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Case History

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Image not available. A 50-year-old man presents with an ulcerated lesion on his shoulder and an axillary mass. Excision biopsy of the lesion reveals a 5 mm Breslow thickness nodular melanoma, and axillary dissection reveals 4/15 lymph nodes positive for melanoma, with no extracapsular spread. He has been referred for consideration of adjuvant treatment.

What is the recommended excision margin for the primary melanoma?

What are the surgical considerations regarding wider excision of this lesion?

If there is no disease elsewhere, what is this patient's prognosis?

What is the evidence for activity of low-dose, medium-dose and high-dose interferon in melanoma?

What are the short-term and long-term side effects of high-dose interferon?

Should this patient have adjuvant axillary radiotherapy?

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Background

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What is the recommended excision margin for the primary melanoma?

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Image not available. The recommended excision margin is 2 cm. Two trials were conducted in patients with melanomas Image not available.2 mm, the World Health Organization (WHO) trial1 compared margins of 1 cm and 3 cm and the Swedish Melanoma Group trial2 compared margins of 2 cm and 5 cm. The Intergroup trial3 randomized patients with 1–4 mm melanomas to 2 cm and 4 cm margins. There were no differences in local recurrence, disease-free survival and overall survival between the narrow and wide excision groups. A UK-MSG trial4 compared 1 cm and 3 cm margins for melanomas >2 mm and showed higher rates of local recurrence in the 1 cm margin arm but no difference in overall survival. Therefore, a 1 cm margin is adequate for melanomas Image not available.2 mm and a 2 cm margin for melanomas >2 mm.

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What are the surgical considerations regarding wider excision of this lesion?

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Wide excision of the shoulder lesion with a 2 cm margin may risk cosmetic morbidity and functional loss, and require skin grafting. Similarly, the axillary dissection may result in lymphoedema, cosmetic disfigurement and functional loss.

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If there is no disease elsewhere, what is this patient's prognosis?

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The patient has T4 N3 M0 stage IIIc disease and the corresponding 5-year and 10-year overall survival rates are 26.7% ± 2.5% and 18.4% ± 2.5% (Table 29.1).5

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Table Graphic Jump Location
Table 29.1Survival rates for melanoma TNM and staging categories

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