Tchernev Georgi
Medical Institute of Ministry of Interior (MVR-Sofia), Department of Dermatology, Venereology and Dermatologic Surgery, General Skobelev 79, 1606, Sofia, Bulgaria.
Onkoderma-Policlinic for Dermatology, Venereology and Dermatologic Surgery, General Skobelev 26, 1606 Sofia, Bulgaria.
Open Access Maced J Med Sci. 2018 Feb 9;6(2):367-371. doi: 10.3889/oamjms.2018.084. eCollection 2018 Feb 15.
We present to the attention of the medical, dermatological and oncosurgical community data that serves to indicate the indispensability of optimisation of the algorithm and recommendations for diagnosis and surgical treatment of cutaneous melanoma. These recommendations could be referred to different subgroups of patients in different clinical stages as well as to patients with different initial characterisation (histological morphology) of the primary tumours. One step surgery is not a myth, even more, it could prove to be one of the best solutions for some patient collectives with advanced stages of melanoma.
We present a case of a 74 - year old patient with a congenital medium sized melanocytic nevus, located directly above the lateral part of the elbow joint. In one month and a half, an achromatic nodular formation evolves with a diameter of 2.7 x 2.3 cm, prominent over the skin level, painful by palpation and spontaneously bleeding. By the anamnestic, clinical and dermoscopic findings the patient was diagnosed with nodular melanoma associated with a congenital medium sized melanocytic nevus. A primary excision with a field of safety 0.5 cm in all directions was performed. After confirmation of the primary diagnosis (tumour thickness 8 mm with no ultrasonographic detection of enlarged lymph nodes), seven days later are - excision was performed with an additional field of surgical safety of 1.5 cm in all directions.
In this case remains unclear the following question: For what reason a preoperative high - frequent ultrasonography (HFUS) is not recommended to be used as it will allow only one surgical excision with the elimination of a tumour with a safety field of 2cm in all directions? The enigma about the obstacles preventing such a rational optimisation of the current diagnostic and therapeutic algorithm in patients with melanomas remains unresolved. One step surgery for cutaneous melanoma is widely used in many countries although it continues to be considered as a matter of dispute for some experts. Once again, by a clinical case and the following analysis, we would like to focus the attention of the dermatosurgical community on this crucial and highly significant problem. Innovations are very often resulting from the simplicity of logic, which unfortunately is not always accepted appropriately.
我们提请医学、皮肤科和肿瘤外科界关注一些数据，这些数据表明优化皮肤黑色素瘤诊断和手术治疗的算法及建议至关重要。这些建议可适用于处于不同临床阶段的不同患者亚组，以及原发性肿瘤具有不同初始特征（组织形态学）的患者。一期手术并非神话，甚至对于某些晚期黑色素瘤患者群体而言，它可能是最佳解决方案之一。
我们呈现一例74岁患者，其先天性中等大小黑素细胞痣位于肘关节外侧正上方。在一个半月内，出现一个直径为2.7×2.3厘米的无色结节状肿物，高出皮肤表面，触痛且自发出血。通过既往史、临床及皮肤镜检查结果，该患者被诊断为与先天性中等大小黑素细胞痣相关的结节性黑色素瘤。进行了四周各0.5厘米安全切缘的初次切除。在确诊原发性诊断（肿瘤厚度8毫米，超声未检测到肿大淋巴结）后，七天后进行了四周各额外1.5厘米手术安全切缘的再次切除。
在该病例中，以下问题仍不明确：为何不建议术前使用高频超声（HFUS），因为它仅允许进行一次手术切除，且能在四周各2厘米安全切缘的情况下切除肿瘤？关于阻碍黑色素瘤患者当前诊断和治疗算法进行合理优化的障碍之谜仍未解开。皮肤黑色素瘤的一期手术在许多国家广泛应用，尽管对一些专家来说它仍是一个有争议的问题。我们再次通过一个临床病例及后续分析，希望引起皮肤外科界对这个关键且极其重要问题的关注。创新往往源于逻辑的简单性，而不幸的是，这种简单性并不总是能得到恰当认可。
