Matthias Möhrle

Malignant Melanoma S3-Guideline "Diagnosis, Therapy and Follow-up of Melanoma"

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.

Is sentinel lymph node biopsy of therapeutic relevance for melanoma

Introduction: It is still unclear whether sentinel lymph node biopsy (SLNB) has an effect on the survival or recurrence-free survival of patients. It would be necessary to draw comparisons between patients with SLNB (or with selective lymph node dissection in the case of positive SLNB) and patients without SLNB who underwent only close clinical and sonographic follow-up. To date no results from prospective, randomized studies of SLNB are available. Material and Methods: Patients with SLNB (n = 283) and patients in clinical stage I and II with close follow-up examinations only (n = 3,514) were studied retrospectively in this investigation with regard to prognostic factors established in the literature: sex, age, tumor thickness, histological tumor type, ulceration and localization. Results: Multivariate analysis showed an independent significant advantage with regard to survival when SLNB had been performed (p = 0.017). Compared with patients in clinical stage I and II with close follow-up only (n = 2,617), patients in stage I with negative SLNB (n = 238) had a significantly lower melanoma-related mortality (p = 0.0042) and, especially, fewer recurrences in the regional lymph node station area (p = 0.0026). With regard to survival without distant metastases, patients with positive SLNB (n = 33) did not significantly benefit by comparison with patients who developed lymph node metastasis identified clinically or sonographically later during follow-up examinations (n = 246; p = 0.0084). Conclusion: In the relatively short follow-up period after SLNB, patients for whom SLNB had been performed had on the whole a prognostic advantage over patients who were subject only to close follow-up monitoring. Patients for whom subclinical lymph node metastases had been removed as the result of a positive SLNB did not have a better prognosis than patients without SLNB who had developed lymph node metastases within the follow-up period.

Microscopically controlled surgery (MCS)

To confirm a local R0 resection of tumors with infiltrative growth at problem sites and for sparing of tissue, microscopically controlled surgery represents a safe and proven method, particularly when there are no gaps between the tissue taken at the incision margins.

Mikrographisch kontrollierte Chirurgie (3D‐Histologie) beim Melanom

Die mikrographisch kontrollierte Chirurgie (3D‐Histologie) wird im englischen Sprachraum nach ihrem Begründer Frederic E. Mohs überwiegend als Mohs Micrographic Surgery (MMS) bezeichnet. Methoden der 3D‐Histologie kamen bislang bei verschiedenen Hauttumoren zum Einsatz. Die 3D‐Histologie ist indiziert bei Tumoren, die sich per continuitatem ausbreiten. Exzisionen mit 3D‐Histologie erfolgen mit primär kleineren Sicherheitsabständen. Hierbei können gesundes Gewebe geschont und bessere kosmetische Ergebnisse erzielt werden.

Diagnosis of cutaneous tumors with in vivo confocal laser scanning microscopy

In recent years, in vivo confocal laser scanning microscopy (CLSM) has become an established method for the non‐invasive examination of the skin. In vivo CLSM allows for real‐time imaging of micro‐anatomic cutaneous structures. It has been used to diagnose ambiguous skin tumors and to measure subclinical tumor spread prior to surgery. By additionally providing high power morphologic information, in vivo CLSM helps to reduce unnecessary biopsies. A multitude of diagnostic features for skin tumors has been published. Here we review published diagnostic in vivo CLSM features, and compare them to our own experience in 100 tumors. In combination with clinical examination and dermatoscopy, in vivo CLSM is a valuable additional tool for non‐invasive skin tumor diagnosis.

Is there a vasospasmolytic effect of acupuncture in patients with secondary Raynaud phenomenon

Background: Raynaud phenomenon (RP) is a vasospastic disorder of the digital arteries. Severe forms are found in patients with connective tissue diseases. Vasospasmolytic therapies are often limited by side effects such as orthostatic hypotension.

S1 guideline: microscopically controlled surgery (MCS)

When using procedures that enable complete examination of surgical margins (3D histology), microscopically controlled surgery (MCS) represents a safe and proven method to confirm R0 resection of infiltrating tumors, especially at problematic sites, while preserving the adjacent tissue. This allows for excellent or good aesthetic results that are superior (cryosurgery, short-range irradiation) or equivalent (PDT) to nonsurgical and less safe procedures (PDT).

Prognostische Faktoren und operative Strategien bei Melanomen des Gesichts

Hintergrund: Bei Melanomen, die im Gesicht lokalisiert sind, lassen sich die am Körper üblichen Sicherheitsabstände aus funktionellen und ästhetischen Gründen nicht realisieren. In der Literatur fehlen kontrollierte Studien zu Sicherheitsabständen bei Gesichtmelanomen. Bei den Melanompatienten der Universitäts‐Hautklinik Tübingen (1980 – 1999) wurde retrospektiv analysiert, welche klinische Parameter und operativen Strategien die Prognose bei Gesichtsmelanomen beeinflussen. Die Bedeutung der lückenlosen histologischen Kontrolle der Exzisatschnittränder (3D‐Histologie) sollte validiert werden.

Wavelet analysis of cutaneous blood flow in melanocytic skin lesions.

Laser Doppler flowmetry (LDF) is frequently used to study the microcirculation. Usually LDF time series are analyzed by conventional linear methods, mainly Fourier analysis. The aim of this study was to observe dynamic blood perfusion of the skin in malignant and benign melanocytic skin lesions. Wavelet transformation was performed on each LDF time series in order to calculate a vasomotion field. First, the differences in vasomotion between healthy and pigmented skin were evaluated visually on six different time scales of the vasomotion field. In order to quantify the findings, vasomotion scale variance (VSV) was calculated for each scale plane of the vasomotion field. These VSV were compared using contrast ΔVSV to determine the difference between healthy skin and a pigmented skin lesion in the same patient. After the measurements, the skin lesions were excised and examined histologically. We found that wavelet analysis of LDF time series is a specific, sensitive method for the in vivo identification of malignant melanoma. It is a non-invasive procedure and takes minimal time to be carried out.

Zum Benefit der Patienten: Die Schildwächterlymphknotenentfernung

JDDG | 11 ̇2011 (Band 9)