Skin Cancer Surgery – Melanoma

What Are The Types Of Skin Cancer?

The vast majority are either basal cell cancers or squamous cell cancers. These thankfully have a very low rate of metastases (spread). For basal cell the metastatic risk is between .003 to .5% and for squamous cell cancer about 2-3 %. Their treatment requires simple excision with negative margins.

Melanomas are the third major type of skin cancer. Though its incidence is dwarfed by basal cell and squamous cell cancer, an estimated 50,000 Americans will develop melanoma in a given year of which 7,700 will die.

Melanoma Surgery

Surgery depends on the Breslow’s thickness of the tumor. The main surgical issues are the margins (amount of tissue excised beyond the melanoma) and the necessity of doing a sentinel node biopsy (see below)

Sentinel node biopsy (SLN): This is a sampling of 1 or 2 lymph nodes in the affected nodal basin (axilla/armpit for arms, inguinal/groin for the legs) to determine whether the cancer has spread to the lymph nodes. This for the most part has replaced the complete removal of all the lymph nodes as part of the staging evaluation for melanoma. The sentinel node is the first lymph node to receive lymphatic drainage and therefore the node most likely to contain metastatic disease. This node is localized by injecting a blue dye and/ or a radioactive particle in the breast just before surgery and then removing that lymph node(s) that is either blue or radioactive.

Margins and Sentinel Node Biopsy Based on Breslows Thickness of the Melanoma

< 1 mm 1cm margin no SLN
1-4 mm 2 cm margin SLN
>4mm 2 cm margin SLN

If SLN biopsy is negative, then no further surgery is done. If the SLN biopsy contains melanoma, then the remainder of the lymph nodes are removed (therapeutic lymph node dissection of either the axilla or inguinal nodal basin)

PreOp Evaluation

  • CXR, blood count, liver profile, and LDH….no need for CT or PET scan till SLN biopsy is back
  • PET scan or CT scan may be warranted for thick melanomas > 4mm Breslow thickness
  • If the lymph node basin is ambiguous (such as melanoma on the trunk), lymphoscintigraphy is performed to determine if the nodal basin at risk is the axilla, inguinal basin, or the neck.
  • If the wound is in a cosmetically sensitive region or the wound cannot be closed primarily, then a plastic surgery consultation is arranged.
  • Do not take blood thinners 5 days before surgery

Post-Op Care

  • The incisions need no special care. It is okay to shower when you get home.
  • If a lymph node dissection (as opposed to a sentinel node biopsy), you will be discharged with drains. Make sure if you do have drains that you go home with antibiotics.
  • If you have drains, make sure you know how to empty these and record the output.  The drain site can be covered with a Band-Aid and antibiotic ointment. If the drainage is about 30to 40cc/day, call the office to have the drains removed.
  • Call the office about 4-5 days after your surgery to set up a 2 week follow up appointment and to get a preliminary report on your pathology.

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