Surgical considerations for cutaneous melanoma

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Primary cutaneous melanoma represents the most frequent clinical presentation of this disease entity. Before the surgeon can adequately plan for operative control of the primary, he must be aware of the biologic differences associated with the different histopathological types. Lentigo maligna occurs most commonly in the older age population. This lesion has a tendency to remain for long periods of time in a radial growth phase with little or no tumor invasion and thus metastatic potential. It is usually on the exposed surfaces of the body with the majority being found on the head and neck. This lesion is usually nonpalpable until a vertical growth phase has begun. Superficial spreading melanoma also has an intraepithelial component with early growth being in a radial direction. This portion of the growth phase may reach 2–3 cm in width before the invasive vertical growth begins. If either lentigo maligna or superfical spreading melanoma were to be recognized early during their radial growth phase, essentially all of these lesions could be cured by adequate surgical excision alone. The vertical growth phase reflects invasion and its degree can be clearly correlated with the incidence of metastatic disease and eventual patient survival. The vertical growth phase is usually quite rapid and the lesion may vary in color from pink to brown, to blue, to black. It is during this phase of growth that ulceration usually occurs.