thickness of 2.01-4 mm, and 2cm margins for melanomas > 4 mm thick [ 29 ]. 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.…”

Section: Discussionmentioning

confidence: 99%

“…[ 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 ]. In some cases, preoperative high-frequency ultrasound diagnosis helps determine the limits of surgical margins, indications for lymph node biopsy, and the need for re-excision [ 31 ].…”

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

Open Access Maced J Med Sci

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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.

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Update and Review on the Surgical Management of Primary Cutaneous Melanoma

Cited by 13 publications

References 60 publications

An Assessment of Histological Margins and Recurrence of Melanoma In Situ

An Assessment of Histological Margins and Recurrence of Melanoma In Situ

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

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

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