Chapter 28. Operative Management of Melanoma

Wide Local Excision of Melanoma

• Biopsy-proven cutaneous melanoma.

Inguinal Lymph Node Dissection

• Documented metastatic disease in the inguinal lymph nodes with no evidence of distant metastases.
• Metastases detected in the inguinal nodes by sentinel lymph node (SLN) biopsy or by fine needle aspiration or excisional biopsy in a patient with a clinically evident lymph node metastasis.

Full-Thickness Skin Graft

• Coverage of large defects created by wide local excision of a melanoma that cannot be closed primarily or with a local flap.

Absolute

• Inability to close donor site incision.

Relative

• Concern about incomplete resection (positive margins).
• Poor wound conditions (poor vascularization, exposed bone, open joint surfaces).

Wide Local Excision of Melanoma

Expected Benefits

• Removal of all melanoma cells at the primary site in order to provide durable local disease control for all patients, even when the likelihood for distant relapse is high, and to effect a cure in patients at low risk of harboring occult metastatic disease.

Potential Risks

• Surgical site infection.
• Bleeding or hematoma formation.
• Scarring.
• Return of melanoma at the surgical site or a distant site.
• Need for reexcision in the event of positive margins.

Inguinal Lymph Node Dissection

Expected Benefits

• Removal of all node-bearing tissue within the femoral triangle and suprainguinal location (superficial inguinal lymph node dissection) and possibly the iliac and obturator nodes (superficial and deep, or ilioinguinal lymph node dissection).

Potential Risks

• Surgical site infection.
• Bleeding or hematoma formation.
• Skin edge necrosis.
• Wound dehiscence.
• Paresthesia.
• Lymphocele.
• Chronic lymphedema.

Full-Thickness Skin Graft

Expected Benefits

• Autologous coverage of a large skin defect created by the excision of a melanoma.

Potential Risks

• Surgical site or donor site infection.
• Bleeding.
• Hematoma.
• Seroma.
• Partial or complete graft loss.

• No special equipment is required.

Wide Local Excision of Melanoma

• A review of the histologic findings of the biopsied lesion should be undertaken before planning a local excision.
• The necessary surgical margins (in centimeters) for excision are determined by the Breslow depth (in millimeters) of the melanoma.
  • In situ lesions require a 0.5-cm margin.
  • Invasive melanomas < 1 mm require a 1-cm margin.
  • Melanomas > 2 mm in depth require a 2-cm margin.
  • Melanomas between 1 and 2 mm should be excised with 2-cm margins when possible, but 1.5-cm or even 1-cm margins are reasonable when 2-cm margins are not feasible without a skin graft or would require an excessively ...