Treatment of Primary Melanomas

The great majority of patients with newly diagnosed melanomas have early-stage disease that is clinically localized to the primary site (AJCC stages I and II). Surgical strategies to treat early-stage melanomas today include two main components: wide excision of the primary melanoma (or biopsy site) and evaluation of the regional lymph node basin by sentinel lymph node biopsy. In the past, the recommended treatment of primary melanoma was aggressive surgery, involving wide resection margins of 3–5 cm around the primary melanoma and, frequently, elective radical dissection of the regional node basin. However, this strategy was not based on sound evidence, but principally on the clinical impressions of surgeons in the early twentieth century.Although such radical management is no longer considered appropriate, surgery remains the single most effective treatment modality for clinically localized melanoma. Over time, a better understanding of the factors governing or predicting the natural history of melanoma and the results of clinical trials that were designed to study less aggressive surgical approaches have led to evidence-based recommendations for surgical excision margins. The objectives that led to this evolution in care were to provide durable local disease control and to optimize the chance of cure, while at the same time minimizingmorbidity associated with the treatment. In this chapter the evidence supporting current margin recommendations for surgical excision of primary melanomas is presented and discussed, and the management of melanomas with unusual histologic findings is also considered.