Surgical treatment of melanoma

Melanom je zloćudan tumor kože i sluznica čija je incidencija u stalnom porastu. Čini 3% tumora kože, ali je odgovoran za 65% smrti prouzrokovanih tumorom kože. Nastaje mutacijom melanocitnih stanica i pokazuje sklonost hematogenom i/ili limfogenom širenju. Postoji mnogo vrsta kutanih melanoma od kojih su najčešći površinsko šireći, nodularni, lentigo i akrlani lentignozni melanom. Za određivanje stadija melanoma, koriste se AJCC i TNM klasifikacija. Za dijagnostiku melanoma važan je samopregled kože i ABCDEFG pravilo koje olakšava pronalazak sumnjivih lezija, dermatoskopija kao brzi, jednostavan i neinvazivan postupak otkrivanja melanoma te djelomična ili potpuna biopsija i patohistološka analiza kao sredstvo za potvrdu konačne dijagnoze melanoma. Za liječenje primarnog melanoma zlatni standard je široka ekscizija melanoma sa određenom porcijom zdrave kože koja je određena po NCCN smjernicama. Kod melanoma in situ, preporučene su margine 0.5-1.0 cm; kod invazivnog melanoma debljine 1.0 mm ili manje, preporučene su margine od1.0 cm; kod invazivnog melanoma debljine veće od 1.0 mm do debljine od 2.0 mm, preporučene su margine 1-2 cm; kod invazivnog melanoma debljine veće od 2.0 mm do debljine od 4.0 mm preporučene su margine 2.0 cm; i na kraju, kod invazivnog melanoma debljine veće od 4 mm, preporučene margine iznose 2.0 cm. Nakon ekscizije radi se patohistološka analiza šire ekscidiranog komada kože s provjerom zdravih rubova; ako na rubovima postoje tumorske stanice indicirana je reekscizija. Prema ovim smjernicama potreba za rekonstrukcijom ne bi trebala biti viša od 5% slučajeva ekscizije. Kod velikih estetskih i funkcionalnih defekata nastalih tokom liječenja melanoma potrebno je napraviti rekonstrukcijski postupak graftom ili režnjem. Postoji više podjela graftova od kojih je najvažnija ona na graftove djelomične debljine kože i graftove pune debljine kože, dok se režnjevi dijele s obzirom na anatomsku lokaciju, vrstu tkiva koju sadrže i način vaskularizacije.Melanoma is a malignant tumor of the skin and mucous membranes, caused by the mutation of melanocytic cells and shows a tendency for hematogenous and/or lymphogenous spread. The incidence of it is constantly increasing. It accounts for 3% of skin tumors, but is responsible for 65% of deaths caused by skin tumors. It is caused by the mutation of melanocytic cells and shows a tendency for hematogenous and/or lymphogenous spread. There are many types of cutaneous melanoma, the most common of which are superficial spreading, nodular, lentigo and akral lentigous melanoma. To determine the stage of melanoma, the AJCC and TNM classification are used. Self-examination of the skin and the ABCDEFG rule, which facilitate the finding of suspicious lesions, dermatoscopy as fast, simple and non-invasive procedure for detecting melanoma, and partial or complete biopsy and pathohistological analysis as a method of confirming the final diagnosis of melanoma are important for the diagnosis of melanoma. For the treatment of primary melanoma, the gold standard is wide excision of the melanoma with a certain portion of healthy skin marigins which are determined by the NCCN guidelines. In case of melanoma in situ, recommended margins are 0.5-1.0 cm; for invasive melanoma with a thickness of 1.0 mm or less, margins of 1.0 cm are recommended; in case of invasive melanoma with a thickness greater than 1.0 mm to a thickness of 2.0 mm, margins of 1-2 cm are recommended; for invasive melanoma with a thickness greater than 2.0 mm to a thickness of 4.0 mm, margins of 2.0 cm are recommended; and finally, in the case of invasive melanoma with a thickness greater than 4 mm, the recommended margins are 2.0 cm. After the excision, a pathohistological analysis of the excised part is made, with special focus given on finding malignant cells on the parts of healthy skin; if there are tumor cells at the edges, reexcision is indicated. According to these guidelines, the need for reconstruction should not exceed 5% in all execisions made. In the case of large aesthetic and functional defects created during the treatment of melanoma, it is necessary to perform a reconstruction procedure with a graft or a flap. There are several types of grafts, the most important of which is partial skin grafts and full skin grafts, while flaps are divided according to anatomical location, the type of tissue they contain and the type of vascularization