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 controversy.

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.

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Society 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

Examination

• Complete dermatologic examination
• Regional and remote lymph nodes
• Regional and remote soft tissue

Laboratory studies

• CBC
• Chemistry profile

Radiology

• 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.

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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.