Hauschild A, Rosien F, Lischner S
Department of Dermatology, University of Kiel, Germany.
Onkologie. 2003 Jun;26(3):218-22. doi: 10.1159/000071616.
Excisional biopsy is recommended as the procedure of choice whenever there is suspicion of malignant melanoma. There are only few indications for incisional biopsies, which--in contrast to former opinions--do not worsen the prognosis. For nearly 70 years the debate about the optimal resection safety margin around the primary tumor was influenced by historical case reports and paradigms. Recently, controlled clinical studies provided new insights. Accumulating evidence over the past two decades showed that narrower surgical margins do not have any influence on the rate of advanced metastatic disease. Local recurrence is rare (approximately 0.1%) when primary tumors are thin and is seen more often (approximately 10%) in primary tumors of greater thickness (>4 mm). Analysis of the overall survival in randomized trials shows equal prognosis for malignant melanoma for narrow and wide resection margins. Due to these findings in-toto excisional biopsy for in-situ melanoma, a resection margin of 1 cm for primary tumors with a tumor thickness up to 2 mm and a resection margin of 2 cm for primary tumors greater than 2 mm appears sufficient. By this procedure primary closure of wounds will be possible in nearly all cases, morbidity and costs of surgical approaches will be reduced. For a long time it has been discussed whether prophylactic removal of lymph nodes ('elective lymph node dissection') is of benefit for melanoma patients. More recently 'selective' lymphadenectomy ('sentinel node biopsy', SNB) has been proposed to evaluate the status of the first draining lymph node ('sentinel node') of the regional basin. Several studies now demonstrate that the sentinel node evaluation for underlying metastatic disease reflects the status of the entire lymph node region and is therefore a useful prognostic factor superior to measurement of tumor thickness in primary melanoma. However, it is unclear whether sentinel node biopsy is of benefit for a better survival in affected patients.
只要怀疑是恶性黑色素瘤，推荐进行切除活检作为首选方法。切取活检的指征很少，与以往观点相反，切取活检不会使预后变差。近70年来，关于原发肿瘤周围最佳切除安全切缘的争论一直受到历史病例报告和范例的影响。最近，对照临床研究提供了新的见解。过去二十年积累的证据表明，更窄的手术切缘对晚期转移性疾病的发生率没有任何影响。当原发肿瘤较薄时，局部复发很少见（约0.1%），而在厚度较大（>4mm）的原发肿瘤中更常见（约10%）。随机试验中总生存分析显示，窄切缘和宽切缘切除的恶性黑色素瘤预后相同。基于这些发现，对于原位黑色素瘤应进行完整切除活检，对于肿瘤厚度达2mm的原发肿瘤，切除切缘为1cm，对于大于2mm的原发肿瘤，切除切缘为2cm似乎就足够了。通过这种方法，几乎所有病例都可以实现伤口一期闭合，将降低手术方法的发病率和成本。长期以来，一直存在关于预防性切除淋巴结（“选择性淋巴结清扫”）对黑色素瘤患者是否有益的讨论。最近，有人提出“选择性”淋巴结切除术（“前哨淋巴结活检”，SNB）来评估区域淋巴结引流区的第一站淋巴结（“前哨淋巴结”）的状态。现在有几项研究表明，对潜在转移性疾病的前哨淋巴结评估反映了整个淋巴结区域的状态，因此是一个优于原发性黑色素瘤肿瘤厚度测量的有用预后因素。然而，尚不清楚前哨淋巴结活检对受影响患者的更好生存是否有益。
