Scalpel Excision of Primary Cutaneous Malignant Melanomas without Metastasis FRED F. CASTROW II, M.D., AND MARVIN E. CHERNOSKY, M.D.
Views and opinions about surgical treatment of primary malignant melanomas that are without local spread or metastasis are presented. An attempt is made to deter mine the limitations of office-based dermatologists in the treatment of malignant melanomas of this stage. Using accepted criteria for clinical recognition of malignant melanomas early, it is suggested that surgical excisions of small malignant melanomas that are judged to be complete obviate preliminary biopsies and furnish surgi cal specimens that can be read histopathologically for confirmation of clinical diagnosis and adequacy of excision.
of this paper is to present our views and opinions as dermatologists about the surgical treat ment of primary malignant melanomas that are without spread or metastasis. Criteria for the clinical recogni tion of malignant melanomas early are well established and have been well publicized by Mihm, Fitzpatrick, Kopf, and their associates.1,2,3 Confusion arises when a decision has to be made as to who should deliver the treatment for particular malignant melanomas and what is considered to be adequate treatment. An at tempt will be made to determine what are the lim itations of office-based dermatologists in the treatment of malignant melanomas. When the diagnosis of a ma lignant melanoma can be made clinically without rea sonable doubt, it is suggested that surgical excision of an early, small malignant melanoma that is clinically judged to be complete may supplant preliminary biopsy and furnish a surgical specimen that can be T h e p u rp o se
Dr. Castrow is Clinical Associate Professor of Dermatology, Uni versity of Texas Medical School at Houston, Houston, Texas. Dr. Chernosky is Professor and Chairman of the Department of Dermatology, University of Texas Medical School at Houston, Houston, Texas. Address reprint requests to Dr. Fred F. Castrow II, 7777 South west Freeway, Suite 1014, Houston, Texas 77074.
read histopathologically for confirmation of diagnosis and adequacy of excision. CLINICAL DIAGNOSIS
A most important judgment of a clinician is early rec ognition of a lesion that may be a malignant melanoma. Groups at Harvard1,2 and New York University3 have delimited and clearly stated the clinical appearance (gross pathology) of the early malignant melanomas: variation in color (red, white and blue), irregularity of borders, and unevenness of surface (nodularity). The publication of the American Academy of Dermatology Independent Study Series entitled: “ Primary Cutane ous Malignant Melanomas: Recognition and Man agement” 2 is recommended for deep study. A patient’s statements about changes in a lesion like inception of pruritus, deepening of color, increase in size, irregular spread, and different characteristics of surface, and about trauma are clues that should raise one’s index of suspicion. Other signs and symptoms like ulceration, bleeding, and pain that are emphasized by the Amer ican Cancer Society for the recognition of skin cancer in general are late events when applied to malignant melanomas. If a patient waits until pain, ulceration, and bleeding have developed before consulting a
J. Dermatol. Surg. Oncol. 5:2 February 1979
109
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specimen should be marked with a small piece o f knot ted suture material adjacent to such suspicious areas to guide the pathologist to inspect those parts o f a lesion suspected o f being a malignant melanoma and of being biologically most aggressive. Frozen sections are not suitable for definitive judgment o f a malignant melanoma. Figure 2 illustrates an agminated spindleand epithelioid-cell nevus that had been read as malig nant melanoma in a frozen section by a competent pathologist. I f the surgeon had not hesitated and waited for fixed and stained sections, the infant patient would have been needlessly mutilated.
CLASSIFICATION FIGURE I. Acral lentiginous malignant melanoma.
physician, the opportunity to cure or extend life sig nificantly may well be lost.
BIOPSY TECHNIQUE All lesions suspected o f being malignant melanomas should be studied histopathologically. Epstein4 and others5 6 have presented data that emphasize the fact that incomplete removal o f a proved malignant melanoma, when followed by adequate surgery, does not decrease the rate of survival if definitive treatment is not delayed more than a month after diagnosis.7 The type of biopsy (total or partial and by scalpel or punch) depends on factors like the size and location of the lesion and the skill o f the surgeon. A shave biopsy o f a suspected malignant melanoma is, in our opinion, inadequate because it does not permit measurement of level and thickness o f the lesion. Biopsy that is clini cally judged to be total8 should be done whenever pos sible; biopsy o f but a part of a lesion suspected of being a malignant melanoma by scalpel or punch is second choice. A biopsy should be deep enough to include some subcutaneous fat, and the long axis o f it should be in the direction o f the probable pathway o f lymphatic drainage. When a diagnosis of malignant melanoma can be made clinically without reasonable doubt, it is suggested that clinically judged complete surgical excision (defined under TREATMENT) o f an early, small malignant melanoma can be the biopsy and curative procedure at once. Figure 1 illustrates a case in which several punch biopsies were read merely as lentigo. Because the reading of lentigo was not credible a complete surgical specimen was obtained by amputation o f the finger, and acral lentiginous malignant melanoma was found in the proximal nail bed. Nodular or indurated areas and deeply pigmented, especially blue-black, portions o f a large surgical
HO
J . Dermatol. Surg. Oncol. 5:2 February 1979
Various authors have attempted to formulate criteria with which to prognosticate probability o f recurrence, metastasis, and survival rates o f patients with malig nant melanoma. They base their conclusions on factors that are still being evaluated, and definitive criteria are not yet available.9 Histologic classification o f type, level, and thickness o f lesions o f malignant melanomas is being used to determine prognosis and extent o f necessary surgery. Type and level of invasion were formulated by Clark et a l.,() and tumor thickness by Breslow11. I f other factors prove to be o f importance, they w ill, no doubt, be incorporated into several schemes o f evaluation. Schmoeckel and BraunFalco's prognostic index (product o f thickness and mitotic rate)12 is being added to our data base, but its weight in the decision-making process will need to stand the test o f time and confirmation before it is fully credited. There should be close communication between sur geon and pathologist. I f a particular pathologist does not have interest or expertise in malignant melanoma or does not furnish sufficient information (i.e ., level of invasion, thickness, and mitotic rate) to make a mod ern judgment, then review by another pathologist who
FIGURE 2. Agminated spindle- and epithelioid-cell nevus.
CASTROW AND CHERNOSKY
does have interest and expertise should be sought. SELECTION OF PATIENTS
In our opinion, only thin primary cutaneous malignant melanomas without local spread or metastasis should be considered for treatment by a dermatologic surgeon in an office operating facility. Thin, as defined by Breslow11, is thickness of less than 0.76 mm and usually comes to level I and level II of Clark’s classification. Melanomas of greater thickness and deeper levels re quire aggressive surgery and possibly adjunctive therapy. They should be referred to specialists in oncology. TREATMENT
Surgical excision is the only method of treating se lected malignant melanomas we use in our office-based dermatologic practices. Adjunctive measures, i.e., limb perfusion, lymph-node dissection and im munotherapy, are not appropriate, applicable, or needed for the thin melanomas that we select to treat. As noted under BIOPSY TECHNIQUE, clinically judged complete surgical excision of early, small melanomas supplants preliminary biopsy procedure when the diagnosis of malignant melanoma can be made clinically without reasonable doubt. Level I lentigo maligna and level II lentigo maligna melanoma are excised with margins of one or more centimeters from lesion edges or biopsy scars, and the excision is carried to the deep fascia. Level I superfi cial spreading “ melanoma” is excised conservatively (narrow margins) because it is not considered by us to be biologically a malignant melanoma. Step sections of the excised tissue should be requested in the pathologic examination in order to ensure that a mis take in classification has not been made. Most authorities2,13 recommend that thin level II and level III superficial spreading malignant melanomas be excised with margins of three to five centimeters from the edges of lesions or biopsy scars. One of us (M.E.C.) has had experience with margins of two cen timeters without recurrence, local spread, or metas tasis. Newer data14 is supporting the practice of less extensive margins as adequate for the definitive treat ment of thin malignant melanomas. The excision should be carried down to the deep fascia and the plane and volume of the excision should be oriented in the probable pathway of lymphatic drainage. In most instances skin grafting should not be necessary.
intervals (every three months) during this time. Care ful examination of the site of excision and then the entire cutaneous surface for melanotic lesions, and palpation for enlarged regional nodes and enlargement of the liver are required. Laboratory tests for liver function should be done at each visit, and X-ray exam ination of the chest should be done every six months. A liver-spleen scan is not necessary unless some ab normality is found on physical examination or in the liver-function tests. After two years, the interval for follow-up may be extended to six months, and after five years to yearly examination for the life of the pa tient. Upon least suspicion of recurrence or metas tasis, referral to specialists in oncology should be made. ACKNOWLEDGMENT Westwood Pharmaceuticals In c., defrayed the cost of reproducing the color illustrations.
1.
2.
3.
4. 5.
6. 7.
8. 9. 10.
11.
12. 13.
FOLLOW-UP
Because the likelihood of recurrence or metastasis of surgically treated malignant melanomas is greatest in the first two years, patients should be seen at frequent
14.
REFERENCES Mihm, M. C., Jr., Fitzpatrick, T. B., Lane Brown, M. M., Parker, J. W., Malt, R. A., and Kaiser, J. S. Early detection of primary cutaneous malignant melanoma. A color atlas. N. Engl. J. Med. 289:989-996, 1973. Sober, A. J., Fitzpatrick, T. B., Mihm, M. C., and Clark, W. H. Primary cutaneous malignant melanomas: recognition and management. American Academy of Dermatology Courses in Clinical Dermatology, 1976. Kopf, A. W:, Bart, R. S., and Rodriguez-Sains, R. S. Malig nant melanoma: a review. J. Dermatol. Surg. Oncol. 3:41-125, 1977. Epstein, E., Bragg, K., and Linden, G. Biopsy and prognosis of malignant melanoma. J.A.M.A. 208:1369-1371, 1969. Jones, W. M., Williams, W. J., Roberts, M. M., and Davies, K. Malignant melanoma of the skin: prognostic value of clinical features and the role of treatment in 111 cases. Br. J. Cancer 22:437-451, 1968. Knutson, C. O., Hori, J. M., and Spratt, Jr., J. S. Melanoma. Curr. Probl. Surg. December, 1971, pp. 1-55. Pack, G. T., Gerber, D. M., and Scharnagel, I. M. End results in the treatment of malignant melanoma: a report of 100 cases. Ann. Surg. 136:905-911, 1952. Harris, M. N., and Gumport, S. L. Total excision biopsy for primary malignant melanoma. J.A.M.A. 226:354-355, 1973. Kopf, A. W. The prognostic index in malignant melanoma. J.A.M.A. 239:2695, 1978. Clark, W. H., Jr., From, L., Bernardino, E. A., et al. The histogenesis and biologic behavior of primary human malig nant melanomas of the skin. Cancer Res. 29:705-726, 1969. Breslow, A. Tumor thickness, level of invasion and node dis section in stage I cutaneous melanoma. Ann Surg. 182:572575, 1975. Schmoeckel, C., and Braun-Falco, O. Prognostic index in ma lignant melanoma. Arch. Dermatol. 114:871-873, 1978. Harris, M. N ., and Gumport, S. L. Present status of surgical management of malignant melanoma. J. Dermatol. Surg. 2:129-133, 1976. Breslow, A., and Macht, S. D. Optimal size of resection mar gin for thin cutaneous melanoma. Surg. Gynecol. Obstet. 145:691-692, 1977.
J. Dermatol. Surg. Oncol. 5:2 February 1979
111
Views and opinions about surgical treatment of primary malignant melanomas that are without local spread or metastasis are presented. An attempt is made to deter mine the limitations of office-based dermatologists in the treatment of malignant melanomas of this stage. Using accepted criteria for clinical recognition of malignant melanomas early, it is suggested that surgical excisions of small malignant melanomas that are judged to be complete obviate preliminary biopsies and furnish surgi cal specimens that can be read histopathologically for confirmation of clinical diagnosis and adequacy of excision.
of this paper is to present our views and opinions as dermatologists about the surgical treat ment of primary malignant melanomas that are without spread or metastasis. Criteria for the clinical recogni tion of malignant melanomas early are well established and have been well publicized by Mihm, Fitzpatrick, Kopf, and their associates.1,2,3 Confusion arises when a decision has to be made as to who should deliver the treatment for particular malignant melanomas and what is considered to be adequate treatment. An at tempt will be made to determine what are the lim itations of office-based dermatologists in the treatment of malignant melanomas. When the diagnosis of a ma lignant melanoma can be made clinically without rea sonable doubt, it is suggested that surgical excision of an early, small malignant melanoma that is clinically judged to be complete may supplant preliminary biopsy and furnish a surgical specimen that can be T h e p u rp o se
Dr. Castrow is Clinical Associate Professor of Dermatology, Uni versity of Texas Medical School at Houston, Houston, Texas. Dr. Chernosky is Professor and Chairman of the Department of Dermatology, University of Texas Medical School at Houston, Houston, Texas. Address reprint requests to Dr. Fred F. Castrow II, 7777 South west Freeway, Suite 1014, Houston, Texas 77074.
read histopathologically for confirmation of diagnosis and adequacy of excision. CLINICAL DIAGNOSIS
A most important judgment of a clinician is early rec ognition of a lesion that may be a malignant melanoma. Groups at Harvard1,2 and New York University3 have delimited and clearly stated the clinical appearance (gross pathology) of the early malignant melanomas: variation in color (red, white and blue), irregularity of borders, and unevenness of surface (nodularity). The publication of the American Academy of Dermatology Independent Study Series entitled: “ Primary Cutane ous Malignant Melanomas: Recognition and Man agement” 2 is recommended for deep study. A patient’s statements about changes in a lesion like inception of pruritus, deepening of color, increase in size, irregular spread, and different characteristics of surface, and about trauma are clues that should raise one’s index of suspicion. Other signs and symptoms like ulceration, bleeding, and pain that are emphasized by the Amer ican Cancer Society for the recognition of skin cancer in general are late events when applied to malignant melanomas. If a patient waits until pain, ulceration, and bleeding have developed before consulting a
J. Dermatol. Surg. Oncol. 5:2 February 1979
109
SC A L P E L EXCI SIO N OF PRIMARY M E L A N O M A S W IT H O U T METASTASIS
specimen should be marked with a small piece o f knot ted suture material adjacent to such suspicious areas to guide the pathologist to inspect those parts o f a lesion suspected o f being a malignant melanoma and of being biologically most aggressive. Frozen sections are not suitable for definitive judgment o f a malignant melanoma. Figure 2 illustrates an agminated spindleand epithelioid-cell nevus that had been read as malig nant melanoma in a frozen section by a competent pathologist. I f the surgeon had not hesitated and waited for fixed and stained sections, the infant patient would have been needlessly mutilated.
CLASSIFICATION FIGURE I. Acral lentiginous malignant melanoma.
physician, the opportunity to cure or extend life sig nificantly may well be lost.
BIOPSY TECHNIQUE All lesions suspected o f being malignant melanomas should be studied histopathologically. Epstein4 and others5 6 have presented data that emphasize the fact that incomplete removal o f a proved malignant melanoma, when followed by adequate surgery, does not decrease the rate of survival if definitive treatment is not delayed more than a month after diagnosis.7 The type of biopsy (total or partial and by scalpel or punch) depends on factors like the size and location of the lesion and the skill o f the surgeon. A shave biopsy o f a suspected malignant melanoma is, in our opinion, inadequate because it does not permit measurement of level and thickness o f the lesion. Biopsy that is clini cally judged to be total8 should be done whenever pos sible; biopsy o f but a part of a lesion suspected of being a malignant melanoma by scalpel or punch is second choice. A biopsy should be deep enough to include some subcutaneous fat, and the long axis o f it should be in the direction o f the probable pathway o f lymphatic drainage. When a diagnosis of malignant melanoma can be made clinically without reasonable doubt, it is suggested that clinically judged complete surgical excision (defined under TREATMENT) o f an early, small malignant melanoma can be the biopsy and curative procedure at once. Figure 1 illustrates a case in which several punch biopsies were read merely as lentigo. Because the reading of lentigo was not credible a complete surgical specimen was obtained by amputation o f the finger, and acral lentiginous malignant melanoma was found in the proximal nail bed. Nodular or indurated areas and deeply pigmented, especially blue-black, portions o f a large surgical
HO
J . Dermatol. Surg. Oncol. 5:2 February 1979
Various authors have attempted to formulate criteria with which to prognosticate probability o f recurrence, metastasis, and survival rates o f patients with malig nant melanoma. They base their conclusions on factors that are still being evaluated, and definitive criteria are not yet available.9 Histologic classification o f type, level, and thickness o f lesions o f malignant melanomas is being used to determine prognosis and extent o f necessary surgery. Type and level of invasion were formulated by Clark et a l.,() and tumor thickness by Breslow11. I f other factors prove to be o f importance, they w ill, no doubt, be incorporated into several schemes o f evaluation. Schmoeckel and BraunFalco's prognostic index (product o f thickness and mitotic rate)12 is being added to our data base, but its weight in the decision-making process will need to stand the test o f time and confirmation before it is fully credited. There should be close communication between sur geon and pathologist. I f a particular pathologist does not have interest or expertise in malignant melanoma or does not furnish sufficient information (i.e ., level of invasion, thickness, and mitotic rate) to make a mod ern judgment, then review by another pathologist who
FIGURE 2. Agminated spindle- and epithelioid-cell nevus.
CASTROW AND CHERNOSKY
does have interest and expertise should be sought. SELECTION OF PATIENTS
In our opinion, only thin primary cutaneous malignant melanomas without local spread or metastasis should be considered for treatment by a dermatologic surgeon in an office operating facility. Thin, as defined by Breslow11, is thickness of less than 0.76 mm and usually comes to level I and level II of Clark’s classification. Melanomas of greater thickness and deeper levels re quire aggressive surgery and possibly adjunctive therapy. They should be referred to specialists in oncology. TREATMENT
Surgical excision is the only method of treating se lected malignant melanomas we use in our office-based dermatologic practices. Adjunctive measures, i.e., limb perfusion, lymph-node dissection and im munotherapy, are not appropriate, applicable, or needed for the thin melanomas that we select to treat. As noted under BIOPSY TECHNIQUE, clinically judged complete surgical excision of early, small melanomas supplants preliminary biopsy procedure when the diagnosis of malignant melanoma can be made clinically without reasonable doubt. Level I lentigo maligna and level II lentigo maligna melanoma are excised with margins of one or more centimeters from lesion edges or biopsy scars, and the excision is carried to the deep fascia. Level I superfi cial spreading “ melanoma” is excised conservatively (narrow margins) because it is not considered by us to be biologically a malignant melanoma. Step sections of the excised tissue should be requested in the pathologic examination in order to ensure that a mis take in classification has not been made. Most authorities2,13 recommend that thin level II and level III superficial spreading malignant melanomas be excised with margins of three to five centimeters from the edges of lesions or biopsy scars. One of us (M.E.C.) has had experience with margins of two cen timeters without recurrence, local spread, or metas tasis. Newer data14 is supporting the practice of less extensive margins as adequate for the definitive treat ment of thin malignant melanomas. The excision should be carried down to the deep fascia and the plane and volume of the excision should be oriented in the probable pathway of lymphatic drainage. In most instances skin grafting should not be necessary.
intervals (every three months) during this time. Care ful examination of the site of excision and then the entire cutaneous surface for melanotic lesions, and palpation for enlarged regional nodes and enlargement of the liver are required. Laboratory tests for liver function should be done at each visit, and X-ray exam ination of the chest should be done every six months. A liver-spleen scan is not necessary unless some ab normality is found on physical examination or in the liver-function tests. After two years, the interval for follow-up may be extended to six months, and after five years to yearly examination for the life of the pa tient. Upon least suspicion of recurrence or metas tasis, referral to specialists in oncology should be made. ACKNOWLEDGMENT Westwood Pharmaceuticals In c., defrayed the cost of reproducing the color illustrations.
1.
2.
3.
4. 5.
6. 7.
8. 9. 10.
11.
12. 13.
FOLLOW-UP
Because the likelihood of recurrence or metastasis of surgically treated malignant melanomas is greatest in the first two years, patients should be seen at frequent
14.
REFERENCES Mihm, M. C., Jr., Fitzpatrick, T. B., Lane Brown, M. M., Parker, J. W., Malt, R. A., and Kaiser, J. S. Early detection of primary cutaneous malignant melanoma. A color atlas. N. Engl. J. Med. 289:989-996, 1973. Sober, A. J., Fitzpatrick, T. B., Mihm, M. C., and Clark, W. H. Primary cutaneous malignant melanomas: recognition and management. American Academy of Dermatology Courses in Clinical Dermatology, 1976. Kopf, A. W:, Bart, R. S., and Rodriguez-Sains, R. S. Malig nant melanoma: a review. J. Dermatol. Surg. Oncol. 3:41-125, 1977. Epstein, E., Bragg, K., and Linden, G. Biopsy and prognosis of malignant melanoma. J.A.M.A. 208:1369-1371, 1969. Jones, W. M., Williams, W. J., Roberts, M. M., and Davies, K. Malignant melanoma of the skin: prognostic value of clinical features and the role of treatment in 111 cases. Br. J. Cancer 22:437-451, 1968. Knutson, C. O., Hori, J. M., and Spratt, Jr., J. S. Melanoma. Curr. Probl. Surg. December, 1971, pp. 1-55. Pack, G. T., Gerber, D. M., and Scharnagel, I. M. End results in the treatment of malignant melanoma: a report of 100 cases. Ann. Surg. 136:905-911, 1952. Harris, M. N., and Gumport, S. L. Total excision biopsy for primary malignant melanoma. J.A.M.A. 226:354-355, 1973. Kopf, A. W. The prognostic index in malignant melanoma. J.A.M.A. 239:2695, 1978. Clark, W. H., Jr., From, L., Bernardino, E. A., et al. The histogenesis and biologic behavior of primary human malig nant melanomas of the skin. Cancer Res. 29:705-726, 1969. Breslow, A. Tumor thickness, level of invasion and node dis section in stage I cutaneous melanoma. Ann Surg. 182:572575, 1975. Schmoeckel, C., and Braun-Falco, O. Prognostic index in ma lignant melanoma. Arch. Dermatol. 114:871-873, 1978. Harris, M. N ., and Gumport, S. L. Present status of surgical management of malignant melanoma. J. Dermatol. Surg. 2:129-133, 1976. Breslow, A., and Macht, S. D. Optimal size of resection mar gin for thin cutaneous melanoma. Surg. Gynecol. Obstet. 145:691-692, 1977.
J. Dermatol. Surg. Oncol. 5:2 February 1979
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