Surgical techniques of melanoma and sentinel node biopsy

Primary Melanoma: from History to Actual Debates

PURPOSE OF REVIEW

This review describes the long scientific background followed to design guidelines and everyday clinical practice applied to melanoma patients. Surgery is the first option to cure melanoma patients (PTS) at initial diagnosis, since primary cutaneous lesions are usually easily resectable. An excisional biopsy of the lesion, with minimal clear margins, can be obtained in the vast majority of cases. Punch biopsies may be proposed only in case of large lesions located on specific cosmetic or functional areas like the face, extremities, or genitals where a mutilating complete resection would not be performed without prior histological diagnosis.

RECENT FINDINGS

After the histologic confirmation of melanoma, definite surgical excision of the scar and surrounding tissue is planned, to obtain microsatellite free margins. The width of these margins has been identified following the results of several clinical trials and it is either 1 or 2 cm, depending on the Breslow thickness of the primary tumor. Following the latest staging system proposed by the American Joint Cancer commission (AJCC), a sentinel node biopsy (SNB) is usually performed in case of a primary lesion > 0.8 mm thickness or for high-risk thinner lesions, if no evidence of nodal involvement has been identified clinically or radiographically. Surgical management of primary melanoma is well established. There is debate on the optimal surgical margins for 1-2 mm melanomas. There are specific considerations for special primaries (bulky, extremity, mucosal). Sentinel node (SN) evaluation does not improve survival, but is routinely used as staging.

Mise au point sur la prise en charge chirurgicale du mélanome malin cutané. Revue de la littérature

Nowadays managing a cutaneous malignant melanoma can concern different kind of physicians: dermatologists, general or plastic surgeons The primary surgical procedure is a major step of the treatment. Biopsy must be total to properly determine the thickness of the tumor in case of malignancy. Wide local excision of the scar is often necessary to decrease the local and general recurrence rates. Wide local excision must be performed conforming to its own surgical rules. Managing tumor located on the face or limb extremities is a matter of plastic surgery. Sentinel node biopsy has succeeded to elective lymph node dissection. This procedure allows research of lymphatic spreading of the disease. Practice of sentinel node biopsy must be achieved in a protocolar way. Topography of the lesion can modified achievement and results of this procedure. Prognosis benefit of sentinel biopsy is now clear. Elective lymph node dissection is only performed in case of invaded sentinel node or clinically invaded lymph nodes. Local or locoregional recurrences mainly respond to surgical treatment using wide excision. However, alternative solutions are being evaluated (isolated limb perfusion).

Phenotypic and functional changes of human melanoma xenografts induced by DNA hypomethylation: immunotherapeutic implications

Emerging in vitro evidence points to an immunomodulatory activity of DNA hypomethylating drugs in human malignancies. We investigated the potential of 5-aza-2'-deoxycytidine (5-AZA-CdR) to modulate the expression of cancer testis antigens (CTA) and of HLA class I antigens by melanoma xenografts, and the resulting modifications in immunogenicity of neoplastic cells. Three primary cultures of melanoma cells, selected for immune phenotype and growth rate, were grafted into BALB/c nu/nu mice that were injected intraperitoneally with different dose- and time-schedules of 5-AZA-CdR. Molecular analyses demonstrated a de novo long-lasting expression of the CTA MAGE-1, -2, -3, -4, -10, GAGE 1-6, NY-ESO-1, and the upregulation of MAGE-1, MAGE-3, and NY-ESO-1 levels in melanoma xenografts from 5-AZA-CdR-treated mice. Serological and biochemical analyses identified a de novo expression of NY-ESO-1 protein and a concomitant and persistent upregulation of HLA class I antigens and of HLA-A1 and -A2 alleles. Immunization of BALB/c mice with 5-AZA-CdR-treated melanoma cells generated high titer circulating anti-NY-ESO-1 antibodies. Altogether, the data obtained identify an immunomodulatory activity of 5-AZA-CdR in vivo and strongly suggest for its clinical use to design novel strategies of CTA-based chemo-immunotherapy for melanoma patients.

Sentinel lymph node biopsy

The introduction of sentinel lymph node biopsy (SLNB) has been an important development in the management of malignant melanoma. Lymph nodes have long been known to play a key role in melanoma metastasis. The importance of nodal staging accounted for the previous surgical practice of elective lymph node dissection (ELND) even with its controversial impact on final outcomes and associated morbidity. Although this morbidity has been reduced with the ability to identify the SLN, numerous questions have subsequently surfaced with respect to this procedure's utility and therapeutic efficacy. This chapter will focus on the indications for SLNB, as well as the current controversies surrounding this procedure.

Sentinel node biopsy in melanoma of the trunk and the extremities in tumescent local anesthesia

BACKGROUND

The sentinel node biopsy (SNB) of axilla and groin is a common staging procedure and can be done in both general anesthesia and local anesthesia.

OBJECTIVE

To investigate the efficacy of tumescent local anesthesia (TLA) as a widely used type of local anesthesia in dermatologic surgery for the SNB of axilla and groin.

METHOD

From 1999 to 2002, 195 patients underwent a SNB of axilla or groin. A 0.1% tumescent solution with prilocaine was used. In cases in which local anesthesia did not produce complete analgesia, there was additional medication using Midazolam and Tramadol.

RESULTS

In 74.9% of the patients, TLA was sufficient as the sole method. In 25.1%, sedation became necessary. Additional medication was required for 31.9% of the patients with SNB in the axilla and for 17.3% with SNB in the groin; 26.6% of the patients with SNB of both axillas and 25% with SNB of the axilla and the groin received additional medication using Midazolam. Two patients with a SNB of the axilla received a combination of Midazolam and Tramadol.

CONCLUSION

SNB of the axilla and the groin in TLA is a good alternative to other anesthetic techniques, for example, general anesthesia or infiltration anesthesia.