Abstract
The surgical management of malignant melanoma historically called for wide excision of skin and subcutaneous tissue for any given lesion, but has evolved to be rationally-based on pathological staging. Breslow and Clark independently described level and thickness as determinant in prognosis and margin of excision. The American Joint Committee of Cancer (AJCC) in 1988 combined features from each of these histologic classifications, generating a new system, which is continuously updated and improved. The National Comprehensive Cancer Network (NCCN) has also combined several large randomized prospective trials to generate current guidelines for melanoma excision as well. In this article, we reviewed: (1) Breslow and Clark classifications, AJCC and NCCN guidelines, the World Health Organization’s 1988 study, and the Intergroup Melanoma Surgical Trial; (2) Experimental use of Mohs surgery for in situ melanoma; and (3) Surgical margins and utility and indications for sentinel lymph node biopsy (SLNB) and lymphadenectomy. Current guidelines for the surgical management of a primary melanoma of the skin is based on Breslow microstaging and call for cutaneous margins of 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 2 cm margins for melanomas >4 mm thick. Although the role of SLNB, CLND, and TLND continue to be studied, current recommendations include SLNB for Stage IB (includes T1b lesions ≤1.0 with the adverse features of ulceration or ≥1 mitoses/mm2) and Stage II melanomas. CLND is recommended when sentinel nodes contain metastatic deposits.
Highlights
Melanoma accounts for 75% of all deaths related to skin cancer
The Thomas trial found that 1 cm margins were associated with higher local recurrence for melanomas thicker than 2 mm compared to 3 cm margins, though with similar overall survival rates [6,7,20]
For thick melanomas (>4 mm), it is unclear whether margins exceeding 2 cm affect local recurrence and survival rates owing to the fact that thick melanomas may reflect biologic aggressiveness of the melanoma that cannot be cured through wide excision alone [5]
Summary
An important prognostic indicator for melanoma is the disease status of regional lymph nodes inasmuch as the initial melanoma metastasis is likely to occur through the lymphatic system. SLN biopsy has prognostic value and can determine the stage of melanoma without subjecting a patient to the heretofore recommended elective lymph node dissection (ELND) [25]. If the SLNB is positive for metastases by light microscopy or immunohistochemistry, a completion lymph node dissection (CLND), where the rest of the lymph nodes are explored and examined, is currently recommended [12,26,27,28]. Patients with clinically detectable lymph nodes proven by preoperative biopsy to be positive for metastases, undergo a therapeutic lymph node dissection (TLND) and forego a SLNB [30]. CLND when the SLNB is positive is currently the recommended standard care for melanoma in accordance with guidelines jointly promulgated by the Society of Surgical Oncology and the American Society of Clinical Oncology [26,27]
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