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Case History

Image not available. A 28-year-old woman who is 14 weeks pregnant with her first child presents with an enlarging pigmented lesion on her lower leg which has bled on several occasions. Excision biopsy under local anaesthetic reveals an ulcerated nodular malignant melanoma of 3.6 mm Breslow thickness, with excision margins of less than 3 mm.

What should be the further surgical management?

What staging investigations should she have?

What are the implications for her pregnancy?

How will her pregnancy influence her prognosis?

Background

What should be the further surgical management?

Image not available. This patient has a T3b primary lesion. Although she is pregnant, appropriate surgery at the site of the primary lesion should not be delayed. She requires a wide local excision (WLE) of the primary lesion. Wide excision minimizes the risk of leaving behind malignant cells that may locally recur or metastasize. Risk factors for local recurrence are thick primaries, ulceration and head and neck primaries.1 Inappropriately large excisions may lead to cosmetic disfigurement, functional deficits and require major surgery with skin grafting, therefore a minimal (but appropriate) excision margin is essential. The recommended excision margin in this case is 2 cm (see Chapter 29) to the level of the deep fascia with a split skin graft or flap. This may be done under local anaesthestic.

The management of the lymph node basin for T2–3 lesions remains an area of controversy. The rationale that early removal of subclinically involved nodes is superior to removal once obvious nodal disease develops is supported by several retrospective studies showing that 5-year survival rates improved in patients with intermediate thickness lesions. Subsequent prospective studies including the World Health Organization (WHO) trial,2 the Intergroup Melanoma trial3 and a systematic review4 have shown that elective lymph node dissection (ELND) compared with delayed node dissection had no effect on survival.

ELND is associated with considerable morbidity with overall reported rates of wound morbidity, infection, lymphoedema and delayed healing between 35% and 51% in the axilla and 25–90% in the inguinal region. A post hoc subgroup analysis in the WHO trial showed that patients with positive nodes on ELND had a marked survival advantage over the group with positive nodes and a delayed LND but 80% of patients who received ELND did not have nodal metastases and therefore only 20% receiving ELND may have benefited. These findings support use of sentinel node biopsy (SNB) to identify patients with a high risk of nodal disease. Several small studies have shown that SNB is a highly sensitive and specific test for nodal staging and SLN status is a powerful independent factor predicting survival.5

Several confirmatory randomized trials of SNB are ongoing. The MSLT-1 trial compared WLE/SNB with WLE alone; patients with positive SNB underwent immediate LND and the WLE-alone arm underwent delayed LND after clinical detection of nodal disease. ...

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