Surgical margins are based on the maximal melanoma Breslow thickness (measured in millimeters) of the melanoma. If the resected margins are not clear from malignant melanoma at histological examination, any remaining melanoma cells in the surrounding tissue should be included in a re-excision. The standard treatment of melanoma is wide and radical excision including deep tissue. The aim of this review is to present data for the optimal surgical management of patients with malignant melanoma. The general main surgical treatment for invasive malignant melanoma consists of wide surgical excision with clear histological margins and removal and examination of the sentinel node-the first drained lymph node to be affect by metastatic disease-to detect occult disease for staging and prognosis, and in selected cases complete lymph node dissection.
This suggests a distinct molecular etiology for acral and mucosal compared with cutaneous melanomas. More recent studies have shown that acral and mucosal melanomas can lack mutations in TP53, PTEN, and RB1, as well as having lower mutation rates. Large efforts have been directed towards describing the genomic landscape in melanoma disease, which has been divided into four genetic subclasses: BRAF mutations, RAS mutations, mutant NF1, and triple WT (wild-type). Malignant melanoma is characterized by high mutation rates, higher than most cancer types. While 5-year survival in localized disease is 98%, survival from disease with distant metastasis is much lower 22%. There has been a substantial improvement in the 5-year overall survival over the last decades from 81% in 1970 to 92% 2008–2014. There is a rising incidence of melanoma and the expected incidence of cutaneous melanoma in the USA is 91.270 cases 2018 with 22 new cases per 100.000, constituting approximately 5 % of all cancer cases according to Surveillance, Epidemiology, and End Results (SEER) National Cancer Institute. Isolated limb perfusion (ILP) or isolated limb infusion (ILI) with melphalan and actinomycin D is recommended for large and multiple in-transit metastases and satellite metastases in the extremities when local excision is considered ineffective or too extensive. In the MSLT-2 study, the disease control rate was improved in the immediate CLND group compared with observation but there was no difference in 3-year melanoma specific survival (86% ± 1.3% and 86% ± 1.2%, respectively p = 0.42). Two randomized controlled trials have been published-DeCOG (German Dermatologic Cooperative Oncology Group Selective Lymphadenectomy) and MSLT-2 (Multicenter Selective Lymphadenectomy Trial) comparing the complete lymph node dissection (CLND) with observation after positive sentinel node biopsy.
Sentinel node biopsy may be considered for patients with at least T1b melanomas thickness 0.8 to 1.0 mm or less than 0.8 mm Breslow thickness with ulceration, classified as T1b lesion, per recent AJCC guidelines. A surgical excision margin of 1–2 cm is recommended for invasive melanoma depending on the thickness of the melanoma.
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