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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The management of cutaneous melanoma has changed radically in the last 30 years&#46; While initial approaches involved wide excision with 5-cm margins and prophylactic radical lymph node dissection&#44; now the tendency is to use increasingly conservative treatments based on the findings of multicenter clinical trials&#46; New data continue to emerge that are driving changes at a dizzying speed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest version of the National Comprehensive Cancer Network &#40;NCCN&#41; guidelines on the surgical treatment of melanoma recommends narrow excision with margins of 1&#8211;3&#8239;mm followed by a second surgical intervention to widen margins following histologic determination of Breslow thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Wider margins in the initial procedure are advised against as they could alter local lymphatic drainage patterns and interfere with accurate sentinel lymph node &#40;SLN&#41; identification&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">SLN biopsy has been considered a valuable staging tool in cutaneous melanoma for many years&#44; as it provides prognostic information for patients with clinical stage I&#47;II disease &#40;without clinical or radiographic evidence of lymph node involvement&#41; and guides diagnostic and treatment decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the most important implications of SLN biopsy for melanoma management&#44; based on findings from the first multicenter selective lymphadenectomy trial &#40;MSLT I&#41;&#44; was that immediate complete lymph node dissection &#40;CLND&#41; was recommended in patients with a positive SLN biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nonetheless&#44; the later DeCOG trial showed no significant survival advantage for CLND compared with observation only&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This lack of advantage was confirmed by the recently published findings from the second MSLT trial &#40;MSLT-II&#41; showing similar survival rates for patients with SLN positivity regardless of whether they underwent CLND or nodal basin ultrasound surveillance&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The results of the above trials led some authors to recommend replacing CLND with nodal basin ultrasound surveillance&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The 2019 NCCN guidelines mention this as an option&#44; that is&#44; they say that a patient with positive SLN status can be observed by nodal basin ultrasound&#44; without the need for CLND&#46; These recommendations have led to a dramatic reduction in the performance of CLND among patients with a positive SLN biopsy at specialized melanoma centers&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Many authors are of the opinion that if SLN biopsy is no longer needed to determine whether or not CLND is indicated&#44; then it should be purely considered a staging procedure and that its role in the management of melanoma needs to be rethought&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> SLN biopsy is starting to lose its status as a standard procedure in melanoma&#44; particularly outside the setting of clinical trials&#46; There are numerous reasons for this&#44; including false-positive and -negative rates&#44; cost&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the risk of morbidity &#40;6&#37; of patients develop lymphedema&#41;&#46; SLN biopsy may still&#44; however&#44; continue to have a role in the selection of candidates for clinical trials evaluating adjuvant therapy with new biologic drugs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This latest information should be clearly explained to patients in understandable language so that they can actively participate in decisions regarding their care&#46; The NCCN guidelines have always referred to SLN biopsy as an option that should be &#34;discussed and considered&#34;&#44; not just with members of multidisciplinary melanoma committees but also with patients&#46; The latest NCCN guidelines also mention CLND as an option to be discussed with SLN-positive patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Equipped with clear information about their options&#44; a considerable proportion of patients will probably choose the &#8220;interventional&#8221; route&#44; that is&#44; SLN biopsy&#44; followed or not by CLND&#44; and enrolment in a clinical trial investigating adjuvant therapy with biologics&#46; Others will choose the &#8220;conservative&#8221; route&#44; consisting of wide surgical excision &#40;without SLN biopsy&#41; and close nodal basin ultrasound surveillance&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Those who choose the first route probably consider that this is their best option&#44; as by benefiting from the latest diagnostic and treatment methods&#44; they will trust they are receiving the best possible care&#46; The NCCN strongly encourages enrolment of melanoma patients in clinical trials as it considers this to be the best management option&#46; In addition&#44; clinical trials will obviously help advance existing diagnostic tools and treatments&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients who choose the more conservative route probably do so as they consider this to be the safest route&#44; as they will not be exposed to the risks associated with SLN biopsy or CLND or new adjuvant drugs whose adverse effects and efficacy remain to be fully elucidated&#46; Considering the latest findings that do not support the use of CLND in patients with positive SLN status&#44; it is possible that we will see an increase in the percentage of melanoma patients who opt for wide excision and nodal basin ultrasound surveillance&#46; The decision not to perform SLN biopsy can also be influenced by other factors&#44; such as the patient&#8217;s age and general health status&#44; presence of the primary tumor in an area with multiple lymphatic drainage pathways&#44; and a high risk of comorbidity &#40;positive SLN in the parotid gland&#41;&#46; It should also be noted that not all patients are referred to specialist centers equipped with multidisciplinary melanoma units&#46; Many patients&#44; whether for geographic or personal reasons&#44; may decide not to travel to such centers&#44; opting instead for a local or private hospital that may not have the latest technology or tools for the diagnosis and treatment of melanoma or that may not be participating in a clinical trial&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients who for whatever reason do not undergo SLN biopsy are candidates for 1-step melanoma surgery&#46; The NCCN&#39;s recommendation for 2-step excision is based on the need to avoid disruption to lymphatic drainage patterns that could interfere with subsequent SLN identification&#46; If&#44; however&#44; there are no plans to perform SLN biopsy&#44; 1-step wide excision is perfectly feasible&#44; as it was before the advent of SLN biopsy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Noninvasive techniques such as dermoscopy or high-resolution ultrasound can help determine margin size for the excision of tumors with an unknown Breslow thickness&#46; Clear correlations have been found between thickness and certain dermoscopic and histopathologic features&#46; The irregular pigment network observed by dermoscopy&#44; for example&#44; corresponds to atypical melanocytic hyperplasia at the dermal-epidermal junction&#44; which has been shown to be common in early-stage melanoma and much rarer in thicker melanomas because of the destruction of rete ridges&#46; Blue-gray areas&#44; in turn&#44; reflect the presence of pigmented melanocytes or melanophages in the mid reticular dermis and are observed in melanomas that have reached this depth&#46; Other dermoscopic findings observed in thicker tumors are radial streaming and an atypical vascular pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Melanoma thickness measured by high-resolution ultrasound also correlates well with histologic Breslow thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The availability of ultrasound in many dermatology departments has led to an increasing use of this tool for routine preoperative assessment&#46; Integration of clinical characteristics &#40;e&#46;g&#46;&#44; macules&#44; papules&#44; nodules&#44; ulceration&#44; &#62; 4 colors&#41; and dermoscopic and ultrasound findings can provide a highly accurate estimate of tumor thickness prior to surgery&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The recommended margin sizes for wide surgical excision of melanoma according to the NCCN are 0&#46;5&#8211;1&#8239;cm for melanoma in situ&#44; 1&#8239;cm for tumors with a Breslow thickness of 1&#8239;mm or less&#44; 1&#8211;2&#8239;cm for tumors with a thickness of 1&#8211;2&#8239;mm&#44; and 2&#8239;cm for tumors with a thickness of 2&#8239;mm or more&#46; These sizes may be modified by individual anatomic or functional factors&#46; The prospective multicenter prospective trials on which the NCCN recommendations are based recommend a Breslow thickness of 2&#8239;mm as the best cutoff for deciding whether to use an excision margin of 1 or 2&#8239;cm&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In the international prospective study conducted by the World Health Organization&#44; patients with a Breslow thickness of less than 2&#8239;mm had similar survival rates regardless of the surgical margins used &#40;1&#8239;cm or larger&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Studies conducted in Sweden<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and France<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> have confirmed that excision with 1-cm margins does not affect survival in patients with melanomas with a Breslow thickness of less than 2&#8239;mm&#46; In addition&#44; a European multicenter trial found that excision with margins of over 2&#8239;cm did not provide any survival advantage to patients with a Breslow thickness of over 2&#8239;mm&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Being able to distinguish between thin melanoma &#40;Breslow thickness &#8804;&#8239;2&#8239;mm&#41; and intermediate-thickness melanomas &#40;&#62;2&#8239;mm&#41; is very useful when planning 1-step melanoma surgery&#44; as one of the limitations of dermoscopic and ultrasound evaluation is their limited ability to differentiate between melanoma in situ and thin melanoma&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Integration of clinical&#44; dermoscopic&#44; and ultrasound findings&#44; however&#44; provides a very accurate means of determining whether a melanoma has a thickness of more or less than 2&#8239;mm&#44; guiding thus the decision on whether to use surgical margins of 1 or 2&#8239;cm&#44; respectively&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Obviously&#44; this preoperative estimate is not as accurate as postoperative histologic measurement and could give rise to the use of excessively large or small margins&#46; In a recent study of 78 melanomas excised using 1-step melanoma surgery guided by high-resolution ultrasound&#44; 91&#37; of margins were found to be adequate based on subsequent histologic evaluation of Breslow thickness&#46; Just 2 of the 78 melanomas required a repeat intervention due to insufficient margins&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the above approach would result in few cases with excessively large or small margins&#44; it is worth analyzing the potential consequences&#46; Excision using 1-cm margins of a melanoma subsequently staged as in situ in the histologic examination would result in an excessive margin of 0&#46;5&#8239;cm&#46; The aesthetic consequences would be a slightly longer scar than necessary&#44; but this would be acceptable in most cases&#46; Use of 2-cm margins to remove a melanoma subsequently found to have a Breslow thickness of less than 2&#8239;mm&#44; by contrast&#44; would result in an excessive margin of 1&#8239;cm&#46; If the melanoma was located in a critical anatomic location&#44; the resulting surgical defect might need complex reconstruction&#46; In such cases&#44; it might be more sensible to perform an excisional biopsy in the event of doubt&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Use of 1-cm margins to remove a melanoma with a Breslow thickness of over 2&#8239;mm in the histologic examination would be insufficient and would require a second intervention&#46; This situation would be similar to standard 2-step surgery&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although high diagnostic accuracy for melanoma has been observed among dermatologists&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 1-step surgery should be reserved for lesions with an unequivocal clinical and dermoscopic diagnosis to prevent benign lesions from being excised with excessively large margins&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">It could be postulated that wide 1-step surgical removal of a melanoma would rule out the possibility of subsequent SLN biopsy&#44; but findings have shown that wide local excision does not affect SLN identification&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The NCCN guidelines clearly state that even though its sensitivity might be affected&#44; SLN biopsy is an option to consider after the repair of large defects using turnover flaps or grafts&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although most lesions suspicious for melanoma can be easily biopsied by excision or saucerization&#44; it is important to explain to the patient that 1-step surgery has the advantage of eliminating the need for a second procedure&#44; saving the patient thus time&#44; travel&#44; and lost hours at work and reducing by half the risk of surgical complications and discomfort associated with local anesthesia and wound dressing&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">One-step melanoma surgery also reduces costs&#44; as there is no need for a second procedure or a second histologic study&#44; which in any case&#44; has a very low diagnostic yield&#44; as additional findings are rarely observed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A re-excision procedure to widen margins can also have a psychological impact on many patients who&#44; despite having been previously informed&#44; may think that something untoward was observed in the first operation that worsened their prognosis&#44; calling for a second&#44; more complex&#44; operation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; based on current evidence&#44; 1-step melanoma surgery is a perfectly valid option for duly informed patients who opt for the more conservative approach of wide excision and close surveillance without the need for an SLN biopsy&#46; Integration of clinical&#44; dermoscopic&#44; and&#47;or ultrasound findings can be used to estimate tumor thickness &#40;&#60;&#8239;2&#8239; vs&#46; &#62;&#8239;2&#8239;mm&#41; before the operation and decide whether to use 1-cm or 2-cm margins&#44; respectively&#46; This approach avoids the need for a second operation to obtain wider margins in a high proportion of patients&#44; bringing many benefits&#46;</p></span>"
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                            2 => "M&#46;C&#46; Kelley"
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                            4 => "S&#46; Stern"
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Opinion Article
One-Step surgical removal of a cutaneous melanoma: Current evidence
Evidencia actual del tratamiento quirúrgico del melanoma cutáneo en un solo tiempo
F. Russo - de la Torre
Consulta Dermatológica, Algeciras, Cádiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The management of cutaneous melanoma has changed radically in the last 30 years&#46; While initial approaches involved wide excision with 5-cm margins and prophylactic radical lymph node dissection&#44; now the tendency is to use increasingly conservative treatments based on the findings of multicenter clinical trials&#46; New data continue to emerge that are driving changes at a dizzying speed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest version of the National Comprehensive Cancer Network &#40;NCCN&#41; guidelines on the surgical treatment of melanoma recommends narrow excision with margins of 1&#8211;3&#8239;mm followed by a second surgical intervention to widen margins following histologic determination of Breslow thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Wider margins in the initial procedure are advised against as they could alter local lymphatic drainage patterns and interfere with accurate sentinel lymph node &#40;SLN&#41; identification&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">SLN biopsy has been considered a valuable staging tool in cutaneous melanoma for many years&#44; as it provides prognostic information for patients with clinical stage I&#47;II disease &#40;without clinical or radiographic evidence of lymph node involvement&#41; and guides diagnostic and treatment decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the most important implications of SLN biopsy for melanoma management&#44; based on findings from the first multicenter selective lymphadenectomy trial &#40;MSLT I&#41;&#44; was that immediate complete lymph node dissection &#40;CLND&#41; was recommended in patients with a positive SLN biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Nonetheless&#44; the later DeCOG trial showed no significant survival advantage for CLND compared with observation only&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This lack of advantage was confirmed by the recently published findings from the second MSLT trial &#40;MSLT-II&#41; showing similar survival rates for patients with SLN positivity regardless of whether they underwent CLND or nodal basin ultrasound surveillance&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The results of the above trials led some authors to recommend replacing CLND with nodal basin ultrasound surveillance&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The 2019 NCCN guidelines mention this as an option&#44; that is&#44; they say that a patient with positive SLN status can be observed by nodal basin ultrasound&#44; without the need for CLND&#46; These recommendations have led to a dramatic reduction in the performance of CLND among patients with a positive SLN biopsy at specialized melanoma centers&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Many authors are of the opinion that if SLN biopsy is no longer needed to determine whether or not CLND is indicated&#44; then it should be purely considered a staging procedure and that its role in the management of melanoma needs to be rethought&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> SLN biopsy is starting to lose its status as a standard procedure in melanoma&#44; particularly outside the setting of clinical trials&#46; There are numerous reasons for this&#44; including false-positive and -negative rates&#44; cost&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the risk of morbidity &#40;6&#37; of patients develop lymphedema&#41;&#46; SLN biopsy may still&#44; however&#44; continue to have a role in the selection of candidates for clinical trials evaluating adjuvant therapy with new biologic drugs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This latest information should be clearly explained to patients in understandable language so that they can actively participate in decisions regarding their care&#46; The NCCN guidelines have always referred to SLN biopsy as an option that should be &#34;discussed and considered&#34;&#44; not just with members of multidisciplinary melanoma committees but also with patients&#46; The latest NCCN guidelines also mention CLND as an option to be discussed with SLN-positive patients&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Equipped with clear information about their options&#44; a considerable proportion of patients will probably choose the &#8220;interventional&#8221; route&#44; that is&#44; SLN biopsy&#44; followed or not by CLND&#44; and enrolment in a clinical trial investigating adjuvant therapy with biologics&#46; Others will choose the &#8220;conservative&#8221; route&#44; consisting of wide surgical excision &#40;without SLN biopsy&#41; and close nodal basin ultrasound surveillance&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Those who choose the first route probably consider that this is their best option&#44; as by benefiting from the latest diagnostic and treatment methods&#44; they will trust they are receiving the best possible care&#46; The NCCN strongly encourages enrolment of melanoma patients in clinical trials as it considers this to be the best management option&#46; In addition&#44; clinical trials will obviously help advance existing diagnostic tools and treatments&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients who choose the more conservative route probably do so as they consider this to be the safest route&#44; as they will not be exposed to the risks associated with SLN biopsy or CLND or new adjuvant drugs whose adverse effects and efficacy remain to be fully elucidated&#46; Considering the latest findings that do not support the use of CLND in patients with positive SLN status&#44; it is possible that we will see an increase in the percentage of melanoma patients who opt for wide excision and nodal basin ultrasound surveillance&#46; The decision not to perform SLN biopsy can also be influenced by other factors&#44; such as the patient&#8217;s age and general health status&#44; presence of the primary tumor in an area with multiple lymphatic drainage pathways&#44; and a high risk of comorbidity &#40;positive SLN in the parotid gland&#41;&#46; It should also be noted that not all patients are referred to specialist centers equipped with multidisciplinary melanoma units&#46; Many patients&#44; whether for geographic or personal reasons&#44; may decide not to travel to such centers&#44; opting instead for a local or private hospital that may not have the latest technology or tools for the diagnosis and treatment of melanoma or that may not be participating in a clinical trial&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients who for whatever reason do not undergo SLN biopsy are candidates for 1-step melanoma surgery&#46; The NCCN&#39;s recommendation for 2-step excision is based on the need to avoid disruption to lymphatic drainage patterns that could interfere with subsequent SLN identification&#46; If&#44; however&#44; there are no plans to perform SLN biopsy&#44; 1-step wide excision is perfectly feasible&#44; as it was before the advent of SLN biopsy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Noninvasive techniques such as dermoscopy or high-resolution ultrasound can help determine margin size for the excision of tumors with an unknown Breslow thickness&#46; Clear correlations have been found between thickness and certain dermoscopic and histopathologic features&#46; The irregular pigment network observed by dermoscopy&#44; for example&#44; corresponds to atypical melanocytic hyperplasia at the dermal-epidermal junction&#44; which has been shown to be common in early-stage melanoma and much rarer in thicker melanomas because of the destruction of rete ridges&#46; Blue-gray areas&#44; in turn&#44; reflect the presence of pigmented melanocytes or melanophages in the mid reticular dermis and are observed in melanomas that have reached this depth&#46; Other dermoscopic findings observed in thicker tumors are radial streaming and an atypical vascular pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Melanoma thickness measured by high-resolution ultrasound also correlates well with histologic Breslow thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The availability of ultrasound in many dermatology departments has led to an increasing use of this tool for routine preoperative assessment&#46; Integration of clinical characteristics &#40;e&#46;g&#46;&#44; macules&#44; papules&#44; nodules&#44; ulceration&#44; &#62; 4 colors&#41; and dermoscopic and ultrasound findings can provide a highly accurate estimate of tumor thickness prior to surgery&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The recommended margin sizes for wide surgical excision of melanoma according to the NCCN are 0&#46;5&#8211;1&#8239;cm for melanoma in situ&#44; 1&#8239;cm for tumors with a Breslow thickness of 1&#8239;mm or less&#44; 1&#8211;2&#8239;cm for tumors with a thickness of 1&#8211;2&#8239;mm&#44; and 2&#8239;cm for tumors with a thickness of 2&#8239;mm or more&#46; These sizes may be modified by individual anatomic or functional factors&#46; The prospective multicenter prospective trials on which the NCCN recommendations are based recommend a Breslow thickness of 2&#8239;mm as the best cutoff for deciding whether to use an excision margin of 1 or 2&#8239;cm&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In the international prospective study conducted by the World Health Organization&#44; patients with a Breslow thickness of less than 2&#8239;mm had similar survival rates regardless of the surgical margins used &#40;1&#8239;cm or larger&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Studies conducted in Sweden<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and France<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> have confirmed that excision with 1-cm margins does not affect survival in patients with melanomas with a Breslow thickness of less than 2&#8239;mm&#46; In addition&#44; a European multicenter trial found that excision with margins of over 2&#8239;cm did not provide any survival advantage to patients with a Breslow thickness of over 2&#8239;mm&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Being able to distinguish between thin melanoma &#40;Breslow thickness &#8804;&#8239;2&#8239;mm&#41; and intermediate-thickness melanomas &#40;&#62;2&#8239;mm&#41; is very useful when planning 1-step melanoma surgery&#44; as one of the limitations of dermoscopic and ultrasound evaluation is their limited ability to differentiate between melanoma in situ and thin melanoma&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Integration of clinical&#44; dermoscopic&#44; and ultrasound findings&#44; however&#44; provides a very accurate means of determining whether a melanoma has a thickness of more or less than 2&#8239;mm&#44; guiding thus the decision on whether to use surgical margins of 1 or 2&#8239;cm&#44; respectively&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Obviously&#44; this preoperative estimate is not as accurate as postoperative histologic measurement and could give rise to the use of excessively large or small margins&#46; In a recent study of 78 melanomas excised using 1-step melanoma surgery guided by high-resolution ultrasound&#44; 91&#37; of margins were found to be adequate based on subsequent histologic evaluation of Breslow thickness&#46; Just 2 of the 78 melanomas required a repeat intervention due to insufficient margins&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the above approach would result in few cases with excessively large or small margins&#44; it is worth analyzing the potential consequences&#46; Excision using 1-cm margins of a melanoma subsequently staged as in situ in the histologic examination would result in an excessive margin of 0&#46;5&#8239;cm&#46; The aesthetic consequences would be a slightly longer scar than necessary&#44; but this would be acceptable in most cases&#46; Use of 2-cm margins to remove a melanoma subsequently found to have a Breslow thickness of less than 2&#8239;mm&#44; by contrast&#44; would result in an excessive margin of 1&#8239;cm&#46; If the melanoma was located in a critical anatomic location&#44; the resulting surgical defect might need complex reconstruction&#46; In such cases&#44; it might be more sensible to perform an excisional biopsy in the event of doubt&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Use of 1-cm margins to remove a melanoma with a Breslow thickness of over 2&#8239;mm in the histologic examination would be insufficient and would require a second intervention&#46; This situation would be similar to standard 2-step surgery&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although high diagnostic accuracy for melanoma has been observed among dermatologists&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 1-step surgery should be reserved for lesions with an unequivocal clinical and dermoscopic diagnosis to prevent benign lesions from being excised with excessively large margins&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">It could be postulated that wide 1-step surgical removal of a melanoma would rule out the possibility of subsequent SLN biopsy&#44; but findings have shown that wide local excision does not affect SLN identification&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The NCCN guidelines clearly state that even though its sensitivity might be affected&#44; SLN biopsy is an option to consider after the repair of large defects using turnover flaps or grafts&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although most lesions suspicious for melanoma can be easily biopsied by excision or saucerization&#44; it is important to explain to the patient that 1-step surgery has the advantage of eliminating the need for a second procedure&#44; saving the patient thus time&#44; travel&#44; and lost hours at work and reducing by half the risk of surgical complications and discomfort associated with local anesthesia and wound dressing&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">One-step melanoma surgery also reduces costs&#44; as there is no need for a second procedure or a second histologic study&#44; which in any case&#44; has a very low diagnostic yield&#44; as additional findings are rarely observed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A re-excision procedure to widen margins can also have a psychological impact on many patients who&#44; despite having been previously informed&#44; may think that something untoward was observed in the first operation that worsened their prognosis&#44; calling for a second&#44; more complex&#44; operation&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; based on current evidence&#44; 1-step melanoma surgery is a perfectly valid option for duly informed patients who opt for the more conservative approach of wide excision and close surveillance without the need for an SLN biopsy&#46; Integration of clinical&#44; dermoscopic&#44; and&#47;or ultrasound findings can be used to estimate tumor thickness &#40;&#60;&#8239;2&#8239; vs&#46; &#62;&#8239;2&#8239;mm&#41; before the operation and decide whether to use 1-cm or 2-cm margins&#44; respectively&#46; This approach avoids the need for a second operation to obtain wider margins in a high proportion of patients&#44; bringing many benefits&#46;</p></span>"
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Article information
ISSN: 15782190
Original language: English
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Idiomas
Actas Dermo-Sifiliográficas
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