Tchernev Georgi, Chokoeva Anastasiya Atanasova
Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology, Venereology and Dermatologic Surgery, Sofia, Bulgaria.
"Onkoderma"- Policlinic for Dermatology and Dermatologic Surgery, Sofia, Bulgaria.
Open Access Maced J Med Sci. 2017 Jun 11;5(3):352-358. doi: 10.3889/oamjms.2017.068. eCollection 2017 Jun 15.
The American Joint Committee on Cancer (AJCC's) skin melanoma surgical treatment recommendations from 2011 are characterised by a prima facie "freedom of choice" regarding how extensive should be the excisions for melanomas with tumour thickness up to 2 mm and melanoma in situ. It is unclear why the recommended surgical security margins vary between 0.5 and 1 cm for melanoma in situ, whereas for melanomas with a tumour thickness of up to 1.99 mm, the range of variation is also between 1 and 2 cm, without specifying when the surgical field should be broader and, narrower, accordingly. This "uncertainty or lack of intent" of the guilders often leads to the same surgical approach to melanomas at different stages, or to a different approach in cases of melanomas at the same stage, in contrast. Therefore, this should be defined as wrong, logically.
We present 3 patients with cutaneous melanomas, treated with similar fields of surgical security. Current issues, generated within the framework of melanoma's surgery guided by the recommendations of the AJCC are also discussed. A new surgical approach in patients with melanoma is recommended, discussed for the first time in world literature. We hypothesize that the introduction of a certain recommendations for a 2 cm surgical field in all directions during the initial excision, combined with the parallel performance of a sentinel lymph node biopsy, will lead in fact to several important advantages: 1) avoiding of the secondary excision in at least 70% - 90% of the patients (depending on the tumor thickness), 2) minimizing the risk of lymphatic effusion change and misinterpretation of the sentinel lymph node biopsy's results in patients with secondary excision; 3) optimization of the surgical team's work; 4) minimizing the possibility of unprepared/uninformed personnel to take part in decisions for treating a specific disease such as skin melanoma, 4) facilitating the appropriate patients' group selection at the appropriate stage when involving them in different studies, leading to equal leveling of the initial positions.
Whether the proposed approach will be subjected to a detailed discussion of AJCC's expert's remains currently unclear.
美国癌症联合委员会（AJCC）2011年发布的皮肤黑色素瘤手术治疗建议的特点是，对于肿瘤厚度达2毫米的黑色素瘤及原位黑色素瘤，其切除范围表面上有“选择自由”。目前尚不清楚为何原位黑色素瘤推荐的手术安全切缘在0.5至1厘米之间变化，而对于肿瘤厚度达1.99毫米的黑色素瘤，变化范围在1至2厘米之间，且未具体说明何时手术视野应更宽或更窄。这种指南中的“不确定性或意图缺失”往往导致不同分期的黑色素瘤采用相同的手术方法，或者相反，相同分期的黑色素瘤采用不同的方法。因此，从逻辑上讲，这应被定义为错误的。
我们介绍了3例皮肤黑色素瘤患者，他们接受了类似的手术安全范围治疗。同时也讨论了在AJCC建议指导下黑色素瘤手术框架内产生的当前问题。本文推荐了一种黑色素瘤患者的新手术方法，这是世界文献中首次讨论。我们假设，在初次切除时向各个方向引入2厘米手术视野的特定建议，并同时进行前哨淋巴结活检，实际上将带来几个重要优势：1）至少70% - 90%的患者（取决于肿瘤厚度）避免二次切除；2）将二次切除患者中淋巴管积液变化及前哨淋巴结活检结果误判的风险降至最低；3）优化手术团队的工作；4）尽量减少无准备/不知情人员参与皮肤黑色素瘤等特定疾病治疗决策的可能性；4）在将患者纳入不同研究的适当阶段促进适当患者群体的选择，使初始条件达到平等。
目前尚不清楚所提出的方法是否会受到AJCC专家的详细讨论。
