SURGICAL TREATMENT OF MALIGNANT MELANOMA
Section snippets
SURGICAL TREATMENT OF THE PRIMARY LESION
Biopsy of the primary suspicious lesion through a punch biopsy or preferably an excisional biopsy should first be performed. The longitudinal axis of the ellipse for the excisional biopsy should be directed toward the regional nodes so that it can more easily be encompassed in the definitive resection. This means that for extremity melanomas the ellipse should be placed in a longitudinal direction. It is now well known that for melanomas less than 1 mm thick, a 1cm margin is adequate. At any
ELECTIVE NODE DISSECTION
Malignant melanomas can disseminate through both the lymphatic and hematogenous routes. For intermediate-thickness lesions, the proportion of lymphogenous spread is higher than for thicker lesions, in which the hematogenous spread predominates.1 Two previous, prospective randomized studies showed no benefit from elective node dissection (END).53, 56 However, one of these studies was relatively small and the other concerned itself only with extremity melanomas. The results of the Intergroup
SENTINEL NODE BIOPSY
A recent development, the method of intraoperative lymphatic mapping and sentinel node biopsy pioneered by Morton et al,51 has cast an entirely new light in this area. In this method patent blue-V or isosulfan blue dye is injected intradermally (0.5 to 1 ml, which may be repeated every 20 min during the procedure if needed) at the site of the melanoma on either side of the biopsy scar. An incision is then made over the regional lymph basin, the skin flap closest to the primary melanoma is
Groin Dissection
When elective dissection is done, usually a superficial inguinal dissection is performed. The specimen is interrupted just below the inguinal ligament at the femoral canal. Some authors believe that frozen section evaluation of Cloquet's node is valuable as a predictor of possible involvement of the deep nodes.12, 20 In their opinion, if this node is negative, even though other more distal inguinal nodes may be microscopically positive, the chance of involvement of the deep nodes is minimal.
ADJUVANT TREATMENT FOR PATIENTS WITH POSITIVE REGIONAL NODES
Recently, it has been shown in a prospective randomized trial that adjuvant treatment with interferon 2b increases significantly (P = 0.0023) the 5-year disease-free survival of patients with positive regional nodes, from 26% for the observation to 37% for the treated group.41 This is the first time that improved disease-free and overall survival has been shown in a prospective randomized trial.
INTRANSIT METASTASES
Local recurrence is by definition considered to be that occurring within 2 cm of the surgical scar of the primary site. It should be treated with wide resection as a primary lesion, supplemented ideally by regional perfusion or infusion. Intransit metastases are those occurring beyond 2 cm from the primary site and are usually multiple. These lesions arise from melanoma cells, trapped within lymphatics, en route to the regional lymph nodes. They may occur at any place between the primary site
RESECTION OF DISTANT METASTASES
Malignant melanoma disseminates widely through the hematogenous route. It can involve any organ or tissue. The only known predilection is that of ocular melanoma, which, when it metastasizes, does so in the liver with higher frequency than cutaneous melanomas do.52 Tissues more commonly involved in melanoma than in other forms of malignancy are distant subcutaneous sites or lymph nodes and the gastrointestinal tract, particularly the small intestine. Some patients develop multiple subcutaneous
MELANOMA OF SPECIFIC SITES
Ocular melanoma is a specific entity in itself and is handled by ophthalmology clinics. Its propensity for hepatic metastases is well known.52
Mucosal melanomas are uncommon and carry a grave prognosis owing to the late detection of these lesions. Melanoma of the anal canal may be treated with wide local excision if the lesion is superficial or with abdominoperineal resection. The prognosis for anorectal melanoma is grave, although a 25% 5-year survival rate has been recorded with
References (58)
Surgical management of regional lymph nodes in cutaneous melanoma
J Am Acad Dermatol
(1980)Abdominoinguinal incision in resection of pelvic tumors with lateral fixation
Am J Surg
(1992)Ilioinguinal lymph node dissection
Am J Surg
(1981)- et al.
Positive deep nodes in the groin and survival in malignant melanoma
Am J Surg
(1996) - et al.
Prognostic parameters in localised melanoma. Gender versus anatomical location
Eur J Cancer
(1995) - et al.
Groin dissection in malignant melanoma
Am J Surg
(1986) - et al.
Axillary node dissection in malignant melanoma
Am J Surg
(1991) - et al.
Claviculectomy for the exposure and en-bloc resection of adjacent tumors
Am J Surg
(1992) - et al.
Survival of patients with Stage IA malignant melanoma
Surg Oncol
(1995) - et al.
A multifactoral analysis of melanoma: Prognostic histopathologic features comparing Clark's and Breslow's staging methods
Ann Surg
(1978)
Tumor thickness as a guide to surgical management of clinical stage I melanoma patients
Cancer
A comparison of prognostic factors and surgical results in 19,786 patients with localized (stage I) melanoma treatment in Alabama, USA, and New South Wales, Australia
Ann Surg
A prospective surgical trial of 742 melanoma patients comparing the efficacy of elective (immediate) lymph node dissection versus observation
American Surgical Association, 116th Annual Meeting Program, Phoenix, AZ, April
Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1–4 mm): Results of a multi-institutional randomized surgical trial
Ann Surg
Cancer Statistics, 1992: Cancer J Clin
Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma
Ann Surg
The histogenesis and biologic behavior of primary human malignant melanomas of the skin
Cancer Res
Staging laparotomy in the treatment of metastatic melanoma of the lower extremities
Ann Surg
Extent of lymph node dissection in melanoma of the trunk or lower extremity
Arch Surg
Prognostic factors in patients with melanoma metastatic to axillary or inguinal nodes: A multivariate analysis
Ann Surg
A selective approach to resection of deep iliac nodes: Results in 1278 groin dissections [Abstract]
The natural history of resectable metastatic melanoma (stage IVA melanoma)
Cancer
Results of ilioinguinal dissection for stage II melanoma
Ann Surg
Results of groin dissection for malignant melanoma in 220 patients
Surgery
Symptomatic gastrointestinal metastases from malignant melanoma
Cancer
Hyperthermic perfusion of recurrent malignant melanoma on the extremities
Acta Chir Scand
The pathology of melanotic growth in relation to their operating treatment
Lancet
Diagnostic excision of the Rosenmuller's node: Screening for occult metastases before elective regional lymph node dissection in patients with lower limb melanoma?
Cancer
Results of radical dissection of the groin in patients with stage II melanoma and histologically proved metastases of the iliac or obturator lymph nodes or both
Surg Gynecol Obstet
Cited by (32)
The role of resection for melanoma metastases to the pancreas
2022, HPBCitation Excerpt :The systematic search of the electronic databases produced a total of 471 reports. Out of these, we identified 72 retrospective studies and no prospective studies published between 1964 and 2021 that reported data of pancreatic resection for PMM in 109 patients.3,4,7,17-25, 26-35, 36-45, 46-55, 56-65, 66-75, 76-85 The median MINORS score16 was 11 (range 6–13).
Melanoma of the Vulva and Vagina: Surgical Management and Outcomes Based on a Clinicopathologic Reviewof 68 Cases
2019, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :In addition, gynaecologic oncologists, the primary surgical specialists who manage melanomas of the female genital tract, are influenced by the management principles for squamous cell carcinoma of the vulva, the most common vulvar malignancy. Multiple trials have examined the optimal surgical excision margin for cutaneous melanomas, evaluating margins ranging from 1 to 5 cm.18–23 On the basis of these data, current National Comprehensive Cancer Network Guidelines recommend that primary surgical excision aim for surgical margins of 0.5–1.0 cm for in situ melanoma, a 1.0-cm margin for melanomas with thickness less than 1.0 mm, 1- to 2-cm margins for a thickness of 1.01–2 mm, and 2-cm margins for melanomas with thickness greater than 2.01 mm.24
Cutaneous malignant melanoma
2006, Mayo Clinic ProceedingsCitation Excerpt :Melanoma in situ, wherein the tumor is limited to the epidermis, is excised with 5-mm borders. Invasive melanoma that extends into the dermis or deeper is excised with margins of 1 to 2 cm, determined by tumor thickness.72 Success rates are high for thin tumors (<1.5 mm), approaching 90% survival at 5 years.73
Selective sentinel lymphadenectomy for malignant melanoma
2003, Surgical Clinics of North AmericaBrain metastases in melanoma: A European perspective
2002, Seminars in OncologyCitation Excerpt :The relative radioresistance of melanoma, and consequent transient impact of conventional radiotherapy, means that isolated or localized small-volume brain metastases in patients without large-volume disease elsewhere are usually considered for surgical resection. The evidence to support surgery as a treatment modality comes from a number of small retrospective analyses, with series describing experience from between six and 136 patients.2-5 Median survivals of 5.4 to 12 months are quoted, with 1-year disease-free survival rates between 28% and 36.3%.
Surgical management of cutaneous malignancies
2001, Clinics in Dermatology
Address reprint requests to C. P. Karakousis, MD, PhD, Department of Surgical Oncology, Millard Fillmore Hospital, State University of New York at Buffalo, 3 Gates Circle, Buffalo, NY
- *
From the Division of Surgical Oncology, Millard Fillmore Hospital, State University of New York at Buffalo, Buffalo, New York