1. DIAGNOSTIC EVALUATION
2. EXAMINATION UNDER ANESTHESIA AND BIOPSY
3. TREATMENT
4. ADJUVANT THERAPY
5. FOLLOW UP
6. BIBLIOGRAPHY

I. DIAGNOSTIC EVALUATION:

Clinical Evaluation:

• Complete history and physical examination
  
  Includes careful examination of the skin of the head and neck, scalp and lymph node bearing areas.    Neuralgic history and exam is used to screen for CNS metastases.

• Biopsy of primary
  
  This should be an excision biopsy (whenever possible) incorporating the full thickness of the skin and a minimum of surrounding normal skin.  A punch biopsy can be used for larger tumors by taking the sample from the most raised area., care being taken to orient the biopsy specimen properly for the pathologist. 

Imaging Studies:

• Chest x-ray

  This is necessary to determine the presence of pulmonary metastases.  It is unnecessary for patients whose primary tumor is in situ or <1 mm in thickness.

• A CAT/ MRI

  These examinations are only indicated when patients have symptoms of local or distant metastases or if adenopathy is found or suspected from the physical examination.

Laboratory Tests:

• Serum liver function tests
  
  These tests screen for the presence of liver metastases.  They are rarely elevated in symptomatic patients.

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Usually not indicated.  Fine needle aspiration and occasionally open biopsy of an enlarged nodes is appropriate to confirm the suspicion of metastasis tumor.

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III. TREATMENT:

Primary tumor:

• Surgery

  Adequate local excision incorporates a margin of skin around the biopsy scar which is proportional to the thickness of the primary tumor.  These margins are

  Thickness	Radius of excision
  < 1 mm	1 cm
  1-4 mm	2 cm
  > 4 mm	2-3 cm

  Margins may be reduced to avoid excision of functionally important structures such as the eye.  The depth of the excision extends to the level of the deep fascia.   Incorporation of fascia or underlying muscle is not essential.

• Reconstruction

  Depending upon the size and location of the surgical defect a skin graft or a local skin flap may be used.

• Radiation
  
  Primary radiation has been successfully employed for superficial lesions, however, experience with its use is limited.

• Chemotherapy/Immunotherapy
  
  Not indicated

Neck:

• Surgery

  Regional node dissection  is performed for palpable lymph node metastases. The use of elective neck dissection is controversial but may be of value in patients with tumors 1-4 mm in thickness.  Radioisotope and dye techniques are now available to identify a sentinel lymph node in the drainage basin. 

• Radiation

Radiation therapy , given in high dose fractions, may be effective in controlling sub clinical metastases and in reducing local/regional recurrence. Limited data has been published on this subject. At this time, unconventional fractionation regimens should be used under IRB approved investigational protocols.

Preoperative 

• Not proven to be effective.

Postoperative 

• There are no prospective trials demonstrating an advantage to adjuvant therapy.  Several trials are ongoing and patients who have > 30% risk of mortality should be encouraged to participate in these studies when available.

V. FOLLOW UP:

Patient should be instructed in self-examination and sun protection measures.  The frequency of follow-up examinations are timed according to the risk of recurrence.  Exams include history and physical examination.  Most recurrences will be detected by the patient and the physician.  laboratory tests are of limited value and may include chest x-ray and liver function tests done at least yearly.

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Veronesi U, Cascinelli N, Adamus J, et al. 1988.  Thin stage I primary cutaneous malignant melanoma.  Comparison of excision with margins of 1 or 3 cm.  N Engl J Med 318:  1159-62.

 Balch CM, Urist MM, Karakousis CP, et al. 1993.  Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm).  Results of a multi-institutional randomized surgical trial.  Ann Surg 218(3):  262-69.

Urist MM, Balch CM, Soong S-j, Shaw HM, Milton GW, Shaw HM, et al. 1984.  Head and neck melanoma in 534 clinical stage I patients:  A prognostic factors analysis and results of surgical treatment.  Ann Surg 200:  769-775.

Singletary SE, Byers RM, Shallenberger R, McBride CM, Guinee VF.  1986.  Prognostic factors in patients with regional cervical nodal metastases from cutaneous malignant melanoma.  Am J Surg  152:  371.

Morton DL, Wen D-R, Wong JH, et al.  1993.  Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck.  J Clin Oncol 11(9):  1751-56.

Soong S-j.  1992.  A computerized mathematical model and scoring system for predicting outcome in patients with localized melanoma.  In Cutaneous Melanoma, ed. CM Balch, AN Houghton, GW Milton, et al, 16:200-12, Philadelphia:  Lippincott.  583 pp.

National Institutes of Health Consensus Development Conference Statement on Diagnosis and Treatment of Early Melanoma.  Am J Dermatopathol  15:34-43, 1993.

Ang KK, Byers RM, Peters LJ, et al:  Regional radiotherapy as adjuvant treatment for head and neck melanoma.  Preliminary results.  Arch Otolaryngol Head Neck Surg 116:169-172, 1990.