One Step Melanoma Surgery (OSMS) Without Using Ultrasonography for Preoperative Tumour Thickness Measurement? - ʺA Question that Sometimes Drives Me Hazy: Am I or Are the Others Crazy! ʺ

Abstract

BACKGROUND:One step melanoma surgery is a new surgical approach by which specific groups of patients with cutaneous melanoma may be operated only by or within a single surgical session. Until now, the Bulgarian Society for Dermatologic Surgery (BULSDS) has presented models of clinical behaviour, in which preoperative measurement of tumour thickness in combination with echographic measurement of the locoregional lymph nodes could lead to the conduct of the so-called one-step melanoma surgery. Although this one step surgery currently does not fit in the recommended guidelines, it ensures compliance of the recommended boundaries of operational security while saving patients a repeated excision and relieves the healthcare institutions or the patients themselves financially.CASE REPORT:We at this moment present another case from the Bulgarian Society for Dermatologic Surgery (BULSDS) of one step melanoma surgery with a perfect end result, where the tumour thickness was not preoperatively determined by high-frequency echography. Preoperative assessment of tumour thickness was performed based on the clinical picture and dermatoscopy. The histologically established tumour thickness was identical to the preoperative assessment, i.e. <1 mm. Removal of the melanocytic lesion was performed with operational security field of 1cm in all directions, where, as a rule, no further removal of the draining lymph nodes is required.CONCLUSION:One step melanoma surgery has two significant advantages: 1) it saves a re-excision in certain groups of patients, which in turn is 2) significantly more favourable from a financial point of view. Its applicability in the appropriate groups of patients and the postoperative (although in a limited number of patients) results achieved indicate the need to optimise the current algorithms and direct them individually to each patient. Guidelines may not and should not be unified or set strict limits given the fact that they show a significant level of variability themselves regarding some key moments in the initial surgical treatment of melanoma. More than 10% of the primary melanoma cases refer to thin melanomas, and dermatoscopy and clinics are a sufficient method of optimising the planned surgical excision.

A novel surgical margin (1 cm) might be from benefit for patients with dysplastic nevi, thin melanomas, and melanoma in situ: Analysis based on clinical cases

“…Our findings indicate that two operative interventions can be reduced to one, following the innovative approach of one‐stage melanoma surgery (OSMS) (Tchernev, ; Tchernev & Temelkova, ; Tchernev & Temelkova, ; Tchernev & Temelkova, ; Tchernev, Temelkova, & Stavrov, ). In this case, thin melanomas/melanoma in situ and dysplastic nevi (clinically and dermatoscopically) were resected with a primary surgical safety margin of 1 cm (Table ; Tchernev, ).…”

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

“…In the event of hesitation, One step melanoma surgery (OSMS) is found to be a very useful approach, since it clearly defines the surgical safety margins in a) melanoma in situ resection with 1 cm surgical safety margin, b) tumours 1 to 2 mm thick resection with 1 cm surgical safety margin, and c) thickness of 2 to 4 mm – 2 cm surgical safety margin, where, in the event of b) and c), it is obligatory or highly recommended to perform, simultaneously or in parallel, detection and removal of the draining lymph node (regardless of whether the node is echographically enlarged); d) tumour thickness above 4 mm – resection with 2 cm in all directions and if there are no enlarged lymph nodes, 2 cm resection is sufficient, together with control/instrumental examinations every two months, but in the presence of enlarged lymph nodes, it is recommended that they will be removed and examined for the BRAF V600mutation, followed by computed tomography scan (CT) with contrast or PET scan. Interestingly, the abovementioned guidelines for One step melanoma surgery do not change and completely overlap with AJCC recommendations (relative to the result or efficiency score), however OSMS is a less traumatic method requiring additional preoperative preparation and judgment [ 32 ], [ 33 ], [ 34 ], [ 35 ], [ 36 ].…”

“…It is believed that in the case of melanomas with a thickness of over 4mm ELND is not of paramount importance as the draining lymph nodes may not be affected [ 32 ]. The reasons for this may be different: 1) accessory parallel lymphatic pathways available, on the one hand, and the other; 2) tumour cells may have passed the draining lymph node without stopping there, or there has already been primary haematogenous dissemination without involving the lymph nodes and pathways [ 32 ]. However, it should be taken into account that OSMS applies to all melanoma patient groups, which makes it more appropriate therapeutic endpoint [ 32 ].…”

“…One stage melanoma surgery results in a reduction of the number of steps of the so-called melanoma treatment programs by reducing the number of stages in which an error (or deviation from the guidelines) could occur [ 35 ]. Meanwhile, OSMS saves the patients repeated surgical interventions and relieved them emotionally and financially [ 32 ], [ 36 ], [ 37 ].…”

Comparative Analysis of the ʺScholasticʺ Recommendations of the AJCC From 2011 for the Surgical Treatment of Cutaneous Melanoma with the Newly Suggested Guidelines for OSMS From the Bulgarian Society For Dermatologic Surgery!

“…At this stage, melanoma surgery is based on the recommendations of the American Joint Committee of Cancer (AJCC) [1], [2]. One step melanoma surgery (OSMS) is a new and innovative method that offers a completely different model for the treatment of patients with malignant melanoma [3]. Its advantage is that on the one hand we have clear and precisely defined therapeutic steps that do not lead to hesitation and ambiguity, and on the other are performed in a single surgical session [3], [4], [5].…”