Initial surgical management of melanoma of the skin and unusual sites
- Michael Stone, MD
Michael Stone, MD
- Chairman of Surgery
- Stamford Hospital
- Section Editors
- Michael B Atkins, MD
Michael B Atkins, MD
- Section Editor — Malignant Melanoma and Other Cutaneous Neoplasms; Cancer of the Kidney
- Deputy Director
- Georgetown Lombardi Comprehensive Cancer Center
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
- Hensin Tsao, MD, PhD
Hensin Tsao, MD, PhD
- Section Editor — Melanocytic Lesions and Disorders of Pigmentation
- Professor of Dermatology
- Harvard Medical School
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
Proper surgical management is critical for the diagnosis, staging, and optimal treatment of primary cutaneous melanoma.
The goals of surgery include:
●Histologic confirmation of the diagnosis, which ideally has been established through an appropriately planned biopsy. (See "Pathologic characteristics of melanoma".)
●Obtaining complete and accurate microstaging of the primary tumor to guide therapy. (See "Tumor node metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma".)
●Appropriate excision of the margin around the primary site to minimize the risk of local recurrence without compromising additional staging maneuvers (eg, sentinel lymph node biopsy potentially is less accurate after wide margin excision).
- NIH Consensus conference. Diagnosis and treatment of early melanoma. JAMA 1992; 268:1314.
- Cascinelli N. Margin of resection in the management of primary melanoma. Semin Surg Oncol 1998; 14:272.
- Veronesi U, Cascinelli N, Adamus J, et al. Thin stage I primary cutaneous malignant melanoma. Comparison of excision with margins of 1 or 3 cm. N Engl J Med 1988; 318:1159.
- Veronesi U, Cascinelli N. Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. Arch Surg 1991; 126:438.
- Cohn-Cedermark G, Rutqvist LE, Andersson R, et al. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0 mm. Cancer 2000; 89:1495.
- Khayat D, Rixe O, Martin G, et al. Surgical margins in cutaneous melanoma (2 cm versus 5 cm for lesions measuring less than 2.1-mm thick). Cancer 2003; 97:1941.
- Gillgren P, Drzewiecki KT, Niin M, et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: a randomised, multicentre trial. Lancet 2011; 378:1635.
- Balch CM, Urist MM, Karakousis CP, et al. Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multi-institutional randomized surgical trial. Ann Surg 1993; 218:262.
- Karakousis CP, Balch CM, Urist MM, et al. Local recurrence in malignant melanoma: long-term results of the multiinstitutional randomized surgical trial. Ann Surg Oncol 1996; 3:446.
- Balch CM, Soong S, Ross MI, et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. Ann Surg Oncol 2000; 7:87.
- Thomas JM, Newton-Bishop J, A'Hern R, et al. Excision margins in high-risk malignant melanoma. N Engl J Med 2004; 350:757.
- Hayes AJ, Maynard L, Coombes G, et al. Wide versus narrow excision margins for high-risk, primary cutaneous melanomas: long-term follow-up of survival in a randomised trial. Lancet Oncol 2016.
- Heaton KM, Sussman JJ, Gershenwald JE, et al. Surgical margins and prognostic factors in patients with thick (>4mm) primary melanoma. Ann Surg Oncol 1998; 5:322.
- Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012; 66:438.
- Grotz TE, Glorioso JM, Pockaj BA, et al. Preservation of the deep muscular fascia and locoregional control in melanoma. Surgery 2013; 153:535.
- Temple CL, Arlette JP. Mohs micrographic surgery in the treatment of lentigo maligna and melanoma. J Surg Oncol 2006; 94:287.
- Naylor MF, Crowson N, Kuwahara R, et al. Treatment of lentigo maligna with topical imiquimod. Br J Dermatol 2003; 149 Suppl 66:66.
- Powell AM, Robson AM, Russell-Jones R, Barlow RJ. Imiquimod and lentigo maligna: a search for prognostic features in a clinicopathological study with long-term follow-up. Br J Dermatol 2009; 160:994.
- Morton DL, Thompson JF, Cochran AJ, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med 2014; 370:599.
- Coit D. Sentinel lymph node biopsy for melanoma: a plea to let the data speak. Ann Surg Oncol 2014; 21:3359.
- Koops HS, Vaglini M, Suciu S, et al. Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593. J Clin Oncol 1998; 16:2906.
- Goldsmith HS. Melanoma: an overview. CA Cancer J Clin 1979; 29:194.
- Gibbs P, Robinson WA, Pearlman N, et al. Management of primary cutaneous melanoma of the head and neck: The University of Colorado experience and a review of the literature. J Surg Oncol 2001; 77:179.
- Golger A, Young DS, Ghazarian D, Neligan PC. Epidemiological features and prognostic factors of cutaneous head and neck melanoma: a population-based study. Arch Otolaryngol Head Neck Surg 2007; 133:442.
- Lentsch EJ, Myers JN. Melanoma of the head and neck: current concepts in diagnosis and management. Laryngoscope 2001; 111:1209.
- Glat PM, Longaker MT, Jelks EB, et al. Periorbital melanocytic lesions: excision and reconstruction in 40 patients. Plast Reconstr Surg 1998; 102:19.
- Hudson DA, Krige JE, Grobbelaar AO, et al. Melanoma of the face: the safety of narrow excision margins. Scand J Plast Reconstr Surg Hand Surg 1998; 32:97.
- Zitelli JA, Moy RL, Abell E. The reliability of frozen sections in the evaluation of surgical margins for melanoma. J Am Acad Dermatol 1991; 24:102.
- de Rosa N, Lyman GH, Silbermins D, et al. Sentinel node biopsy for head and neck melanoma: a systematic review. Otolaryngol Head Neck Surg 2011; 145:375.
- Leong SP, Accortt NA, Essner R, et al. Impact of sentinel node status and other risk factors on the clinical outcome of head and neck melanoma patients. Arch Otolaryngol Head Neck Surg 2006; 132:370.
- Pawlik TM, Ross MI, Prieto VG, et al. Assessment of the role of sentinel lymph node biopsy for primary cutaneous desmoplastic melanoma. Cancer 2006; 106:900.
- Livestro DP, Muzikansky A, Kaine EM, et al. Biology of desmoplastic melanoma: a case-control comparison with other melanomas. J Clin Oncol 2005; 23:6739.
- Quinn MJ, Crotty KA, Thompson JF, et al. Desmoplastic and desmoplastic neurotropic melanoma: experience with 280 patients. Cancer 1998; 83:1128.
- Hawkins WG, Busam KJ, Ben-Porat L, et al. Desmoplastic melanoma: a pathologically and clinically distinct form of cutaneous melanoma. Ann Surg Oncol 2005; 12:207.
- Lens MB, Newton-Bishop JA, Boon AP. Desmoplastic malignant melanoma: a systematic review. Br J Dermatol 2005; 152:673.
- Posther KE, Selim MA, Mosca PJ, et al. Histopathologic characteristics, recurrence patterns, and survival of 129 patients with desmoplastic melanoma. Ann Surg Oncol 2006; 13:728.
- Chen JY, Hruby G, Scolyer RA, et al. Desmoplastic neurotropic melanoma: a clinicopathologic analysis of 128 cases. Cancer 2008; 113:2770.
- Skelton HG, Smith KJ, Laskin WB, et al. Desmoplastic malignant melanoma. J Am Acad Dermatol 1995; 32:717.
- Sassen S, Shaw HM, Colman MH, et al. The complex relationships between sentinel node positivity, patient age, and primary tumor desmoplasia: analysis of 2303 melanoma patients treated at a single center. Ann Surg Oncol 2008; 15:630.
- Murali R, Shaw HM, Lai K, et al. Prognostic factors in cutaneous desmoplastic melanoma: a study of 252 patients. Cancer 2010; 116:4130.
- Strom T, Caudell JJ, Han D, et al. Radiotherapy influences local control in patients with desmoplastic melanoma. Cancer 2014; 120:1369.
- Guadagnolo BA, Prieto V, Weber R, et al. The role of adjuvant radiotherapy in the local management of desmoplastic melanoma. Cancer 2014; 120:1361.
- Wasif N, Gray RJ, Pockaj BA. Desmoplastic melanoma - the step-child in the melanoma family? J Surg Oncol 2011; 103:158.
- McLaughlin CC, Wu XC, Jemal A, et al. Incidence of noncutaneous melanomas in the U.S. Cancer 2005; 103:1000.
- Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society. Cancer 1998; 83:1664.
- Chiu NT, Weinstock MA. Melanoma of oronasal mucosa. Population-based analysis of occurrence and mortality. Arch Otolaryngol Head Neck Surg 1996; 122:985.
- Kim KB, Sanguino AM, Hodges C, et al. Biochemotherapy in patients with metastatic anorectal mucosal melanoma. Cancer 2004; 100:1478.
- Kuchelmeister C, Schaumburg-Lever G, Garbe C. Acral cutaneous melanoma in caucasians: clinical features, histopathology and prognosis in 112 patients. Br J Dermatol 2000; 143:275.
- Slingluff CL Jr, Vollmer R, Seigler HF. Acral melanoma: a review of 185 patients with identification of prognostic variables. J Surg Oncol 1990; 45:91.
- Phan A, Touzet S, Dalle S, et al. Acral lentiginous melanoma: a clinicoprognostic study of 126 cases. Br J Dermatol 2006; 155:561.
- Bello DM, Chou JF, Panageas KS, et al. Prognosis of acral melanoma: a series of 281 patients. Ann Surg Oncol 2013; 20:3618.
- Bradford PT, Goldstein AM, McMaster ML, Tucker MA. Acral lentiginous melanoma: incidence and survival patterns in the United States, 1986-2005. Arch Dermatol 2009; 145:427.
- Levit EK, Kagen MH, Scher RK, et al. The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol 2000; 42:269.
- Park KG, Blessing K, Kernohan NM. Surgical aspects of subungual malignant melanomas. The Scottish Melanoma Group. Ann Surg 1992; 216:692.
- Heaton KM, el-Naggar A, Ensign LG, et al. Surgical management and prognostic factors in patients with subungual melanoma. Ann Surg 1994; 219:197.
- Finley RK 3rd, Driscoll DL, Blumenson LE, Karakousis CP. Subungual melanoma: an eighteen-year review. Surgery 1994; 116:96.
- O'Leary JA, Berend KR, Johnson JL, et al. Subungual melanoma. A review of 93 cases with identification of prognostic variables. Clin Orthop Relat Res 2000; :206.
- Nguyen JT, Bakri K, Nguyen EC, et al. Surgical management of subungual melanoma: mayo clinic experience of 124 cases. Ann Plast Surg 2013; 71:346.
- Dwyer PK, Mackie RM, Watt DC, Aitchison TC. Plantar malignant melanoma in a white Caucasian population. Br J Dermatol 1993; 128:115.
- Cascinelli N, Santinami M, Maurichi A, et al. World Health Organization experience in the treatment of melanoma. Surg Clin North Am 2003; 83:405.
- INITIAL BIOPSY
- WIDE LOCAL EXCISION
- Melanomas ≤2 mm thick (T1, T2)
- Melanomas 2.01 to 4 mm (T3)
- Melanomas >4 mm (T4)
- In situ melanomas
- Management of muscular fascia
- Experimental approaches
- REGIONAL LYMPH NODES
- ADJUVANT THERAPY
- Regional chemotherapy
- SKIN OF HEAD AND NECK
- Surgical management
- Regional nodes
- Adjuvant RT
- DESMOPLASTIC MELANOMA
- UNUSUAL SITES
- Acral melanomas
- - Subungual
- - Plantar/palmar
- Mucosal melanomas
- SURVEILLANCE AFTER SURGERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Cutaneous melanoma
- Melanomas in unusual sites