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10th
International Inter University Scientific Meeting
Academy of Studenica
PERSPECTIVES
IN MELANOMA MANAGEMENT
& NANOTECHNOLOGY IN BIOMEDICINE
Organizers:
Institute of Oncology
Sremska Kamenica; Union of Cancer Prevention
Societies of Vojvodina, Novi Sad; Clinic of Oncology, Nis; Institute
for Oncology and Radiology of Serbia, Belgrade Center for Bioengineering,
Faculty of Mechanical Engineering, University of Belgrade
President:
Vladimir Baltic Vice-presidents: Zlata
Janjic, Radan Dzodic, Borislava Nikolin; Djuro Koruga
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SURGICAL
TREATMENT OF SKIN MELANOMA
Džodić R, Marković I, Inić M, Žegarac
M, Đurišić I.
Institute
of oncology and radiology of Serbia, Belgrade, Serbia and Montenegro
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ABSTRACT
Surgery
is still the therapy of choice in treatment of both primary skin
melanoma and loco-regional relapse and solitary distant visceral
metastases. Early detection and timing of surgery are the key stones
in melanoma treatment. Incidence of skin melanoma is increasing
in the world.
The highest incidenec is in Australia (40/100.000 inhabitants).
Recognised risk factors are: over congenital moles, atypical nevi,
dysplastic nevi, sun burns ane exposure to UV beams, other non-melanocytic
skin cancers, positive familial history.
In women it usually appears on lower-leg, while in men it is more
often on the back. In older patients (over 65years) it skin melanoma
appears on the face as "lentigo maligna". Usual types of melanoma
spreding are: superficial spreding (60-70%), lentigo melanoma (5-15%),
acral (hand, foot, nails; 8%) and nodular melanom (15%). Unfortunately,
in Serbia and Montenegro the ratio between superficial and nodular
melanoma is almost reverse, because of insufficient education of
both patients and physions.
Stage of the disease is determined by Breslow (tumor thickness in
milimeters) and pTNM classification. The ABCD-system (assimetry,
boundary, colour, dimension), and Glassgow sistem.
The adequacy of surgical approach is a central aspect in front of
the initial clinical appearance of the disease. The best results
are obtained with a correct treatment of primary melanoma and lymph
node metastases. Great numbers of randomized trials have been conducted
in the last four decades in a goal to reach a general consensus
of the extent and timing of surgery for primary melanoma.
Surgery of primary skin melanoma
The operation must be done under
general or regional (spinal) anesthesia in a goal to avoid dissemination
of fragile melanoma cells in case of injection of local anesthetic
drugs. The distance from tumor should be estimated according to
clinical finding and frozen-section pathology report of melanoma
thickness (Clark or Breslow) (Table 1). The thickness is determined
by the depth to muscle fascia.
Table WHO recommendation of free margins in skin melanoma
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TNM
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Breslow
(mm)
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Clark
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Distance
from tumor (mm)
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Tis
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I
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5
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T1
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0.75
- 1.5
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II
and III
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10
- 20
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T3
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1.5
- 4
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IV
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20
- 30
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T4
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>
4
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V
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30
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Desmoplstic
and neurotropic
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30
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Acral
and face
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10
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Subungval
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Amputation
of distal phalanga
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The closure should be done primary
or immediately covered with free skin graft (Wolf ili Thiersch)
or local flap.
Surgery of regional lymph nodes
Elective lymph node dissections
(ELND) are abandoned in most centers. It is not rational to perform
dissection in cases of clinically negative lymph nodes. The studies
performed have shown no benefit in survival in compare to patients
with no dissection.
Delayed (when lymph nodes were enlarged during follow-up; DLND)
or therapeutic lymph node dissection in cases of clinically enlarged
regional or distant lymph nodes is recommended. Before the operation
chest X-ray and ultra-sonography of abdomen has to be done to exclude
distant metastases.
Selective lymph node dissection (SLND) in thin and intermediate
thick melanoma (up to 1,5 mm) with clinically not enlarged regional
lymph nodes is probably the most appropriate approach. The technique
is based on biopsy of sentinel lymph nodes (SLN) previously mapped
either with blue dye, radio-colloid or both. Theoretically, SLN
is the first node draining the primary tumor. Numerous studies have
shown beneficial effect of this technique. The results have shown
that in thin melanoma (1mm) in about 20% micro-metastases were found
in SLN.
Surgery for local and regional relapse
Local and regional relapse should
be surgically treated as well. In cases of locally advanced disease
of extremities isolated limb perfusion with chemotherapeutic drugs
could be consider previous to radical operation.
Surgery for isolated distant metastases
In respect to low response to other
therapeutic modalities, palliative surgical treatment could be suggested
to patients with solitary distant metastases (visceral, lung, brain).
In some cases the disease free interval is satisfactory as well
as quality of life. |
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Keywords:
Skin melanoma, Surgery |
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