Surgical Treatment Of Melanoma, Search For Sentinel Lymph and lymph node dissection
The treatment of choice for primary melanoma is surgical excision of the tumor with a margin of skin unscathed, with his achievement in depth without removal of the fascia. The removal is performed under local anesthesia. Currently, for patients with lesions from 0.75 to 4 mm thickness, performing sentinel node biopsy and possible, if positive, selective lymph node dissection. The appearance of lymph node metastases is a relatively frequent occurrence, and closely related to the thickness of the tumor. About 60% of patients with Breslow comprised between 2 and 4 mm, in particular when there is ulceration of the primary tumor or this is ulcerated or nodular type, is at risk of developing metastases to locoregional lymph nodes.
The introduction of the sentinel node technique seems to have solved these problems effectively eliminating a lymphadenectomy of choice, that in 80% of patients would prove an intervention not clinically useful for patient survival, also burdened with complications and functional sequelae sometimes disabling. The technique, now standardized, makes use of the injection, a few hours before the operation, at the site of excision of the primary lesion, a tracer substance that spreads along the lymphatics to selectively “sentinel lymph node” (the first lymph node draining the lesion ), and whose migration is recorded by a gamma camera. At the time of the labeled lymph node it is located and identified with the gamma camera. This method is combined injection in melanoma headquarters, a few minutes before the intervention, the vital dye that, following the lymphatic pathways, go to color the sentinel node. The therapeutic lymph node dissection is performed after joint evaluation with the reference oncologist, in the case of positive sentinel node micrometastases for clinical or lymph node metastases. Prophylactic lymph node dissection is no longer performed for <4mm thick tumors. The randomized trials conducted to date have failed to demonstrate a significant difference in survival. It is therefore resorts to the therapeutic dissection only in case of real nodal metastases. In this case, the surgery of regional lymph node dissection is an intervention that requires precise timing, accuracy by the surgeon because potentially affected by non-negligible complications. The lymph nodes that may be affected by the treatment of excision, in relation to the primary tumor site are the ‘inguinal-iliac-obturator (superficial and deep groin was not considered sufficient as an extension), the axillary and lateral cervical . The surgical technique required in order to consider the radical intervention, ie to gain the minimum percentage of regional recurrence, varies widely in the literature, it is now well defined and standardized. This has meant that complications are also acceptable. In particular, the infection of the wound in the literature has a frequency between 9-20%; skin necrosis between 0-15%; the appearance of lymphocele and / or lymphorrhagia between 6-17%; while the most feared late complication and disabling lymphedema, frequently appears significantly for mild to moderate (19-44%) for much less severe (less than 7%).
Once formulated the diagnosis of melanoma, it is necessary to determine whether the cancer is localized at the site of biopsy or spread to other organs, since the therapeutic program should be defined based on the extent of the disease. To this can be generally referred to X-rays, ultrasounds, CT scans, PET and / or other investigations. As with any cancer, the treatment of melanoma depends on the stage of the disease and may include surgery, chemotherapy, immunotherapy and / or radiotherapy.
1. Melanoma localized. Melanoma localized only to the skin is treated with surgical removal of the tumor with a “safety margin” of healthy skin around the lesion to ensure that all cancer cells have been removed. The extent of the “safety margin” depends on the thickness of the tumor and its location. In some cases it may be necessary to match a plastic surgery with the creation of a skin flap or skin graft from other parts of the body, to replenish the skin continuity in the venue where the removal of melanoma occurred. Melanoma can give metastases. In the case of cutaneous melanomas with an infiltration depth greater than a millimeter, or ulcerated or nodular with a number of mitosis> 1, is performed sentinel node biopsy for early identification of the presence of cancer cells in / the node / s that drain the area where the tumor has grown. The sentinel lymph node is then removed and analyzed by the histological point of view to determine the presence of melanoma metastatic cells. If cancer cells are found in the sentinel node, they are then removed all the lymph nodes in the region. Knowledge of the status of the sentinel node is also important to assess the risk of recurrence. The greatest risk is has on thick melanomas than 1.5 mm (around 25% positivity). This percentage rises to 60% in thickness of melanomas greater than 4.
2. Metastatic Melanoma. The treatment of advanced or metastatic melanoma, which spread to nearby lymph nodes, skin or other distant organs, may provide a combination of surgery, chemotherapy, immunotherapy and / or radiation therapy, even in the context of clinical research programs.
Chemotherapy is playing a central role in the treatment of metastatic melanoma. It is a systemic therapy, administered intravenously. It includes various drugs, which can be used individually or in combination depending on the stages of the disease, of any previous treatments and the patient’s general condition. In many cases chemotherapy can be associated to immunotherapy.
Immunotherapy is a treatment capable of activating the patient’s immune system in fighting against melanoma. In most cases it is associated to chemotherapy. It was recently made available a new drug that is giving good results, ipilimumab, which is administered individually (without attaching chemotherapy) in patients who have received prior chemotherapy.
Radiation therapy for advanced melanoma can be used alone or in combination with other treatments, such as surgery, chemioterapiaco and imunoterapico.
The subjects who had the removal of a melanoma are treated with regular medical visits and check-ups.