SURGICAL TREATMENT OF MELANOMA
Melanoma is the most lethal form of skin cancer, accounting for an estimated 76,380 new cases and 10,130 deaths in the United States each year.
Though medical management of melanoma has improved markedly over the past several years, surgical treatment remains the mainstay of early melanoma management.
Thorough physical examination is required at diagnosis and preoperative evaluation, and any clinically apparent nodal metastases should be confirmed via FNA.
A complete staging workup is required after confirmation of nodal metastases.
As a general rule, all melanoma excisions should be taken to the level of the fascia.
SLNB should be considered for melanomas greater than 1 mm in depth.
Combination blue dye and 99mTc permits SLN detection of at least 98%, though SLN detection in the head and neck is particularly challenging.
Extensive or recurrent melanoma on the extremity may be treated with adjuvant hyperthermic isolated limb perfusion, though this approach has significant morbidity as well.
Melanomas on the trunk may drain to contralateral or multiple basins.
Effective SLNB is contingent on close coordination between the surgeon, the nuclear medicine specialist, and the pathologist.
Lymphoscintigraphy with SLNB has had the greatest effect on patients with microscopic nodal metastases.
Pitfalls and Cautions
Complication rates from lymph node dissection range from 50% to 90%.
Experience with SLNB has a significant impact on the ability to reliably reduce nodal relapse. It remains unclear whether patients with positive SLNB would benefit from complete LND.
Patient Education Points
Preoperative consultation should include not only general education regarding the nature of the disease, but also the morbidity associated with various approaches.
Given the very high rate of complications, patients must be informed regarding these risks well ahead of surgery and should be highly motivated.
In general, once patients understand the significant mortality associated with the disease, the morbidity associated with SLNB and CLND are more palatable.
Elliptical melanoma excisions are generally coded with the malignant excision code series (11600 series) and the intermediate (12030 series) or complex repair (13101 series) codes, depending on the complexity of closure.
SLNB is generally not performed by dermatologic surgeons in the United States.
Melanoma is the most lethal form of skin cancer. In 2016, there were an estimated 76,380 new cases (21.8 per 100,000) and 10,130 deaths (2.7 per 100,000) from the disease in the United States.1 The annual incidence is projected to increase to 230,000 by 2030, due to several factors including better detection and reporting, an aging population, and continued high-risk behaviors.2 Innovations in targeted molecular and immunotherapies have advanced our ability to treat disseminated disease, though surgery remains the mainstay of curative therapy for patients with early-stage melanoma. Over the last ...