Cutaneous Melanoma Surgical Management · Copyright © 2004 Pearson Education, Inc., publishing as...

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings

CutaneousCutaneous MelanomaMelanomaSurgical ManagementSurgical Management

EMAD KANDIL, MD EMAD KANDIL, MD


Case Presentaion• 71 y.o female was scheduled for re-

excision of L shoulder melanoma.

• PMHx:Afib, HTN, osteoprosis, depression• PSHx: Resection of L shoulder melanoma

1m ago with a satellite lesion @ peripheral margin with 1.2mm depth.

• Meds: Coumadin, metoprolol, lenoxin, buspirone and zoloft.

• NKDA• Social Hx: denies smoking, alcohol or

IVDA.

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PE

• A&OX3• Cardiac: S1/S2 RRR• Lungs: CTA B/L• Abdominal exam:soft, NT, ND, +BS• Ext:L arm 1cm scar • Neurological exam: no focal abnormalities, intact cranial

nerves, nystagmus, abnormal ocular movements or peripheral neuropathy


Labs• WBC 5.1• Hct 39.4• Plt 227• PTT 55• INR: 1.0

• Na 143 • K 4.7• Cl 106 • CO2 28• BUN/Cr 20/0.8• Glu 85• Alb=4.0


OR

• Lymphazurin blue was administrated intradermallyinto old incsion.

• Eliptical skin incision with 13mm margin @all sides

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OR• Intraop hand held gamma

probe was used.• Axillary dissection:

• Axillary vein was visualized

• Long thoracic and thoracodorsal nerves were identified.

• Single LN was identified as sentinle LN @ level 1

• Specimen included axillary LNs @level1&2

• The area between the injection site and sentinel node bed(s) was also surveyed for in-transit nodes.

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Pathology

• Skin:• No residual malig melanoma• FB giant cell reaction

• LN: • Sentinle LN : neg• 11 LN :neg

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Post-op Course

• Started on heparin drip.

• POD#3 L arm hematoma (5cm X 7cm)

• POD#7 D/C Home

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CutaneousCutaneous MelanomaMelanomaSurgical ManagementSurgical Management

EMAD KANDIL, MD EMAD KANDIL, MD


Incidence

• In 2004, an estimated 55,000 Americans received a diagnosis of cutaneous melanoma, and 7900 will die from the disease.• 5th in incidence among men • 7th among women • 1/100 persons in US can expect to

develop this cancer in a lifetime.

• MC cancer among women 20-29 y of age.• Jemal A, Tiwari RC, Murray T, et al. Cancer statistics,

2004. CA Cancer J Clin 2004;54:8-29

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Identification of High-Risk Persons

• Light complexions• Inability to tan• Blond or red hair, or blue

eyes • Inherited mutations in the

melanocortin-1 receptor• Having many pigmented

lesions, and or atypical moles

• Severe sunburns, especially during childhood

• Use of tanning beds Bliss JM, Ford D, Swerdlow AJ, et al. Risk of cutaneous melanoma associated with pigmentation characteristics and freckling: systematic overview of 10 case-control studies. Int J Cancer 1995;62:367-376mm


Risk Factors

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Bevona, C. et al. Arch Dermatol 2003;139:1620-1624.

Distribution of melanomas by age groupDistribution of Melanomas by age group

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% of Melanomas associated with nevi by age group

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MelanomaSuperficial Spreading Melanoma

Nodular Melanoma

Lentigo Maligna Melanoma

Acrolentiginous Melanoma







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% melanomas associated with nevi by anatomic location

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% melanomas associated with nevi by anatomic location and sex

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Is Physician Detection Associated With Thinner Melanomas?

Table 2. Classification of Melanoma Pathologic Thickness Level Grouped by Detection Pattern

Darin S. Epstein; etal,JAMA. 1999;281:640-643mm


Dermoscopy

• Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions -- a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001;2:443-449

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Ordinary Mole & Malig Melanoma

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Dermoscopy

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Clark WH Jr, From L, Bernadino EA, et al: The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res 29:705–727, 1969.

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Relationship between the Stage of Melanoma and Survival

Balch CM, Buzaid AC, Soong SJ, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 2001;19:3635-3648

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Relationship between thickness of Melanoma and Survival


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Balch, C. M. et al. J Clin Oncol; 19:3635-3648 2001

One-year survival rates from the AJCC melanoma staging database comparing the different M categories

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Regional node evaluation

• Malignant melanoma metastasizes through lymphatic channels to regional LN(most important prognostic factor for patients with clinically node negative melanoma.

• PE is often inaccurate:• 20% of clinically node-negative

patients have metastatic deposits

• 20% of clinically node-positive patients have pathologically negative nodes.

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Ultrasonography

• US aspect of axillary lymph node metastasis(oval , hypoechoic, enlarged node with no hyperechoic hilum)

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Saiag, P. et al. Arch Dermatol 2005;141:183-189.

Summary of Studies Comparing Palpation and Ultrasonography to Diagnose Melanoma Nodal Metastasis

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2 cm vs 4 cm radial margin of surgical excision


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Thomas JM, Newton-Bishop J,. N Engl J Med 2004;350:757-766


Thomas JM, Newton-Bishop J,. N Engl J Med 2004;350:757-766




ELND for subclinical disease

• Rationale : • Cancers spread first to lymph

nodes and only afterwards to the bloodstream.

• Removal of subclinical regional disease in patients with melanoma should provide a survival benefit over delayed resection after the disease becomes clinically evident.???

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Complications

• Long-term include lymphedema and paresthesias.

• Lymphedema is more common after groin dissection.

• It is preferable to avoid deep groin dissection; this will reduce the lymphedemarate from 67 to 18%.

• compression support stockings for at least 6 m.

• Borgstein, PJ, Meijer, S, van Diest, PJ. Are locoregional cutaneous metastases in melanoma predictable? Ann Surg Oncol 1999; 6:315.

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WHO Trial

• 1st randomized study was the World Health Organization (WHO) Melanoma Group trial.

• 533 pt were randomized to wide excision plus either ELND or delayed lymph node dissection when clinical involved nodes were detected at routine 3 m f/u exam.

Kuvshinoff, BW, Kurtz, C, Coit, DG . Computed tomography in evaluation of patients with stage III melanoma. Ann Surg Oncol 1997; 4:252.

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WHO Trial

• Limitations:• Only patients with melanomas on the distal 2/3 of an

extremity were included and 85% were female. • Female patients with distal extremity primary

melanomas have a highly favorable prognosis, making it difficult to demonstrate a benefit from ELND.

• Melanomas of all thickness levels were included and the trial was not stratified for thickness or ulceration, features now known to be important prognostic factors.

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Intergroup melanoma trial

• 740 patients with melanoma 1-4 mm thick were randomly assigned to immediate ELND or wide excision only.

• Patients with truncal lesions underwent lymphoscintigraphy to be certain that the proper node basins were dissected.

• The patients were stratified for thickness, site, and ulceration.

Balch, CM, Soong, S, Ross, MI, Urist, MM. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. Ann Surg Oncol 2000; 7:87.

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Intergroup melanoma trial

• Subgroups that benefited from ELND included :• tumor thickness between 1

and 2 mm• tumor without ulceration• patients < 60 y of age

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Copyright © 2004 Pearson Education, Inc., publishing as Benjamin CummingsCopyright © American Society of Clinical Oncology

Gershenwald, J. E. et al. J Clin Oncol; 17:976 1999

Kaplan-Meier survival for patients undergoing successful lymphatic mapping and SLN biopsy stratified by SLN status

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Lymphatic mapping and SLNB

• Tumor cells migrating from a primary tumor colonize the first node(s) receiving lymphatic drainage from the primary tumor site (the sentinel node[s]) before involving other nodes.

• The concept of the SLN was initially developed for squamous cell penile cancer

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Leong SP. Sentinel lymph node mapping and selective lymphadenectomy: the standard of care for melanoma. Curr Treat Options Oncol. 2004;5:185-194


Technique

• Intradermal injection of a radiolabeled tracer(isosulfanblue dye).

• Proper injection is accompanied by the development of a tense wheal as the tracer is injected.

• Because the tracer is injected intradermally, many patients experience an uncomfortable burning at the site of injection for several seconds.

• Well-tolerated by most patients.

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Technique• Because lymphatic drainage is

variable, images should usually include both axillary and inguinal node beds when the primary lesion is located anywhere on the trunk.

• The area between the injection site and sentinel node bed(s) should also be surveyed for in-transit nodes.

• For extremity lesions, crossover to contralateral node beds is rare, but in-transit nodes should again be considered when obtaining images.

• Care must be taken to image all nodal basins (SLNs in more than one nodal basin are common)

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Hand-held Gamma Probe

• The tracer is subsequently picked up by the lymphatic channels and is deposited in the nodal tissue receiving lymphatic flow from the site of injection.

• The SLN is often detected within 10-30 min of injection.

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SLNB

• All nodes with radioactive counts greater than 10% of the hottest node be resectedfor analysis

• If the sentinel node is negative for metastasis, the remaining regional nodes are also very likely to be negative.



Lymphoscintigram

• Lateral view of a patient with a primary melanoma of the back.

• Note 3 parallel lymphatic vascular pathways leading to the axillary SLN.


SLN Bx

• False negative rate is typically 5% or less.

• Causes include:• inadequate pathologic

examination of the SLN• poor tracer injection technique• imaging the wrong nodal

basin• not imaging all possible nodal

basins

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Kaplan-Meier survival for patients undergoing successful lymphatic mapping and SLN biopsy stratified by SLN status

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Surgical management of 612 stage I or II melanoma patients eligible for lymphatic mapping and SLN biopsy

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Kirkwood, J. M. et al. J Clin Oncol; 18:2444-2458 2000

Post-relapse survival for the Obs arm (relapsed patients only) with and without IFN{alpha}-containing salvage therapy

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Manola, J. et al. J Clin Oncol; 18:3782-3793 2000

Overall survival by protocol

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Gollob, J. A. et al. J Clin Oncol; 21:2564-2573 2003

Dosing schedule for first 6-week cycle of interleukin-12 (IL-12) + IL-2

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Gollob, J. A. et al. J Clin Oncol; 21:2564-2573 2003

Fig 6. (ABiopsy of cutaneous metastasis in melanoma patient before & after start of interleukin-12 (IL-12)/IL-2

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Isolated limb perfusion (ILP)


• Surgical isolation of the vascular inflow and outflow of an extremity to separate the circulation of the affected limb from that of the remainder of the body.




• By connecting the limb vasculature to a bypass circuit, high conc. of chemotherapy can be circulated locally without exposing the rest of the body.

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• The isolated extremity can also be subjected to mild hyperthermia (eg 40ºC) to improve antineoplastic efficacy without subjecting the entire body to the risks of hyperthermia.

• Nitrogen mustard • Melphalan• TNFa


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• Tsao H, Atkins MB, Sober AJ. Management of cutaneous melanoma. N Engl J Med 2004; 351:998-1012

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