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Observation and biannual follow-up
0%
0/3
Excisional biopsy with minimal tissue loss
33%
1/3
Wide surgical excision with 0.5cm margins
Wide surgical excision with 1cm margins
Wide surgical excision with 2cm margins
67%
2/3
Select Answer to see Preferred Response
Based on the description of the lesion and the image, this patient has cutaneous malignant melanoma, for which treatment is wide surgical excision with 2cm margins and sentinel lymph node biopsy with the possibility of subsequent radical axillary lymph node dissection. Malignant melanoma is a skin cancer known for its high metastatic potential and mortality rate. The depth (Breslow's depth) of the lesion is the single most important prognostic factor for survival, and is used to determine the appropriate surgical margin for excision. In situ lesions require 5mm margins. Lesions with depth less than or equal to 2mm require 1cm margins, and lesions with depth >2mm necessitate 2cm margins. Shenenberg reports that cutaneous malignant melanoma accounts for up to 5% of all skin cancers and is responsible for roughly 75% of all skin cancer deaths. Persons with an increased number of moles, dysplastic (also called atypical) nevi, or a family history of the disease are at increased risk compared with the general population. The histologic depth of lesion penetration, known as the Breslow depth, is the most important prognostic parameter in evaluating the primary tumor and determines appropriate surgical margins. Horst et al. shed light on the controversial nature of the surgical treatment of malignant melanoma in their discussion regarding the proper margins for melanoma in situ citing their prior study that showed the historically recommended 5mm margin for excision of melanoma in situ to be inadequate, only clearing 86% of tumors. They recommended a 9mm margin for standard excision of melanoma in situ to achieve a 99% clearance rate. Image A shows a skin lesion that demonstrates the classic findings that would raise concern for cutaneous malignant melanoma, including asymmetry, irregular borders, and uneven coloration. Incorrect Answers: Answers 1-4: The appropriate treatment for a cutaneous malignant melanoma with Breslow depth of >2mm is wide surgical excision with 2cm margins. This patient should also be referred to a surgical oncologist for regular follow-up and metastatic work-up, as well as be seen by the dermatologist for biannual surveillance exams.
3.3
(6)
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