MBA according to CA procedure 1

Skin cancer (malignant melanoma)

Skin cancer (malignant melanoma)

Background: Malignant melanoma is a malignant tumor that arises from the pigment-bearing cells of the skin. Formation is possible anywhere on the body, including under the fingernails and toenails. Malignant melanoma is one of the malignancies with the highest rate of population growth in recent decades. A total of 4 main types are distinguished: superficial spreading malignant melanoma (60-70% of cases), nodular melanoma (20% of cases), acral localized melanoma (5-10%) and lentigo maligna melanoma.

Diagnosis: The diagnosis of skin cancer relates primarily to the skin change itself, but also to the associated lymphatic drainage pathways. In particular, ultrasound (sonography) and, if advanced tumor disease is suspected, radiological cross-sectional imaging (CT) and nuclear medicine imaging (scintigraphy, PET) are used.

Therapy: If a malignant melanoma is suspected, the entire lesion should be excised in a healthy area. Then, after the diagnosis has been confirmed histologically, another differentiated approach takes place. For example, with a Breslow tumor thickness of up to 2 mm, a re-excision with a safety margin of 1 cm and with a tumor thickness> 2.00 mm a re-excision with 2 cm.

Sentinel Node Biopsy (SNB): From a tumor thickness of 1.0 mm, a sentinel node biopsy (SNB) is performed. If there are additional risk factors (ulceration, evidence of mitoses), sentinel lymph node biopsy should be performed from a tumor thickness of 0.75 mm. The purpose of the targeted removal of the sentinel lymph nodes is to detect or exclude an early spread of the malignant melanoma into the lymph nodes if the lymph node findings are unremarkable. If the sentinel lymph node is free of relevant tumor cell infestation, no further surgical therapy is necessary for the time being, only regular tumor follow-up. Further additional medication measures are decided individually.

Follow-up excision procedure and sentinel lymph node biopsy: You present yourself to nuclear medicine on the day before the planned operation. There, a lymph drainage scintigraphy is performed with a harmless radioactive substance, the sentinel lymph nodes are identified with a special detector and the site is marked on the skin. The sentinel lymph node is the first lymph node seen as a filter from the tumor. After the examination, you can go home and present yourself for an operation in the surgical ward the next day. At the beginning of the operation, a lymph-permeable dye (patent blue) is also injected around the scar in order to further optimize the accuracy of finding the sentinel lymph node. With the help of a gamma probe, the sentinel lymph node is identified intraoperatively through the stored residual activity and removed in a targeted manner and, if necessary, the primary tumor site is re-excised with the necessary safety margin in the same operation under general anesthesia.

Depending on the size of the wound, a drain may be inserted, which can normally be removed the following day. You can be discharged home about 1 to 2 days after the operation. If primary closure of the wound is not possible, a vacuum bandage (VAC therapy) is applied or, if necessary, the defect is covered with plastic. The inpatient stay is then longer depending on the further therapy required.

Lymph node dissection (lymphadenectomy, LAD): If there is evidence of lymphogenic metastasis (histologically or morphologically), a lymph node dissection must be performed. This involves the complete removal of the lymph node package in a drainage area (e.g. armpit or groin). After the lymph nodes have been removed, several drains are usually inserted intraoperatively to drain the lymph fluid from the wound area.

It is not uncommon for patients to be discharged with a drain that may have to be left in place for up to 3 weeks postoperatively. During the inpatient stay, an (arm / leg) compression stocking is fitted by an orthopedic technician. In this way, swelling of the arm or leg (due to the postoperatively disturbed lymphatic drainage after LAD) can be prevented or minimized.

Hyperthermic Limb Perfusion (ILP): In patients with multiple, rapidly recurring skin and subcutaneous metastases (satellitosis, in-transit metastases, local metastases) on a limb that cannot be completely removed surgically, isolated hyperthermic limb perfusion may be performed. Here, the extremity is decoupled from the rest of the body's circulation with the help of a heart-lung machine, heated to approx. 40 ° C and flushed with a high-dose drug (cytostatic). In around 80% of patients, the metastases respond to this special treatment method. Long-term permanent healing is thereby possible.

Particularities: The surgical clinic works in close contact with the dermatology clinic of the university clinic. Joint tumor boards are held regularly, in which the therapies for patients with malignant melanoma are discussed individually on an interdisciplinary basis. All patients with malignant melanoma should first be examined in the dermatology clinic and, if necessary, be presented to the surgical clinic for a consultation by colleagues in dermatology.

Consultation hour: Contact persons for malignant melanoma in the surgical clinic are Prof. Dr. J. Göhl and PD Dr. V. Schellerer.