Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures—ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.
After viewing this course, the participant should be able to:
1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins.
2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient.
3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options.
4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature.
5. Discuss the medical therapies available to patients with metastatic melanoma.
Sabrina N. Pavri M.D, James Clune MD, Stephan Ariyan MD, Deepak Narayan MD
Plastic and Reconstruction Surgery® Editors:
Editor-in-Chief: Rod J. Rohrich, MD
Co-Editor: James M. Stuzin, MD
Section Editor: Donald H. Lalonde, MD
Patient Safety Credit:
Journal Article, Video Publish Date:
8/1/2016Estimated time to complete this course:
Directly provided by the American Society of Plastic Surgeons® (ASPS®)
The American Society of Plastic Surgeons (ASPS) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The ASPS designates this enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This educational activity is intended for plastic surgery practitioners, residents, and other healthcare professionals interested in translating expanded knowledge into practice for the improvement of patient outcomes in plastic and reconstructive surgery.
Dr. Rohrich, MD is the Principal/Co-Principal Investigator of research grants awarded to the University of Texas Southwestern Medical Center, Dallas, from Medicis, Mentor, and Contura Pharmaceutical. All research funds are provided directly to UT Southwestern. Dr. Stuzin has no relevant financial relationships or affiliations to disclose. Dr. Lalonde is a consultant for ASSI Instruments. None of the authors have any relevant financial relationships or affiliations to disclose.
All ASPS staff members
managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials.
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