Multiple Primary Cutaneous Melanomas in a Bulgarian Patient: The Possible Role of One Step Melanoma Surgery (OSMS) As the Most Adequate Treatment Approach!

Abstract

BACKGROUND:Simultaneous occurrence of multiple primary melanomas is a rare, however possible phenomenon, and it is believed that older, male, white, Atypical Mole Syndrome carriers (sporadic and familial) are part of the possible risk factors for its occurrence. In these patients, it is possible to observe involutional changes or (partial/complete) regression of melanocytic lesions, which are likely to be caused by the generation of a spontaneous immune reaction against specific tumour antigens.CASE REPORT:A 58-year-old male patient is presented with two melanocytic lesions located in the right clavicle (subclavicular area) and left the scapular area that meets clinically and dermatoscopically the requirements for malignant melanoma. The lesions were removed by a radical excision with 0.5 cm surgical safety margin in all directions. During the subsequent histological verification it was established it was melanoma with a tumour thickness of 1 mm that in one case, and the other 2 mm. A week later, according to the recommendations of the current guidelines, a re-excision was performed with a surgical safety margin of 1.5 cm in all directions. Considering the complications that are possible during the parallel removal of a draining lymph node recommended for these tumour thicknesses, the patient definitively refused its detection and removal.CONCLUSION:A rare case of a Bulgarian patient with multiple primary, however partially involutional melanomas existing for over 20 years, is described. The individual recommendations of dermato-oncologists for the patient (according to AJCC) were not in favour of radicality but of a more sparing, individualised approach, appropriate for that patient. Unfortunately, the approach we used, in this case, was inconsistent with the AJCC or OSMS guidelines. The reason for individualising the approach in the case we have described is due to the variability of the recommendations for surgical treatment of melanomas laid down in the AJCC.

Borderline Intermediary Thickness Cutaneous Melanoma: Standard Approach and The New Possibilities for Removal in one Surgical Session

“…In our presenting case of nodular malignant melanoma, implementing personalised melanoma surgery in the face of OSMS would provide a favourable outcome based on the patient's clinical and dermatoscopic findings [2][3].…”

“…A comprehensive approach such as this would achieve the final intended result of AJCC-all in one session [2][3][4]. The benefits of One step melanoma surgery/ OSMS treatment for melanoma are: 1) minimising psycho-emotional stress that comes from two surgical interventions [3]; 2) less room for surgical error and side effects [4]; 3)relieving patients from financial burden [2]; 4) reduced risk of patients not willing to appear for the second procedure due to fear [2,4].…”

The Future of Personalized Medicine: One Step Melanoma Surgery

“…If the primary lesion has a tumor thickness of more than 1 mm and less than 2 mm, the operative field should be 1 cm combined with the simultaneous removal of the draining lymph node within one surgical session (Table 2) [5,14]. In melanomas between 2 and 4 mm thickness, ultrasound can be used again, with the surgical safety field being 2 cm in all directions and the draining lymph node being removed in parallel (Table 2) [5,14]. For tumor thicknesses greater than 4 mm, OSMS again offers adequate treatment within one surgical session (Table 2) [6].…”