Clinical Research in Dermatology: Open Access

We describe a 48-year-old patient with a present cutaneous pigment lesion located in the left scapular area. About 15 years duration of the finding, as the lesion being suspected clinically and dermatoscopically for cutaneous melanoma. The patient was initially treated with a surgical margin of 0.5 cm in all directions, with a tumor thickness of 3 mm immediately established afterwards. The subsequent surgical session 9 days later (as recommended by the AJCC) included: 1) removal of 4 sentinel lymph nodes: 3 of them located infrascapularly and one axillary apically to the left and 2) reexcision of the primary surgical wound with a safety margin of 1.5 cm in all directions. Lymph node involvement data are lacking and the patient is staged as IIA (T3a N0M0).

Using a worldwide medical database as PubMed/Medline, it could be at least suggested that the determination of the tumor thickness in clinically and dermatoscopically indicative for melanoma cutaneous lesions (especially when they are over 2 or 3 mm) should not be a serious challenge. In pigmented lesions with clear clinical and dermatoscopic data in the direction of cutaneous melanoma, the role of high-frequency pre-operative ultrasound could be essential for reducing the number of surgical sessions from two to one. The case presented is indicative of how lesions with similar clinical and dermatoscopic morphology could be treated and how guidelines can be individually optimized on the basis of the individual clinical experience. In fact, it turns out that one-step melanoma surgery (OSMS) could be a good therapeutic option in a specific type of patient.

Keywords: Nevoid Melanoma; One Step Melanoma Surgical Approach;Individualized Approach; OSMS; Preoperative Echographical Tumour Thickness Measurement

According to the current guidelines about performing / conducting SLNB in patients with melanoma, it is recommended to be mandatory for tumor thickness between 1 and 4 mm [1,2]. On the other hand, in the case of cutaneous melanomas with ultrasound or histologically established tumor thickness greater than 4 mm (and lack of enlarged locoregional lymph nodes by ultrasound), the determination of draining or sentinel lymph node/s could be considered controversial by a number of authors [3]. The reason for this clinical behavior is 1) the possible presence of accessory parallel lymphatic pathways on the one hand that the tumor cells have traversed, 2) the tumor cells have undergone, but are not limited to the draining lymph node, or 3) primary haematogenous dissemination that has already occurred without lymph nodes and pathways to be involved [4].

We present a patient with cutaneous melanoma in the area of the back and tumor thickness of 3 mm, discussing the role of sentinel lymph node diagnosis in tumors between 2 and 4 mm thick and the applicability of one step melanoma surgery.

We present a 48-year-old man with melanocytic lesion in the area of the back with a duration of about more than 15 years (Fig. 1a-b). Over the last 2-3 years the patient has observed a change in the color and size of the lesion. During the dermatological examination we found the presence of a melanocytic lesion located in the back area, clinically/dermtoscopically suspected for cutaneous melanoma (Fig. 1a-b). A primary elliptical excision of the melanocytic lesion was performed with an surgical safety margin of 0.5 cm in all directions (Fig. 1c-e). The surgical defect was closed with single interrupted sutures (Fig. 1d). Subsequent

histological examination revealed evidence of nevoid melanoma with nodular and superficial growth, Breslow tumor thickness 3mm, Clark lever III. In a view of the histologically established tumor thickness of 3 mm, re-excision with an additional 1.5 cm in all directions was planned, combined with removal of a sentinel lymph node within one surgical session. Dynamic lymphoscintigraphy for SLN imaging combined with SPECT-CT examination was performed (fig. 2a-2d). The study examined the presence of a sentinel lymph node with infrascapular localization, subcutaneously dorsally to the left of the central axis and three smaller also infrascapular localized lymph nodes measuring < 5 mm, located in the immediate vicinity of it, along the course of the lymphatic drainage (Fig. 2a-b). A single lymph node measuring 14.6 mm was found in the area of the left axilla, apically, near the m. subscapularis (Fig. 2d). Additionally, a single lymph node, defined rather as non-sentinel, subject to ultrasound check- up, was identified in the right axillary region (Fig. 2c). Within the second surgical intervention, 1) removal of a single formation in the area of the left axilla, subsequently verified as a neurinoma, was initiated (Fig 3a-b), followed by 2) axillary lymphatic dissection at two levels in the left axilla (Fig. 3c-f, 4a-f). In the next step, the surgical removal of the marked 3 sentinel lymph nodes was performed infrascapularly to the left, (Fig. 5a-f). In the last step, re-excision was performed in the area of primary surgery paravertebral with an additional surgical safety margin of 1.5 cm in all directions (Fig. 6a-d). The re-excision was elliptical and the closure of the defect was staged with single subcutaneous sutures (Fig. 6e), followed by single interrupted skin sutures (Fig. 6f). Subsequent histological examination of the removed lymph nodes reveal only sinus histiocytosis of the lymph nodes. The diagnosis of melanoma stage IIA (T3aN0M0), was made. With regard to the mildly positive lymph node in the right axillary region, the patient is subject to regular ultrasound monitoring and follow- up. Interferon or BCG vaccine therapy was planned after undergoing an oncology committee.

The present case was treated according to the recommendations of the AJCC during two surgical sessions (1, Table 1). We raise and discuss the possibility of One Step Melanoma Surgery in the patient described (OSMS) (Table 2) [5].

In the latter case, clinical and dermatoscopic data were available on possible “thin”- cutaneous melanoma developed on the basis of pre-existing melanocytic nevus (Fig. 1a-b). If we assume hypothetically that the combination of clinical examination and dermatoscopic findings would be accompanied by additional preoperative ultrasound measurement of tumor thickness, the subsequent clinical approach for melanoma would undoubtedly be more complex or optimized. That is, ultrasound preoperative data would then be available to confirm undoubtedly an available tumor thickness of more than 2 mm. Higher-frequency (50- to 100-MHz) ultrasound is thought to be very high in overestimate tumor thickness if there are infiltrating lymphocytes or nevus remnants present as well as in the patient presented by us, in which we are talking about nevoid- associated melanoma [6]. Preoperative determination of this tumor thickness together with a high-frequency ultrashort combined with SPECT-CT and lymphoscintigraphy would result in the possibility of reducing the number of surgical interventions in a single operation under general anesthesia .Namely, excision of the melanocytic lesion with a direct field of 2 cm surgical safety in all directions, combined with SLND detection and removal, as suggested by the OSMS guides (Table 2) [5]. This, in turn, is a sparing approach for patients, both financially and emotionally.

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