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Melanoma Surgical Practice Guidelines

Melanoma Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim of
the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant

Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.

The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.

of Surgical Oncology Practice Guidelines: Melanoma

Symptoms and Signs

    Early-stage disease
  • Asymptomatic
  • Asymmetry
  • Border irregularity
  • Color: variegated
  • Diameter: > 6 mm
  • Itching, bleeding with minor trauma
    Advanced-stage disease
  • Primary
  1. Nodularity
  2. Friability, bleeding
  3. Satellites
  • Regional disease
    1. Patients may present with metastatic involvement of regional nodes
      even with no known primary.
  • Systemic disease
    1. Unusual for patients to present initially with visceral metastasis
      in the absence of a known primary

    Evaluation of the Symptomatic Patient

      Diagnosis of the primary tumor
    • Plan biopsy with definitive therapy in mind
    • Incisional vs excisional biopsy
    1. Excision increases staging accuracy.
    2. Excision is not always possible (eg, lesions on digit, palm sole, face,
      or ear)
    3. For lesions on digit, palm, sole, face, ear, incisional biopsy of the
      clinically thickest area is appropriate.
  • Shave biopsies are inappropriate.
    • Diagnosis of metastatic disease
    • Excision
    1. Best if no primary known, especially for isolated node
  • Fine-needle aspiration
    1. Sufficient to diagnose recurrence of known melanoma
      Appropriate timeliness of surgical referral
    • Lesions fulfilling criteria for early-stage disease (see above) should
      be biopsied without a period of observation.

    Preoperative Evaluation for Extent of Disease

      Complete history
    • Sun exposure
    • Prior moles
    • Nonmelanoma skin cancers
    • Family history of melanoma
    • Complete dermatologic examination
    • Regional and remote lymph nodes
    • Regional and remote soft tissue
      Laboratory studies
    • CBC
    • Chemistry profile
    • Chest x-ray
    • CT scan—only for advanced stages
    • Pelvic CT for patients with inguinal adenopathy to guide extent of
      lymph node dissection

    Role of the Surgeon in Initial Management

      Evaluation of pigmented lesion
      Diagnosis by biopsy
      Surgical considerations
    • Primary tumor
    1. Margin of excision (may vary with location):
      • In situ primary: 0.5-cm margin
      • < 1-mm thick primary: 1-cm margin
      • 1- to 4-mm thick primary: 2-cm margin
      • > 4-mm thick primary: > 2-
        cm margin
    2. Moh's surgery not appropriate
  • Type of closure (variable):
    • Primary
    • Split-thickness skin graft
    • Local rotation flap
    • Free flap
    • Digital amputation in highly selected patients (eg, subungual lesions)
  • Regional nodes
    1. Intent
      • Elective
      • Selective with intraoperative mapping
      • Therapeutic
      • Palliative
    2. Procedures
      • Neck dissection
      • Axillary dissection
      • Groin dissection
    3. Extent of lymph node dissection
      • Radical vs modified radical neck dissection
      • Indications for elective inguino-femoral-pelvic lymph node dissection
  • In-transit metastases
    1. Excision
    2. Injection
    3. Laser ablation
    4. Hyperthermic isolated limb perfusion
    5. Amputation

    These guidelines are copyrighted by the Society of Surgical Oncology
    (SSO). All rights reserved. These guidelines may not be reproduced in any
    form without the express written permission of SSO. Requests for reprints
    should be sent to: James R. Slawny, Executive Director, Society of Surgical
    Oncology, 85 West Algonquin Road, Arlington Heights, IL 60005.

    Melanoma is now the seventh most common malignancy
    in the United States, and the rateat which its incidence has increased
    (approximately 4% per year since 1973) is higher than that for any other
    cancer. According to American Cancer Society estimates, approximately 38,300
    new cases of melanoma were diagnosed in 1996, and 7,300 deaths were attributable
    to this cancer.

    Early melanoma often arises in the context of a preexisting nevus. Early
    signs of melanoma include the so-called ABCDs: lesion asymmetry, border
    irregularity, variegated color, and diameter over 6 mm. Other, less specific
    symptoms include itching or bleeding with minor trauma.

    More advanced primary melanomas may present as a nodular skin lesion,
    which may be friable or bleeding and occasionally may have clinical satellitosis.
    More advanced lesions are often amelanotic.

    Of patients with melanoma that is clinically metastatic to regional
    lymph nodes, 10% to 15% may present with regional node involvement in the
    absence of a known primary. Fewer than 2% of patients with metastatic disease
    present with visceral metastatic melanoma in the absence of a known primary.


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