Guidelines for Surgical Treatment of Melanoma
Melanoma diagnoses are increasingly common in the United States, and it is now the fifth and sixth most common cancer in men and women, respectively. Because of this increasing incidence, close attention should be paid to patients’ skin during physical examinations and biopsy performed of atypical lesions, especially those that are changing. Wide local excision with sentinel lymph node biopsy is the primary treatment for most patients with early stage disease. Management of patients with more advanced disease is multidisciplinary with consideration for additional surgery, systemic therapy and/or radiation.
Which pigmented lesions should be biopsied?
Pigmented lesions recommended for biopsy follow the “ABCDE” rule:
Lesions that meet some or all of these criteria should be considered for biopsy. Current practice guidelines state that an excisional biopsy with 1-3 mm margins is “preferred.” In some cases, a punch biopsy can be considered an excisional biopsy. Shave biopsies are acceptable when the index of suspicion is low, but may compromise pathologic assessment of the Breslow thickness (if the shave biopsy doesn’t capture full thickness of the skin).
When is surgery necessary?
Wide local excision is the primary treatment for the majority of patients diagnosed with malignant melanoma. The width of excision varies based on the Breslow’s thickness of the melanoma, but typical recommendations are for an excision with 1-2 cm margins. Closure of these wide local excisions is sometimes challenging, but can usually be closed primarily using advancement flaps. A skin graft may be required in some circumstances.
Many patients will also be recommended to undergo evaluation of the lymph nodes, as this is the most common first site that melanoma may spread to. Lymph nodes will be assessed pre-operatively by physical exam, and a needle biopsy will be recommended for any palpable lymph nodes. For other patients, a procedure called a sentinel lymph node biopsy may be recommended at the time of surgery. This procedure involves injecting dye (both a radioactive and a blue dye) into the dermis surrounding the melanoma and tracking which lymph nodes the dye drains to. These lymph nodes are then removed at surgery and sent to pathology to determine whether any microscopic melanoma is present. For any patient with melanoma in the lymph nodes, complete removal of the remaining lymph nodes in that basin is recommended. A recent clinical trial comparing completion lymph node dissection versus observation for patients with melanoma metastatic to the lymph nodes has recently completed accrual and results are being awaited.
Should patients receive treatment beyond surgery?
Management of melanoma is multidisciplinary. However, for the majority of patients, surgery will be the only treatment recommended. Additional treatment such as intravenous drug therapy (Interferon alpha) or radiation may be recommended for patients with more locally advanced primary tumors or those with melanoma in the lymph nodes. These patients will be recommended to have a consultation with a medical and/or radiation oncologist.
One additional consideration for patients is whether to participate in a clinical trial. In recent years, several new drugs have been approved for treatment of patients with melanoma that has spread beyond the lymph nodes to other places in the body (Stage IV disease); many of these therapies are now being tested in patients with earlier stage disease. Participation in such clinical trials is one option recommended by current clinical practice guidelines.
What follow-up is recommended?
Patients are recommended to have ongoing follow-up of their skin and lymph nodes. This can be done by a variety of people, including the treating surgeon, oncologist, dermatologist and primary care providers. All patients with a personal history of melanoma remain at risk of recurrence, although the exact risk varies by the initial melanoma stage. Additionally, patients with a personal history of melanoma are at higher-than-average risk of developing a new melanoma in the future (unrelated to the initial diagnosis); this was estimated to be as high as 10% in one study. Because of this ongoing risk, close follow-up with comprehensive skin examinations is critical.
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