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Chapter 32: Soft Tissue Sarcoma and Skin

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Which of the following is the appropriate surgical management of a 1.5-mm melanoma?

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(A) Excision with 1.0-cm margins

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(B) Excision with 2.0-cm margins

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(C) Excision with 2.0-cm margins and sentinel lymph node (SLN) biopsy

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(D) Excision with 2.0-cm margins and lymph node dissection

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(E) Excision with 3.0-cm margins

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(C) The National Comprehensive Cancer Network (NCCN) Guidelines in Oncology has a set of recommended guidelines for treating malignant melanoma based on depth of the lesion. The current standard is a 1-cm margin for lesions 1 mm or less in depth. For lesions 1–2 mm in depth, a 2-cm margin is appropriate, but a smaller margin is accepted in a cosmetically sensitive area. A smaller margin is also appropriate when a limited resection can help preserve function, such as when crossing a joint. A depth of 2 mm or greater requires a 2-cm margin, and some advocate for a 3-cm margin for lesions greater than 4 mm deep. The tissue should be excised down to the level of the fascia to include all subcutaneous lymphatic channels.

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To provide adequate staging and treatment, lymph node assessment is necessary. The SLN biopsy has become the standard of care and should be performed routinely for melanomas with a depth of 1 mm or greater. It should also be considered for lesions between 0.75 and 1 mm with high-grade features (ulceration, lymphovascular invasion, and high mitotic rate). Lesions less than 0.75 mm are unlikely to have regional lymphadenopathy and do not require biopsy.

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Sentinel lymph node biopsy is a sampling of the first draining lymph node(s) from the lesion and the most likely to have metastasis if any is present. For melanoma, lymphatic mapping (Fig. 32-5) is performed to identify the draining nodal basin. Lymphatic mapping is performed by injecting either isosulfan blue dye (Fig. 32-6) or technetium-labeled sulfur colloid at the site of the lesion and then identifying the “hot” or blue nodes. The hot or blue nodes are the sentinel nodes. They are identified with a gamma probe and exploration of the lymph node basin.

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FIGURE 32-5. Lymphoscintigraphy using sulfur colloid labeled with technetium-99.

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FIGURE 32-6A. Blue dye injected intradermally around the tumor.

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FIGURE 32-6B. Chart of options for melanoma treatment (from Brunicardi F, Andersen DK, Billiar TR, et al., (eds.), Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010: Chapter 16: Image 16-13).

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FIGURE 32-6C. Flow chart ...

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