One Step Melanoma Surgery for Patient with Thick Primary Melanomas: "To Break the Rules, You Must First Master Them!"

  • Georgi Tchernev Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology, Venereology and Dermatologic Surgery, General Skobelev 79, 1606, Sofia; Onkoderma-Policlinic for Dermatology, Venereology and Dermatologic Surgery, General Skobelev 26, 1606 Sofia
Keywords: melanoma, congenital nevus, confocal, surgery, survival benefit


BACKGROUND: We present to the attention of the medical, dermatological and oncosurgical community data that serves to indicate the indispensability of optimisation of the algorithm and recommendations for diagnosis and surgical treatment of cutaneous melanoma. These recommendations could be referred to different subgroups of patients in different clinical stages as well as to patients with different initial characterisation (histological morphology) of the primary tumours. One step surgery is not a myth, even more, it could prove to be one of the best solutions for some patient collectives with advanced stages of melanoma.

CASE REPORT: We present a case of a 74 - year old patient with a congenital medium sized melanocytic nevus, located directly above the lateral part of the elbow joint. In one month and a half, an achromatic nodular formation evolves with a diameter of 2.7 x 2.3 cm, prominent over the skin level, painful by palpation and spontaneously bleeding. By the anamnestic, clinical and dermoscopic findings the patient was diagnosed with nodular melanoma associated with a congenital medium sized melanocytic nevus. A primary excision with a field of safety 0.5 cm in all directions was performed. After confirmation of the primary diagnosis (tumour thickness 8 mm with no ultrasonographic detection of enlarged lymph nodes), seven days later are - excision was performed with an additional field of surgical safety of 1.5 cm in all directions.

CONCLUSIONS: In this case remains unclear the following question: For what reason a preoperative high - frequent ultrasonography (HFUS) is not recommended to be used as it will allow only one surgical excision with the elimination of a tumour with a safety field of 2cm in all directions? The enigma about the obstacles preventing such a rational optimisation of the current diagnostic and therapeutic algorithm in patients with melanomas remains unresolved. One step surgery for cutaneous melanoma is widely used in many countries although it continues to be considered as a matter of dispute for some experts. Once again, by a clinical case and the following analysis, we would like to focus the attention of the dermatosurgical community on this crucial and highly significant problem. Innovations are very often resulting from the simplicity of logic, which unfortunately is not always accepted appropriately.


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Tannous ZS, Mihm MC Jr, Sober AJ, Duncan LM. Congenital melanocytic nevi: clinical and histopathologic features, risk of melanoma, and clinical management. J Am Acad Dermatol. 2005; 52(2):197-203. PMid:15692463

Nikfarjam J, Chambers E. Congenital melanocytic nevi and the risk of malignant melanoma: establishing a guideline for primary-care physicians. Einstein J Biol Med. 2011; 27(2):59.

Kovalyshyn I, Braun R, Marghoob A. Congenital melanocytic naevi. Australas J Dermatol. 2009; 50:231–240. PMid:19916964

Alikhan A, Ibrahimi OA, Eisen DB. Congenital melanocytic nevi: where are we now? Part I. Clinical presentation, epidemiology, pathogenesis, histology, malignant transformation, and neurocutaneous melanosis. J Am Acad Dermatol. 2012; 67(4):495.e1-17; quiz 512-4.

Shah J, Feintisch AM, Granick MS. Congenital Melanocytic Nevi. Eplasty. 2016; 16:ic4. PMid:26904155 PMCid:PMC4740346

Rhodes AR. Melanocytic precursors of cutaneous melanoma. Estimated risks and guidelines for management. Med Clin North Am. 1986; 70(1):3-37.

Viana AC, Gontijo B, Bittencourt FV. Giant congenital melanocytic nevus. An Bras Dermatol. 2013;88(6):863-78. Erratum in: An Bras Dermatol. 2014; 89(1):190. PMid:24474093 PMCid:PMC3900335

Natarajan K, Arunachalam P, Sundar D, Srinivas CR. Congenital Melanocytic Nevi: Catch Them Early! Journal of Cutaneous and Aesthetic Surgery. 2013; 6(1):38-40. PMid:23723605 PMCid:PMC3663176

Mooi WJ, Krausz T. Biopsy Pathology of Melanocytic Disorders. 1st ed. New York: A Hodder Arnold Publication, 1992.

McCarthy SW, Scolyer RA. Pitfalls and Important Issues in the Pathologic Diagnosis of Melanocytic Tumors. The Ochsner Journal. 2010; 10(2):66-74. PMid:21603360 PMCid:PMC3096206

Bastian BC, Xiong J, Frieden IJ, Williams ML, Chou P, Busam K, Pinkel D,LeBoit PE. Genetic changes in neoplasms arising in congenital melanocytic nevi:differences between nodular proliferations and melanomas. Am J Pathol. 2002; 161(4):1163-9.

Rigel DS, Russak, J and Friedman, R. The Evolution of Melanoma Diagnosis: 25 Years Beyond the ABCDs. CA: A Cancer Journal for Clinicians. 2010; 60: 301–316.

Debarbieux S, Depaepe L, Poulalhon N, Balme B, Dalle S, Thomas L. Reflectance confocal microscopy accurately discriminates between benign and malignant melanocytic lesions exhibiting a 'dermoscopic island'. J Eur Acad Dermatol Venereol. 2013; 27(2):e159-65. PMid:22486883

Scope A, Benvenuto-Andrade C, Agero AL, Halpern AC, Gonzalez S, Marghoob AA.Correlation of dermoscopic structures of melanocytic lesions to reflectance confocal microscopy. Arch Dermatol. 2007; 143(2):176-85. PMid:17309998

Wielowieyska-Szybińska D, Białek-Galas K, Podolec K, Wojas-Pelc A. The use of reflectance confocal microscopy for examination of benign and malignant skin tumors. Advances in Dermatology and Allergology/Postȩpy Dermatologii i Alergologii. 2014; 31(6):380-387. PMid:25610353 PMCid:PMC4293386

González S. Confocal reflectance microscopy in dermatology: promise and reality of non-invasive diagnosis and monitoring. Actas Dermosifiliogr. 2009; 100(Suppl 2):59-69.

Guida S, Longo C, Casari A, Ciardo S, Manfredini M, Reggiani C, Pellacani G, Farnetani F. Update on the use of confocal microscopy in melanoma and non-melanoma skin cancer. G Ital Dermatol Venereol. 2015; 150(5):547-63. PMid:26140397

Alarcon I, Carrera C, Palou J, Alos L, Malvehy J, Puig S. Impact of in vivo reflectance confocal microscopy on the number needed to treat melanoma in doubtful lesions. Br J Dermatol. 2014; 170(4):802-8. PMid:24124911 PMCid:PMC3984366

Silva JH, de Sá BCS, de Ãvila ALR, Landman G, Neto JPD. Atypical mole syndrome and dysplastic nevi: identification of populations at risk for developing melanoma - review article. Clinics. 2011; 66(3):493-499. PMid:21552679 PMCid:PMC3072014

Goldstein AM, Tucker MA. Dysplastic Nevi and Melanoma. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2013; 22(4):528-532. PMid:23549396 PMCid:PMC3616416

Zaal LH, Mooi WJ, Sillevis Smitt JH, van der Horst CM. Classification of congenital melanocytic naevi and malignant transformation: a review of the literature. Br J Plast Surg. 2004; 57(8):707-19. PMid:15544766

Roh MR, Eliades P, Gupta S, Tsao H. Genetics of Melanocytic Nevi. Pigment cell & melanoma research. 2015; 28(6):661-672. PMid:26300491 PMCid:PMC4609613

Bloethner S, Snellman E, Bermejo JL, Hiripi E, Gast A, Thirumaran RK, Wellenreuther R, Hemminki K, Kumar R. Differential gene expression in melanocytic nevi with the V600E BRAF mutation. Genes, chromosomes & cancer. 2007; 46:1019–1027. PMid:17696195

Zbytek B, Carlson JA, Granese J, Ross J, Mihm MC, Slominski A. Current concepts of metastasis in melanoma. Expert review of dermatology. 2008; 3(5):569-585. PMid:19649148 PMCid:PMC2601641

Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Annals of Surgery. 1970; 172(5):902-908. PMid:5477666 PMCid:PMC1397358

Tchernev G. One Step Surgery for Cutaneous Melanoma: "We Cannot Solve Our Problems with the Same Thinking We Used When We Created Them?" Open Access Maced J Med Sci. 2017; 5(6):774-776.

Cinotti E, Perrot JL, Labeille B, Adegbidi H, Cambazard F. Reflectance confocal microscopy for the diagnosis of vulvar melanoma and melanosis: preliminary results. Dermatol Surg. 2012; 38(12):1962-7. PMid:23127153

Lazarou I, Purek L, Duc C, Licker M-J, Spiliopoulos A, Tschopp J-M. Primary malignant achromic melanoma of the lung. Thoracic Cancer. 2014; 5(1):85-88. PMid:26766979 PMCid:PMC4704277

How to Cite
Tchernev G. One Step Melanoma Surgery for Patient with Thick Primary Melanomas: "To Break the Rules, You Must First Master Them!". Open Access Maced J Med Sci [Internet]. 2018Feb.9 [cited 2020Dec.2];6(2):367-71. Available from:
C- Case Reports