A 40-yrs-old woman undergoes wide excision of a pigmented

Discussion in 'MRCS Forum' started by Lona., Dec 15, 2007.

  1. Lona.

    Lona. Guest

    A 40-yrs-old woman undergoes wide excision of a pigmented lesion of her thigh. Pathologic examination reveals malignant melanoma that is Clark’s level IV. Findings on examination of the groin are normal. The patient should be advised that -
    a- Radiotherapy will be an important part of subsequent therapy
    b- The likelihood of groin node metastases is remote
    c- Immunotherapy is an effective from of adjunctive treatment for metastatic malignant melanoma
    d- Groin dissection is not indicated unless and until groin nodes become palpable
    e- Intralesional bacilli Calmette-Guerin (BCG) administration has been found to aid in local control in the majority of patients
  2. Lona.

    Lona. Guest

    Answer: d. (Greenfield, 2/E, PP 2231-2242) The survival of patients with malignant melanoma correlates with the depth of invasion (Clark) and the thickness of the lesion (Breslow). It is widely held that patients with thin lesions (<0.76 mm) and Clark level I and II lesions are adequately managed by wide local excision. The incidence of nodal metastases rises with increasing Clark level of invasion such that a level IV lesion has a 30 to 50% incidence of nodal metastases. The assumption that removal of microscopic foci of disease is beneficial, in conjunction with retrospective data indicating improved survival in patients who have undergone removal of clinically negative but pathologically positive nodes, has led to the widely held belief that prophylactic node dissections are indicated for melanoma. Prospective data has challenged this concept. Veronesi and Sim have found that patients undergoing prophylactic node dissections survived no longer than those who were followed closely and underwent node dissections only after nodes became palpable. The subject remains controversial, and further study and follow-up are necessary. Immunotherapy has not been successful in controlling widespread metastatic melanoma even when added to chemotherapy. Intralesional administration of BCG has been demonstrated to control local skin lesions in only 20% of patients. Dinitrochlorobenzene (DNCB) can also be used.

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