Elsevier

Surgical Clinics of North America

Volume 76, Issue 6, 1 December 1996, Pages 1299-1312
Surgical Clinics of North America

SURGICAL TREATMENT OF MALIGNANT MELANOMA

https://doi.org/10.1016/S0039-6109(05)70516-8Get rights and content

Malignant melanoma has shown a dramatic increase in its incidence in the last two decades. It is now estimated that more than 32,000 cases are diagnosed annually in the United States, so it is no longer a rare tumor.7

Until the mid-1970s wide resection of 4 to 5 cm around a melanoma site was practiced without regard to any of the characteristics of the primary lesion, following recommendations made at the beginning of the 20th century on the basis of autopsy findings.19

Perhaps the single most important development in the understanding and treatment of cutaneous malignant melanoma has been the introduction of the microstaging methods for primary lesions by Clark and Breslow.8, 9 Ulceration,2, 4 the location of the primary lesion, and the gender and age of the patient are additional prognostic parameters.30, 34 Any discussion of the surgical treatment of malignant melanoma is meaningful only in the context of the stage of the disease. The American Joint Commission on Cancer (AJCC) staging system, using the prognostic information provided by the microstaging of the primary lesion and the presence or absence of regional or distant metastases, has finally prevailed.40

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)

  • C.M. Balch et al.

    Tumor thickness as a guide to surgical management of clinical stage I melanoma patients

    Cancer

    (1979)
  • C.M. Balch et al.

    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

    (1984)
  • C.M. Balch et al.

    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

    (1996)
  • C.M. Balch et al.

    Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1–4 mm): Results of a multi-institutional randomized surgical trial

    Ann Surg

    (1993)
  • C.C. Boring et al.

    Cancer Statistics, 1992: Cancer J Clin

    (1992)
  • A. Breslow

    Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma

    Ann Surg

    (1970)
  • W.H. Clark et al.

    The histogenesis and biologic behavior of primary human malignant melanomas of the skin

    Cancer Res

    (1969)
  • M.H. Cohen et al.

    Staging laparotomy in the treatment of metastatic melanoma of the lower extremities

    Ann Surg

    (1976)
  • D.G. Coit et al.

    Extent of lymph node dissection in melanoma of the trunk or lower extremity

    Arch Surg

    (1989)
  • D.G. Coit et al.

    Prognostic factors in patients with melanoma metastatic to axillary or inguinal nodes: A multivariate analysis

    Ann Surg

    (1991)
  • A. Conforti et al.

    A selective approach to resection of deep iliac nodes: Results in 1278 groin dissections [Abstract]

  • L.G. Feun et al.

    The natural history of resectable metastatic melanoma (stage IVA melanoma)

    Cancer

    (1982)
  • S.J. Finck et al.

    Results of ilioinguinal dissection for stage II melanoma

    Ann Surg

    (1982)
  • J.G. Fortner et al.

    Results of groin dissection for malignant melanoma in 220 patients

    Surgery

    (1964)
  • P.L. Goodman et al.

    Symptomatic gastrointestinal metastases from malignant melanoma

    Cancer

    (1981)
  • L. Hafstrom et al.

    Hyperthermic perfusion of recurrent malignant melanoma on the extremities

    Acta Chir Scand

    (1980)
  • W.S. Handley

    The pathology of melanotic growth in relation to their operating treatment

    Lancet

    (1907)
  • L. Illig et al.

    Diagnostic excision of the Rosenmuller's node: Screening for occult metastases before elective regional lymph node dissection in patients with lower limb melanoma?

    Cancer

    (1988)
  • A. Jonk et al.

    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

    (1988)
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    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

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