Chapter 12: Skin and Soft Tissue

Melanoma (core)

History of sun exposure

Family history?

Perform thorough ROS to elicit symptoms of metastatic disease

Full skin and nodal basin exam

• - ABCDE of melanoma—asymmetry, irregular borders, color variation, diameter >6 mm, evolving

• - Lesion ulcerated?

Punch or excisional biopsy

If concerning LN on exam, get U/S w/ biopsy of suspicious LNs

TNM staging

• - T stage

  • Tis—melanoma in situ

  • T1 ≤ 1 mm

    • T1a ≤ 0.8 mm without ulceration

    • T1b ≤ 0.8 mm with ulceration or 0.8-1.0 mm without ulceration

  • T2 > 1-2 mm

  • T3 > 2-4 mm

  • T4 > 4 mm

• - N stage

  • N1 1 LN(+)

  • N2 2-3 LN(+)

  • N3 ≥ 4 LN(+)

Do full staging if LN+ or to assess specific signs or symptoms:

• CT C/A/P and/or PET

• Brain MRI

• BRAF testing

• LDH (for stage IV)

Wide local excision of lesion:

• - Recommended margins based on tumor thickness

  • Melanoma in situ → 0.5 cm margins

  • ≤1 mm thick → 1 cm margins

  • >1-2 mm thick → 1-2 cm margins

  • >2 mm thick → 2 cm margins

• - Consider preoperative plastic surgery consult if excision will be in cosmetically sensitive area (ie, face, foot, etc) or will result in large defect requiring flap coverage

Nodal staging:

• - SLNB for clinically node negative patients with tumor ≥1 mm thick or ≥0.8 mm thick with ulceration

  • +SLNB → U/S surveillance vs lymphadenectomy (MSLT-II)

• - Clinically positive lymph nodes → lymphadenectomy

All patients with LN+ disease should be considered for systemic therapy—immunotherapy or targeted therapy:

• - Anti-PD1—pembrolizumab, nivolumab

• - BRAF mutation—dabrafenib

• - Anti-CTLA-4—ipilimumab

M1 disease → systemic therapy

Wide local excision (core):

• - Mark out needed margins (based on thickness)

• - Excise as 3:1-4:1 (length:width) ellipse to allow for closure

• - Excision shoud be down to, but not including, the fascia

• - Close in layers

Inguinal sentinel lymph node biopsy (core):

• - Send to nuclear medicine for tech-99 injection the night before or morning of surgery (requires at least 8 h), confirm activity in nodal basin with gamma probe

• - +/− Intradermal injection of isosulfan blue or methylene blue

• - Borders of inguinal basin are inguinal ligament, adductor longus, sartorius

• - Make vertical or oblique incision in groin below inguinal ligament

• - Dissect down through subcutaneous issue, use gamma probe to localize hot nodes

• - Remove hot, blue, and grossly abnormal nodes, clip/ligate associated lymphatics

• - Do background count (should be <10% of hottest sentinel node)

• - Close in layers

Inguinal lymph node dissection (advanced):

• - Vertical or curvilinear incision below inguinal ...