Surgical Management of Primary Cutaneous Melanoma

UK Guidelines on the Management of Primary Cutaneous Malignant Melanoma

1. Diagnostic Biopsy. Where practicable total excision biopsies should be undertaken. Exceptions include significant doubt about the diagnosis, some anatomical sites and very large lesions such as lentigo maligna where doubt exists about diagnosis. The reason for total biopsy is a) to avoid sampling error and b) to enable optimum treatment to be based on thorough histological examination of the entire specimen.
2. Therapeutic Excision.

All margins are measured at the time of surgery from the clinical edge of the lesion.

In Situ and Horizontal Growth Phase excise 2 – 5 mm around clinical edge.

Vertical Growth Phase

Staging should be undertaken for tumours that are stage 2B or above i.e. tumours greater than 2mm thick with ulceration or greater than 4mm thick without ulceration.

Staging investigations (Appendix A)

For Stage 2A

• Full Blood Count
• Liver Function Tests
• Chest X-ray

For Stage 2B or above

• Liver Ultrasound, or
• CT scan with contrast of chest, abdomen and/or pelvis

Follow up

1. All patients should be taught self examination of local skin and regional nodes.
2. Patients with in situ (horizontal growth phase) tumours need be seen once only post operatively
3. All patients with invasive melanoma (vertical growth phase) should be followed up three monthly for three years. Thereafter patients with tumours less than 1.0mm thick may be discharged and others reviewed six monthly for a further two years.
4. At follow up the following examination should take place.
   1. Examination of primary site and surrounding skin by observation and palpation for local recurrence and local metastatic disease.
   2. The draining regional lymph nodes.
   3. The remaining skin noting any suspicious pigmented lesions (possibly photograph them)

Sentinel Node Biopsy

May be useful for staging patients with stage II melanoma in a specialist centre as part of a clinical trial.

Appendix A

AJCC/UICC staging system recommended.

Key to table