Skip to main content
SpringerLink
Log in

Primary Melanoma Treatment

  • Chapter
  • First Online:
Practical Manual for Dermatologic and Surgical Melanoma Management

  • 385 Accesses

Abstract

An improved understanding of the clinical behavior and molecular biology of melanoma has led to multiple practice-changing advancements in recent decades. Nevertheless, the gold standard for primary melanoma treatment, in most cases, continues to be complete surgical removal of the tumor with a wide excision. Data from multiple prospective randomized trials have led to the development of evidence-based clinical recommendations for melanoma resection margins that are based on a lesion’s Breslow depth. Although resection presents the most effective means of local disease control, some patients are not surgical candidates for a variety of anatomic, cosmetic, or medical reasons. These patients may benefit from non-operative treatment options, which including topical therapies, intralesional injections, radiation therapy, and systemic therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7–30.

    Article  PubMed  Google Scholar 

  2. Balch CM. Microscopic satellites around a primary melanoma: another piece of the puzzle in melanoma staging. Ann Surg Oncol. 2009;16(5):1092–4.

    Article  PubMed  Google Scholar 

  3. Balch CM, Balch GC, Thompson JF. Biopsy and definitive excision of primary cutaneous melanoma. In: Morita SY, Balch CM, Klimberg V, Pawlik TM, Posner MC, Tanabe KK, editors. Textbook of complex general surgical oncology. New York: McGraw-Hill; 2018.

    Google Scholar 

  4. Breslow A, Macht SD. Optimal size of resection margin for thin cutaneous melanoma. Surg Gynecol Obstet. 1977;145(5):691–2.

    CAS  PubMed  Google Scholar 

  5. Veronesi U, Cascinelli N, Adamus J, et al. Thin stage I primary cutaneous malignant melanoma. Comparison of excision with margins of 1 or 3 cm. N Engl J Med. 1988;318(18):1159–62.

    Article  CAS  PubMed  Google Scholar 

  6. Veronesi U, Cascinelli N. Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. Arch Surg. 1991;126(4):438–41.

    Article  CAS  PubMed  Google Scholar 

  7. Ringborg U, Andersson R, Eldh J, et al. Resection margins of 2 versus 5 cm for cutaneous malignant melanoma with a tumor thickness of 0.8 to 2.0 mm: randomized study by the Swedish Melanoma Study Group. Cancer. 1996;77(9):1809–14.

    Article  CAS  PubMed  Google Scholar 

  8. Cohn-Cedermark G, Rutqvist LE, Andersson R, et al. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0 mm. Cancer. 2000;89(7):1495–501.

    Article  CAS  PubMed  Google Scholar 

  9. Khayat D, Rixe O, Martin G, et al. Surgical margins in cutaneous melanoma (2 cm versus 5 cm for lesions measuring less than 2.1-mm thick). Cancer. 2003;97(8):1941–6.

    Article  PubMed  Google Scholar 

  10. Balch CM, Urist MM, Karakousis CP, et al. Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multi-institutional randomized surgical trial. Ann Surg. 1993;218(3):262–7; discussion 267–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Balch CM, Soong SJ, Smith T, et al. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. Ann Surg Oncol. 2001;8(2):101–8.

    CAS  PubMed  Google Scholar 

  12. Thomas JM, Newton-Bishop J, A’Hern R, et al. Excision margins in high-risk malignant melanoma. N Engl J Med. 2004;350(8):757–66.

    Article  CAS  PubMed  Google Scholar 

  13. Hayes AJ, Maynard L, Coombes G, et al. Wide versus narrow excision margins for high-risk, primary cutaneous melanomas: long-term follow-up of survival in a randomised trial. Lancet Oncol. 2016;17(2):184–92.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gillgren P, Drzewiecki KT, Niin M, et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: a randomised, multicentre trial. Lancet. 2011;378(9803):1635–42.

    Article  PubMed  Google Scholar 

  15. Pasquali S, Haydu LE, Scolyer RA, et al. The importance of adequate primary tumor excision margins and sentinel node biopsy in achieving optimal locoregional control for patients with thick primary melanomas. Ann Surg. 2013;258(1):152–7.

    Article  PubMed  Google Scholar 

  16. Koskivuo I, Giordano S, Verajankorva E, Vihinen P. One-cm versus 2-cm excision margins for patients with intermediate thickness melanoma: a matched-pair analysis. Dermatol Surg. 2015;41(10):1130–6.

    Article  CAS  PubMed  Google Scholar 

  17. Hunger RE, Angermeier S, Seyed Jafari SM, Ochsenbein A, Shafighi M. A retrospective study of 1- versus 2-cm excision margins for cutaneous malignant melanomas thicker than 2 mm. J Am Acad Dermatol. 2015;72(6):1054–9.

    Article  PubMed  Google Scholar 

  18. MacKenzie Ross AD, Haydu LE, Quinn MJ, et al. The association between excision margins and local recurrence in 11,290 thin (T1) primary cutaneous melanomas: a case-control study. Ann Surg Oncol. 2016;23(4):1082–9.

    Article  PubMed  Google Scholar 

  19. Haydu LE, Stollman JT, Scolyer RA, et al. Minimum safe pathologic excision margins for primary cutaneous melanomas (1–2 mm in thickness): analysis of 2131 patients treated at a single center. Ann Surg Oncol. 2016;23(4):1071–81.

    Article  PubMed  Google Scholar 

  20. NCCN clinical practice guidelines in oncology: cutaneous melanoma version 1.2019. 2018. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Accessed 28 Dec 2018.

  21. Clausen SP, Brady MS. Surgical margins in patients with cutaneous melanoma—assessing the adequacy of excision. Melanoma Res. 2005;15(6):539–42.

    Article  PubMed  Google Scholar 

  22. National Institutes of Health Consensus Development Conference statement on diagnosis and treatment of early melanoma, January 27–29, 1992. Am J Dermatopathol. 1993;15(1):34–43; discussion 46–51.

    Google Scholar 

  23. Felton S, Taylor RS, Srivastava D. Excision margins for melanoma in situ on the head and neck. Dermatol Surg. 2016;42(3):327–34.

    Article  CAS  PubMed  Google Scholar 

  24. Duffy KL, Truong A, Bowen GM, et al. Adequacy of 5-mm surgical excision margins for non-lentiginous melanoma in situ. J Am Acad Dermatol. 2014;71(4):835–8.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Akhtar S, Bhat W, Magdum A, Stanley PR. Surgical excision margins for melanoma in situ. J Plast Reconstr Aesthet Surg. 2014;67(3):320–3.

    Article  CAS  PubMed  Google Scholar 

  26. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol. 2012;66(3):438–44.

    Article  PubMed  Google Scholar 

  27. Wong JY, Sondak VK. Unanswered questions about margin recommendations for primary cutaneous melanoma. J Natl Compr Cancer Netw. 2012;10(3):357–65.

    Article  Google Scholar 

  28. McGuire LK, Disa JJ, Lee EH, Busam KJ, Nehal KS. Melanoma of the lentigo maligna subtype: diagnostic challenges and current treatment paradigms. Plast Reconstr Surg. 2012;129(2):288e–99e.

    Article  CAS  PubMed  Google Scholar 

  29. King R. Lentiginous melanoma. Arch Pathol Lab Med. 2011;135(3):337–41.

    PubMed  Google Scholar 

  30. Hazan C, Dusza SW, Delgado R, Busam KJ, Halpern AC, Nehal KS. Staged excision for lentigo maligna and lentigo maligna melanoma: a retrospective analysis of 117 cases. J Am Acad Dermatol. 2008;58(1):142–8.

    Article  PubMed  Google Scholar 

  31. Guitera P, Moloney FJ, Menzies SW, et al. Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy. JAMA Dermatol. 2013;149(6):692–8.

    Article  PubMed  Google Scholar 

  32. Walling HW, Scupham RK, Bean AK, Ceilley RI. Staged excision versus Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. J Am Acad Dermatol. 2007;57(4):659–64.

    Article  PubMed  Google Scholar 

  33. Hou JL, Reed KB, Knudson RM, et al. Five-year outcomes of wide excision and Mohs micrographic surgery for primary lentigo maligna in an academic practice cohort. Dermatol Surg. 2015;41(2):211–8.

    Article  CAS  PubMed  Google Scholar 

  34. de Vries K, Greveling K, Prens LM, et al. Recurrence rate of lentigo maligna after micrographically controlled staged surgical excision. Br J Dermatol. 2016;174(3):588–93.

    Article  PubMed  Google Scholar 

  35. Dengel L, Turza K, Noland MM, Patterson JW, Slingluff CL Jr. Skin mapping with punch biopsies for defining margins in melanoma: when you don’t know how far to go. Ann Surg Oncol. 2008;15(11):3028–35.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Nakamura Y, Fujisawa Y. Diagnosis and management of acral lentiginous melanoma. Curr Treat Options Oncol. 2018;19(8):42.

    Article  PubMed  Google Scholar 

  37. Goydos JS, Shoen SL. Acral lentiginous melanoma. Cancer Treat Res. 2016;167:321–9.

    Article  PubMed  Google Scholar 

  38. Sureda N, Phan A, Poulalhon N, Balme B, Dalle S, Thomas L. Conservative surgical management of subungual (matrix derived) melanoma: report of seven cases and literature review. Br J Dermatol. 2011;165(4):852–8.

    Article  CAS  PubMed  Google Scholar 

  39. Bilu D, Sauder DN. Imiquimod: modes of action. Br J Dermatol. 2003;149(Suppl 66):5–8.

    PubMed  Google Scholar 

  40. Cotter MA, McKenna JK, Bowen GM. Treatment of lentigo maligna with imiquimod before staged excision. Dermatol Surg. 2008;34(2):147–51.

    Article  CAS  PubMed  Google Scholar 

  41. Powell AM, Russell-Jones R, Barlow RJ. Topical imiquimod immunotherapy in the management of lentigo maligna. Clin Exp Dermatol. 2004;29(1):15–21.

    Article  CAS  PubMed  Google Scholar 

  42. Kirtschig G, van Meurs T, van Doorn R. Twelve-week treatment of lentigo maligna with imiquimod results in a high and sustained clearance rate. Acta Derm Venereol. 2015;95(1):83–5.

    Article  CAS  PubMed  Google Scholar 

  43. Marsden JR, Fox R, Boota NM, et al. Effect of topical imiquimod as primary treatment for lentigo maligna: the LIMIT-1 study. Br J Dermatol. 2017;176(5):1148–54.

    Article  CAS  PubMed  Google Scholar 

  44. Turza K, Dengel LT, Harris RC, et al. Effectiveness of imiquimod limited to dermal melanoma metastases, with simultaneous resistance of subcutaneous metastasis. J Cutan Pathol. 2010;37(1):94–8.

    Article  PubMed  Google Scholar 

  45. Bong AB, Bonnekoh B, Franke I, Schon M, Ulrich J, Gollnick H. Imiquimod, a topical immune response modifier, in the treatment of cutaneous metastases of malignant melanoma. Dermatology. 2002;205(2):135–8.

    Article  CAS  PubMed  Google Scholar 

  46. Miller AK, Dusing R, Meggison A, Aires D. Regression of internal melanoma metastases following application of topical imiquimod to overlying skin. J Drugs Dermatol. 2011;10(3):302–5.

    PubMed  Google Scholar 

  47. Read T, Webber S, Thomas J, et al. Protocol for the TIDAL Melanoma Study: topical imiquimod or diphenylcyclopropenone for the management of cutaneous in-transit melanoma metastases-a phase II, single centre, randomised, pilot study. BMJ Open. 2017;7(10):e016816.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Hinz T, Ehler LK, Bieber T, Schmid-Wendtner MH. Complete remission of extensive cutaneous metastatic melanoma on the scalp under topical mono-immunotherapy with diphenylcyclopropenone. Eur J Dermatol. 2013;23(4):532–3.

    Article  PubMed  Google Scholar 

  49. Kim YJ. Topical diphencyprone as an effective treatment for cutaneous metastatic melanoma. Ann Dermatol. 2012;24(3):373–5.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Damian DL, Thompson JF. Topical diphencyprone immunotherapy for a large primary melanoma on an elderly leg. Am J Clin Dermatol. 2011;12(6):403–4.

    PubMed  Google Scholar 

  51. Damian DL, Saw RP, Thompson JF. Topical immunotherapy with diphencyprone for in transit and cutaneously metastatic melanoma. J Surg Oncol. 2014;109(4):308–13.

    Article  CAS  PubMed  Google Scholar 

  52. Cohen MH, Jessup JM, Felix EL, Weese JL, Herberman RB. Intralesional treatment of recurrent metastatic cutaneous malignant melanoma: a randomized prospective study of intralesional Bacillus Calmette-Guerin versus intralesional dinitrochlorobenzene. Cancer. 1978;41(6):2456–63.

    Article  CAS  PubMed  Google Scholar 

  53. Krown SE, Hilal EY, Pinsky CM, et al. Intralesional injection of the methanol extraction residue of Bacillus Calmette-Guerin (MER) into cutaneous metastases of malignant melanoma. Cancer. 1978;42(6):2648–60.

    Article  CAS  PubMed  Google Scholar 

  54. Mastrangelo MJ, Sulit HL, Prehn LM, Bornstein RS, Yarbro JW, Prehn RT. Intralesional BCG in the treatment of metastatic malignant melanoma. Cancer. 1976;37(2):684–92.

    Article  CAS  PubMed  Google Scholar 

  55. Kaufman HL, Ruby CE, Hughes T, Slingluff CL Jr. Current status of granulocyte-macrophage colony-stimulating factor in the immunotherapy of melanoma. J Immunother Cancer. 2014;2:11.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Si Z, Hersey P, Coates AS. Clinical responses and lymphoid infiltrates in metastatic melanoma following treatment with intralesional GM-CSF. Melanoma Res. 1996;6(3):247–55.

    Article  CAS  PubMed  Google Scholar 

  57. Ridolfi L, Ridolfi R. Preliminary experiences of intralesional immunotherapy in cutaneous metastatic melanoma. Hepato-Gastroenterology. 2002;49(44):335–9.

    CAS  PubMed  Google Scholar 

  58. Andtbacka RH, Kaufman HL, Collichio F, et al. Talimogene laherparepvec improves durable response rate in patients with advanced melanoma. J Clin Oncol. 2015;33(25):2780–8.

    Article  CAS  PubMed  Google Scholar 

  59. Boyd KU, Wehrli BM, Temple CL. Intra-lesional interleukin-2 for the treatment of in-transit melanoma. J Surg Oncol. 2011;104(7):711–7.

    Article  CAS  PubMed  Google Scholar 

  60. Byers BA, Temple-Oberle CF, Hurdle V, McKinnon JG. Treatment of in-transit melanoma with intra-lesional interleukin-2: a systematic review. J Surg Oncol. 2014;110(6):770–5.

    Article  CAS  PubMed  Google Scholar 

  61. Radny P, Caroli UM, Bauer J, et al. Phase II trial of intralesional therapy with interleukin-2 in soft-tissue melanoma metastases. Br J Cancer. 2003;89(9):1620–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Weide B, Derhovanessian E, Pflugfelder A, et al. High response rate after intratumoral treatment with interleukin-2: results from a phase 2 study in 51 patients with metastasized melanoma. Cancer. 2010;116(17):4139–46.

    Article  CAS  PubMed  Google Scholar 

  63. Thompson JF, Agarwala SS, Smithers BM, et al. Phase 2 study of intralesional PV-10 in refractory metastatic melanoma. Ann Surg Oncol. 2015;22(7):2135–42.

    Article  PubMed  Google Scholar 

  64. Fogarty GB, Hong A, Scolyer RA, et al. Radiotherapy for lentigo maligna: a literature review and recommendations for treatment. Br J Dermatol. 2014;170(1):52–8.

    Article  CAS  PubMed  Google Scholar 

  65. Hedblad MA, Mallbris L. Grenz ray treatment of lentigo maligna and early lentigo maligna melanoma. J Am Acad Dermatol. 2012;67(1):60–8.

    Article  PubMed  Google Scholar 

  66. Rosenberg SA. IL-2: the first effective immunotherapy for human cancer. J Immunol. 2014;192(12):5451–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA

    Reed I. Ayabe

  2. Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA

    Junko Ozao-Choy

  3. David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Junko Ozao-Choy

Authors
  1. Reed I. Ayabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Junko Ozao-Choy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Junko Ozao-Choy .

Editor information

Editors and Affiliations

  1. Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA

    Delphine J. Lee

  2. Cedars-Sinai Medical Center, The Angeles Clinic and Research Institute, Los Angeles, CA, USA

    Mark B. Faries

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ayabe, R.I., Ozao-Choy, J. (2021). Primary Melanoma Treatment. In: Lee, D., Faries, M. (eds) Practical Manual for Dermatologic and Surgical Melanoma Management. Springer, Cham. https://doi.org/10.1007/978-3-030-27400-9_6

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-27400-9_6

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-27399-6

  • Online ISBN: 978-3-030-27400-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation