An incidental finding

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An incidental finding

J Fam Pract. 2013 November;62(11):655-659

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References

1. Fleischer AB, Feldman SR, Clayton E, et al. Melanoma. In: Hefta J, Noujaim SR, Edmonson KG, eds. 20 Common Problems in Dermatology. 1st ed. New York, NY: McGraw-Hill; 2000:201-217.

2. James WD, Berger TG, Elston DM. Melanoma (malignant melanoma). In: James WD, Berger TG, Elston DM, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006:694-699.

3. Marks JG, Miller JJ. Malignant melanoma. In: Marks JG, Miller JJ, Lookingbill DP, eds. Principles of Dermatology. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2006:78-81.

4. Shenenberger DW. Cutaneous malignant melanoma: a primary care perspective. Am Fam Physician. 2012;85:161-168.

5. Melanoma surveillance in the United States. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/cancer/skin/what_cdc_is_doing/melanoma_supplement.htm. Accessed October 11, 2013.

6. Bleyer A, O’Leary M, Barr R, et al, eds. Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. Bethesda, MD: National Cancer Institute, NIH Pub. No. 06-5767; 2006.

7. Usatine RP, Pfenninger JL, Stulberg DL, et al. Choosing the biopsy type. In: Usatine RP, Pfenninger, JL, Stulberg DL, et al, eds. Dermatologic and Cosmetic Procedures in Office Practice. 1st ed. Philadelphia, Pa: Elsevier; 2011: 75.

8. Usatine RP, Pfenninger JL, Stulberg DL, et al. The shave biopsy. In: Usatine RP, Pfenninger, JL, Stulberg DL, et al, eds. Dermatologic and Cosmetic Procedures in Office Practice. 1st ed. Philadelphia, Pa: Elsevier; 2011: 88.

9. Weber, JS. A New Era Approaches: Anti-CTLA-4 Monoclonal Antibodies for the Treatment of Malignant Melanoma. Medscape Education Web site. Available at: http://www.medscape.org/viewprogram/17800. Accessed July 7, 2012.

10. Shao Y, Aplin AE. Akt3-mediated resistance to apoptosis in B-RAF-targeted melanoma cells. Cancer Res. 2010;70:6670-6681.

11. Hatzivassiliou G, Song K, Yen I, et al. RAF inhibitors prime wild-type RAF to activate the MAPK pathway and enhance growth. Nature. 2010;464:431-435.

12. Halaban R, Zhang W, Bacchiocchi A, et al. PLX4032, a selective BRAF(V600E) kinase inhibitor, activates the ERK pathway and enhances cell migration and proliferation of BRAF melanoma cells. Pigment Cell Melanoma Res. 2010;23:190-200.

13. Flaherty KT, Puzanov I, Kim KB, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med. 2010;363:809-819.

14. Ribas A. Tumor immunotherapy directed at PD-1. N Engl J Med. 2012;366:2517-2519.

A deep shave biopsy is less time consuming than elliptical excision, making it easier to perform at the time the lesion is first evaluated. Deep shave biopsy may provide several benefits, including reducing the amount of normal tissue that is removed (especially if pathology is benign) as well as, the cost, scarring, and likelihood of wound infections. Deep shave biopsy also can avoid the need for a second elliptical excision.^7,8

Determine margins, proceed with surgical excision
Early surgical excision is the primary treatment for malignant melanoma. After the diagnosis is confirmed by initial biopsy, the depth of the lesion dictates the surgical recommendations. Recommended surgical margins based on depth are: 5 mm with a layer of subcutaneous fat for melanoma in situ, 1 cm down to the fascia for lesions with a Breslow depth ≤2 mm, and 2 cm down to the fascia for lesions with a depth >2 mm.^1,4

The surgical treatment of lentigo maligna melanoma can be challenging due to indistinct borders and large size. Mohs micrographic surgery can be helpful to fully remove the lesion with sparing of healthy surrounding tissue.⁴ When surgical excision of large lentigo maligna is technically difficult, radiation therapy is another option.³

Subungual melanoma may necessitate amputation or grafting of the digit. Mohs micrographic surgery can be useful in these situations for tissue sparing.² (To learn more, see “When to consider Mohs surgery,” J Fam Pract. 2013;558-564.)

Is a sentinel lymph node biopsy needed?
Sentinel lymph node biopsy is often recommended for melanomas >1 mm in depth.^2-4 It provides guidance on who may benefit from regional lymphadenectomy and adjuvant immunotherapy.^1,3

Adjuvant therapy for patients without evidence of distant metastases can be considered in patients with positive nodes or node-negative melanoma that is 4 mm thick or Clark Level IV or V. Adjuvant high-dose interferon alpha-2b is the most commonly used agent in these situations.² Some studies suggest an increase in median overall survival of up to 11 months with high-dose interferon as compared to no treatment.³ Limitations include toxicity from these high-dose regimens.³ Treatment with interferon does not represent a cure; rather, it should be considered a palliative intervention with marginal benefit.¹