WSHIMA - Case 19: Melanoma

PREOPERATIVE DIAGNOSIS: Invasive malignant melanoma, left lateral arm, 0.95 mm in thickness, Clark level IV with mitotic rate 3 per mm squared.
POSTOPERATIVE DIAGNOSIS: Invasive malignant melanoma, left lateral arm, 0.95 mm in thickness, Clark level IV with mitotic rate 3 per mm squared.
OPERATION PERFORMED: Radical excision left lateral arm for invasive malignant melanoma with reconstruction resulting skin defect utilizing extensive undermining and complex layered closure, 8 cm in length. Sentinel lymph node excision, left axilla.
SUMMARY: This 45-year-old man comes to the operating room with a biopsy-proven invasive malignant melanoma of his left lateral arm which is 0.95 mm in thickness on the biopsy with a Clark level IV at a mitotic rate of 3 per square mm. Since the biopsy was a shave biopsy, it is possible that the melanoma would be thicker than 0.95 mm. In lymphoscintigraphy before surgery, 1 sentinel lymph node was found in his left axilla and this was quite a deep lymph node. Biopsy sentinel lymph node.
OPERATIVE PROCEDURE: With the patient in the supine position in the operating room, his left upper extremity including his left axilla and adjacent chest wall area were all prepped and draped as a sterile field. The area of the melanoma of his arm was infiltrated with Xylocaine 1% with epinephrine and Marcaine 0.5% with epinephrine in a combined solution. Thereafter, this melanoma site was excised widely and deeply with a minimum margin from a tumor 10-12 mm and a deep margin, which included a portion of fascia over his triceps muscle. This tissue specimen was marked with a suture in the proximal margin and sent to pathology for examination. The original size of his melanoma is unknown but is in the range of 1.3 cm in diameter. Hemostasis was gained with electrocautery. Reconstruction of his large open skin wound required wide extensive undermining of adjacent skin flaps, both proximal and distal to the open wound using the #10 scalpel at the subcutaneous tissue level. The resulting skin flaps were advanced and the wound was then closed in a complex layered fashion using interrupted 3-0 Monocryl sutures in subcutaneous tissue and in deep dermis, with final skin approximation being achieved with interrupted 4-0 nylon sutures. Steri-Strips/sterile dressing was applied and attention was turned to his left axilla. His arm was elevated and abducted to give access to his axilla wherein the sentinel node had been located. The Neoprobe was used to find the optimal place for his skin incision and then an incision approximately 5 cm in length was made, after this had also been infiltrated with the same anesthetic solution. This incision was deepened with electrocautery to a relatively deep level. The Neoprobe was used to direct the dissection until the sentinel lymph node in question was located with a count of over 500 in vivo. The node was carefully dissected free from surrounding tissue and removed with an ex vivo count of at least 550. The axillary bed from which this node was taken was then examined with the Neoprobe and very little remaining counts were seen. After final hemostasis was obtained, a 1/4 inch Penrose drain was inserted down to the depth of this deep dissection and brought out through the skin. Closure was carried out with interrupted 3-0 Monocryl sutures in subcutaneous tissue/deep dermis, followed by final skin approximation with interrupted 4-0 nylon sutures.