Primary cutaneous melanoma: surgical management and other treatment options

The incidence of primary cutaneous melanoma continues to increase and is a growing public health problem. By virtue of its metastatic potential, melanoma accounts for most of the deaths from cutaneous malignancies. Management of cutaneous melanoma has undergone a paradigm shift in recent years. Clinical studies have furthered our understanding of the biology of this disease and have changed the standards of care. Specifically, sentinel node biopsy and interferon as the first effective postsurgical therapy have had a significant impact on the treatment of patients with melanoma. Surgery remains the primary treatment modality for cutaneous melanoma. An adequate excision of the primary lesion accomplishes durable local control and is curative for patients without micrometastatic disease. Although the extent of surgical resection has decreased in recent years, the standard treatment for primary cutaneous melanoma remains wide surgical excision with histologically negative margins. The extent of excision is based on the theory that the incidence and radial extent of local recurrences can be predicted by specific primary tumor histopathologic characteristics. Tumor thickness and ulceration are the most important histologic features associated with prognosis and are the basis for the current recommendations for surgical treatment of the primary tumor. The extent of surgical therapy for primary melanoma is an area of ongoing debate. No clinical trial has shown a survival disadvantage for narrow versus wide excision regimens for melanoma of any thickness. Ongoing clinical trials will determine the relationship between the extent of surgical therapy for the primary tumor and the outcomes of recurrence and survival in patients with melanoma.