Information on the surgical therapy of The surgical therapy of melanoma has a dual purpose: diagnostic and prognostic. The margin of healthy skin to be removed is defined according to the staging of the melanoma.
Stage 0: melanoma in situ: the tumor is removed with a margin of healthy skin of 0.5 cm
Stage I: the melanoma is removed with a margin of healthy skin which depends on the thickness of the tumor:
Thickness < 1 mm: 1 cm of healthy skin
1 to 2 mm thick: 1 to 2 cm of healthy skin routine removal of satellite lymph nodes is not performed, lymph node dissection is recommended if the melanoma is stage IB and has features suggestive of lymph node dissemination. In all ways, the presence of distant metastases must be excluded
Stage II: Thickness from 2.1 to 3.0 the margin of healthy skin must be 3 cm. A sentinel lymph node is performed and in case of positivity the satellite lymph nodes must be removed. If the tumor is more than 4 mm thick or if the sentinel lymph nodes are positive, medical therapy is recommended
Stage III: 3.1 and 4.0 mm thick: excision with a wide margin of at least 3 cm, regional lymph node dissection and medical therapy. For limb melanomas, a therapeutic option may be limb perfusion with heated chemotherapy solution (Melphalan). If many lymph nodes are involved, postsurgical radiotherapy can also be performed. All other medical treatments (immunotherapy, cytokines etc) can be performed
Stage IV: tumors that are difficult to treat because there are lymph node and distant metastases. The primary tumor must be removed with a wide margin, satellite or distant skin tumors must be surgically removed and the regional lymph nodes removed. Symptomatic metastases that cannot be removed should be treated with medical or radiation therapy
Relapsing melanoma: if the melanoma relapses in the scarring site of the primary melanoma, it is necessary to perform a wide excision with the possible removal of the regional lymph nodes if it has not been performed in the previous operation. In the case of distant local recurrence of the scar or in the case of satellitosis or recurrences in transit, excision and any sentinel lymph node must be performed. If we have a lymph node recurrence it is necessary to remove the residual lymph nodes. Medical therapy is therefore recommended as for stage IV. Distant melanoma metastases: they can be removed with surgery, laser, electrochemotherapy.
Lentigo maligna melanoma: due to the fact that the limits are ill-defined and that there is often atypical lymphocyte proliferation several centimeters beyond the visible margin, recurrences are often frequent (above 50%); for surgery there are no specific rules, the edge of the lesion is often identified with dermoscopy or Wood’s light. Sometimes an incisional biopsy is performed before excision or Mohs surgery (used only in some centers) can be a useful method.
Experimental therapies: some forms of in situ melanoma of the lentigo maligna type were treated with Imiquimod (Aldara) cream, other surgeons used Aldara in the three months following the treatment which led to a reduction in local recurrences.
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