Background  For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (SLNB), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck.Methods  Using Ovid, the MEDLINE and EMBASE electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of SLNB for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017.Results  Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ SLNB should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection.Conclusions  Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

The role of fludeoxyglucose F 18 positron emission tomography (PET) in the presurgical evaluation of patients with medically intractable epilepsy continues to be refined. The purpose of this study was to systematically review the literature to assess the diagnostic accuracy and utility of PET in this setting. Thirty-nine studies were identified through MEDLINE and EMBASE databases that met the inclusion criteria. In adult patients, PET hypometabolism showed a 56 to 90% agreement with seizure onset localized by intracranial electroencephalogram (pediatric: 21 to 86%). In temporal lobe epilepsy patients with good surgical outcome, PET displayed moderate to high sensitivity in localizing the seizure focus (range: 71 to 89%). The sensitivity increased by 8 to 23% when PET results were combined with magnetic resonance imaging or electroencephalogram. PET has been shown to affect patient management by improving the guidance of intracranial electrodes placement, altering the decision to perform surgery, or excluding patients from further evaluation.RÉSUMÉ: Utilité de la tomographie par émission de positons dans l'épilepsie. Le rôle de la tomographie par émission de positons (PET scan) au 18F fluodésoxyglucose (18F-FDG) dans l'évaluation préchirurgicale de patients présentant une épilepsie réfractaire au traitement médical est constamment raffiné. Le but de cette étude était de revoir systématiquement la littérature afin d'évaluer la précision du diagnostic et l'utilité du PET scan dans ce contexte. Nous avons identifié 39 études dans les bases de données MEDLINE et EMBASE qui rencontraient nos critères d'inclusion. Chez les patients adultes, un hypométabolisme au PET scan concordait entre 56 et 90% avec le début de la crise localisé par l'électroencéphalographie intracrânienne (patients pédiatriques: entre 21 et 86%). Chez les patients atteints d'épilepsie temporale chez qui le résultat chirurgical avait été favorable, le PET scan avait une sensibilité de modérée à élevée pour localiser le foyer épileptogène (écart : 71 à 89%). La sensibilité augmentait de 8 à 23% quand les résultats du PET scan étaient combinés à l'imagerie par résonance magnétique ou à l'électroencéphalographie. Il est démontré que le PET scan influence le traitement du patient en améliorant le guidage lors de la mise en place des électrodes intracrâniennes, en modifiant la décision de procéder à une chirurgie ou en évitant de procéder à des examens plus poussés chez certains patients.

Objective The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastases (ITM) from melanoma.   Methods The guideline was developed by the Program in Evidence-Based Care (PEBC) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group (DSG). Recommendations were drafted by the Working Group based on a systematic review of publications in MEDLINE and Embase. The document underwent patient and caregiver-specific consultation and was circulated to the Melanoma DSG and the PEBC Report Approval Panel for internal review; the revised document underwent external review.   Recommendations Minimal ITM were defined as lesions in a location with limited spread (generally 1 to 4 lesions); lesions are generally superficial, often clustered together, and surgically resectable. Moderate disease was defined as > 5 lesions covering a wider area or when new in-transit lesions develop rapidly (over weeks). Maximal disease was defined as large-volume disease with multiple (more than 15 to 20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.   1. In patients presenting with minimal ITM, complete surgical excision with negative pathological margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered. 2. In patients presenting with moderate, unresectable ITM consider using the following approach for localized treatment: intralesional interleukin-2 or talimogene laherparepvec as first choice, topical diphenylcyclopropenone as second choice, or radiation therapy as third choice. There is insufficient evidence to recommend intralesional bacille Calmette-Guerin or carbon dioxide laser ablation outside of a research setting. 3. In patients presenting with maximal ITM confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference. 4. In cases where local, regional, or surgical treatments for ITM may be ineffective, unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.