Cutaneous Melanoma Flashcards
What are the ABCDs of diagnosing melanomas?
Asymmetric, (irregular) Border, (variegated) Color, or (large) Diameter
What is the ideal biopsy for suspected melanoma
Excisional biopsy including the deepest portion of the melanoma, when possible - depth affects staging and treatment
When lesions are too large to excise for biopsy, what portion should be biopsied?
The darkest or the thickest (by palpation)
What are the depth to margin recommendations in melanoma?
In situ - 5mm, 4mm - 3cm
What mechanisms exist for local recurrence of melanoma after excision?
Radial extension, local dissemination through lymphatics, or neurotropic (along nerves)
True/False: Margins of excision may be modified in subungal lesions.
False - it often requires amputation at midproximal phalanx and replantation of tendons
What is the ideal resection length to width ratio for primary closure with advancement flaps?
3 to 1
What is the most likely first site of melanoma metastasis?
Regional lymph nodes
What pathological findings dictate lymph node biopsy in melanoma
1mm in depth OR, to a lesser extent, ulceration, young age, regression, incomplete biopsy, and high mitotic rate
What is the most important prognostic factor with localized melanoma?
Lymph node status
Why does lymphoscintigraphy imaging have to include the entire body?
Risk of occult sites that could represent the site of the sentinel node - found in 10% of cases
Along with radionucleotide lymphoscintigraphy, what measures are used to identify sentinel nodes?
Injection of blue dye, to visually identify sentinel node
At what level is the blue dye injected to identify melanoma sentinel nodes?
Intradermal - there are relatively few subcutaneous lymphatic channels
In melanoma, the nodal basin is dissected until what is achieved?
The radioactivity count falls below 10 of the hottest node
True/False: All proposed sentinel nodes should be sent for frozen section in melanoma?
False - there is limited accuracy and loss of diagnostic material during cryostat processing
What are the potential complications of sentinel node biopsy?
Wound seroma, hematoma, and infection - nerve injury and lymphedema are also possible, in certain sites.
What is the standard of care in nodal metastasis associated with melanoma?
Complete lymphadenectomy
What are the recommended number of nodes in lymphadenectomy?
Axillary/Cervical - 15, Inguinal - 8 (sup) and 6 (deep), SC- 6, Suprahyoid - 4, Parotid - 3 , Popliteal - 2 to 3
What is the primary determinant in the thickness of skin flaps during lymphadenectomy?
Achieving the thinnest possible flaps WITHOUT compromising perfusion
What modalities are recommended for dissecting visible lymphatics?
Clips, ties, ligating energy sources - NOT electrocautery
True/False: In melanoma, only axillary nodes of levels 1 and 2 need to be dissected.
False - all 3 levels are included.
What are the borders of axillary node dissection for melanoma?
(S) axillary vein from thoracic inlet to latissimus dorsi, (M) serratus anterior and intercostals, including interpectoral (Rotter’s) nodes, (L) latissimus dorsi, (I) Fourth Intercostal space, (P) subscapularis.
What nerves are encountered (and should be spared) during axillary node dissection?
The lateral thoracic and thoracodorsal nerves (do not preserve if involved with tumor)
What muscle is encountered (and sometimes transected or removed) during level 3 axillary node dissection?
Pectoralis minor
