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Guidelines of care for malignant melanoma
Thisreportreflects the best data available at the time the reportwas prepared, but caution should beexercised in interpreting the data;the results offuturestudies may require alteration of the conclusions or recommendations set forth in this report.
Guidelines of care for malignant melanoma Committee on Guidelines of Care: Lynn A. Drake, MD, chairman, Roger I. Ceilley, MD, Raymond 1. Cornelison, MD, William 1. Dobes, MD, William A. Dorner, MD, Robert W. Goltz, MD, Charles W. Lewis, MD, Stuart J. Salasche, MD, and Maria 1. Chanco Turner, MD Task Force on Malignant Melanoma: Maria 1. Chanco Turner, MD, chairman, David R. Arrowsmith, MD, Philip M. Catalano, MD, Calvin 1. Day, MD, Charles W. Lewis, MD, and Arthur J. Sober, MD 1. Introduction The American Academyof Dermatology's Committee on Guidelines of Care is developing guidelinesof care for ourprofession. The development of guidelines will promote the continued delivery of quality care and assist thoseoutsideour profession inunderstandingthe complexities andscope ofcare provided by dermatologists. II. Definition Cutaneous malignant melanoma is a potentially lethal tumor arising most often from epidermal melanocytes and rarelyfrom dermal melanocytes. It is rare beforepuberty. Most Cases are nonfamilial, However, there exists a small but significant number of cases that appear to be genetically determined. Somepigmented lesions may be precursors to melanoma. III. Rationale A. Scope Melanoma is the mostfrequent cause of death of diseases arising in the skin. There has been an exponential increasein its incidence during the past 50 years. The lifetimerisk of a person developing melanoma in 1935 was 1:1500; by 1985 that risk had increased to 1:150. If the current trend continues, the estimatedlifetime risk will be 1;90 by the year 2000. It is estimated that in 1992, there were approximately 32,000 new cases of melanoma and 6700 deaths in the United States alone from melanoma. Nearly half of these melanomas Reprint requests: Lynn A. Drake, MD, Department of Dermatology, Wellman-2, Massachusetts General Hospital, Boston, MA 02114, JAM ACAD DERMATOL 1993;28:638-41. Copyright@l 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00+ .10 16/1/43691
638
will occur in people younger than 40 years of age. Despitethe rapidlyincreasingincidenceof melanoma between 1940 and 1980, there has been a gradual increase in the 5-year survival rate, from 41% to 83%. Because advanced melanoma is difficult to treat successfully, this improvementin survival rate can be ascribedto early detection and surgical excision of early primary lesions. B. Issue Many malignant melanomas are potentially curableby surgicalexcision, especially in early, thin lesions. Once totally removed, melanoma in situ should have essentially no effect on a patient's longevity, and no impact on insurability. Early detection, diagnosis, and removalof such lesions is desirable. Theseeffortsshouldbe especially directed toward those who are at an increased risk of developing melanoma. Risk factors may include: 1. Family and/or personal history of melanoma 2. Light complexion 3. Tendency to freckle 4. Tendency to sunburn 5. History of severe sunburn 6. Many nevi 7. Presence of clinically atypical nevi 8. Other IV. Diagnostic criteria A. Clinical 1. Patient history a) Growth or change in size, shape, or height of a skinlesion(usuallypigmented), either preexisting or new.The time over which such change was noted to take place may be useful.
Journal of the American Academyof Dermatology Volume 28, Number 4
b) Changes in color of a skin lesion-
lightening, darkening, redness, shades of blue and/or gray to black c) A skin lesion with itching, crusting, bleeding, erosion, ulceration d) Personal and/or family history of melanoma and/or nonmelanoma cancers of the skin e) Personal and/or familyhistoryof atypical nevi j) Other 2. Physical examination a) Record location of lesion. b) Note appearance of lesion. 1) Asymmetry 2) Border irregularity 3) Color variegation-generally gray to blue-black, but may have white areas as wellas varyingshadesor red and/or brown 4) Diameter 5) Elevation c) Inspect and palpate around lesion and over lymphatic drainage area for satellites and/or in-transit metastases. d) Palpate regional lymph nodes for clinical presenceof metastases. e) Examine cutaneous surface for other melanomas,congenitaland/or atypical nevi. j) Examine pigmentation of nailfold and nail plate g) Other B. Diagnostic tests 1. Biopsy As management and prognosis is dependent on primary tumor thickness, the biopsytechniqueof choicefor suspectlesions is generally a total excisional biopsy with narrow margins. Sometimes, to establish the diagnosis a punch, saucerization, or elliptical biopsy may be performed, taking care to sample what appears to be the thickest, darkest part of the lesion. 2. Histopathology The histopathology report should indicate whether the lesion is benign or malignant. A histopathology report for melanoma should include the diagnosis, thickness of the lesion in millimeters (measured from the top of the granular cell layer to the deepestpointoftumor invasion), and status of the margins,if the nature ofthe specimen permits such evaluations. In borderline or equivocal lesions, additionaldermatopathologic consultation may be requested. Im-
Drakeet al. 639 munohistochemical stains may be helpful in doubtful cases. 3. The following may be indicated at times: a) Radiographic studies b) Hematologic and/or chemistrystudies c) CT or MRI scan d) Technetium scan e) Ultrasound j) Aspiration or open lymph node biopsy g) Scintigraphy to determine direction of lymph flow h) Other C. Inappropriate diagnostic tests Extensive diagnostic studies are generally not indicated in asymptomatic patients with early melanoma (melanoma in situ or <1.0 mm). D. Exceptions Not applicable E. Evolving diagnostic tests Radionuclide scans using gallium-67 citrate, radioactive iodinated compounds, and monoelonal antibodies are currently under investigation. F. Staging criteria A thorough history and complete physical examination is usually sufficient. Althoughother staging methods are available, a practical, clinically useful system is as follows: 1. Stage I-(localized disease)-absence of clinical and/or histologic evidence of tumor in regionalnodes or distant sites. This stage may also include rare cases of local recurrence, satellitosis, and/or in-transitmetastases. 2. Stage II-(regional node metastases)elinically and/or histologically positive regionallymph nodes. 3. Stage III-(systemic metastases}-distant metastases as determined by history, physicalexamination,radiographic studies, laboratoryexamination and/or histologic documentation at sites beyond the regional lymph node basin(s). G. Prognostic evaluation The prognosis of Stage I melanoma may be basedon Breslow thickness and can be categorized as follows: Thickness of
Risk category Minimum risk Low risk Intermediate risk High risk
primary lesion (mm)
Five-year survival (%)
<0.76 0.76-1.50 1.51-4.0 >4.0
96-99 87-94 66-77 <50
Prognosis of stage II melanomas depends on the
640 Drake et al. number of nodes involved and the extensiveness of nodalreplacementbytumor.Prognosis forstage II melanoma is guarded. For stage III melanoma prognosisis influenced bythe numberofmetastatic sites,visceraland/or nonvisceral involvement, and resectabilityof the metastases. Prognosis for stage III is usually grave. V. Recommendations A. Treatment 1. Surgery is the treatment of choice for primary melanomas and for some operable metastases.Althoughthereissomeconsensus developing amongdermatologists; these guidelines will probablyundergocontinued changes in the future. a} Surgical excision 1) For melanoma in situ: Excision of the lesion orbiopsysitewitha border ofclinically normalskinand layer of the subcutaneous tissue is currently considered adequate. This may be modified according to the anatomic location, proximity to vital structures, and other patient considerations. 2) Less than 1.0 mm thick: Approximatelya 1 em margin is usually adequate for tumors less than 1.0 mm thick. Thismay be modified according to the anatomic location, proximity to vital structures, and other patient considerations. 3) More than 1.0 mm thickness: Margins are usually larger than 1.0 em but no uniform standard exists at present. 4) Elective regional Lymph node dissection: For tumors less than 0.76 mm thick,node dissection is usually not indicated. For tumors thicker than 0.76 mm there is no uniform standard at this time. b) Mohs micrographic surgery: Occasionally used as a tissue-saving technique, especially on the face. e) Cryosurgery: Recommended by some for certain lentigo maligna lesions. d) Elective regional lymphnodedissection (ERLND); The role of this form of surgeryis controversiaLERLNDis not recommended for early melanoma,i.e., less than 1 mm thick. e) Therapeutic lymph node dissection: When clinically suspect lymph nodes
Journal of the American Academy of Dermatology April 1993
are identified, regional lymphadenectomy is generallyrecommendedexcept in patients with uncontrolled distant metastasis or other medical contraindications. j) Surgery formetastatic lesions: Effective palliative treatment for some isolated, operablemetastasesis surgicalexcision. 2. Chemotherapy a} When used as adjuvant therapy for high-riskstage I or stage II melanomas following excision and therapeutic lymph node dissection, chemotherapy has been disappointing. b) For metastatic melanoma, dacarbazine (DTIC) is currently regarded as the most effective singledrug. Combination chemotherapy's benefits are not clear and can be associated with significant morbidity. High-dose chemotherapy followed by autologous bone marrow transplantationshowssomepromisebut needs further evaluation. 3. Isolation perfusion: May be useful in selected cases of in-transit metastases on the limbs 4. Radiotherapy: May be used for large lentigo maligna in the elderly or for palliative treatment of metastases (e.g., cerebral, bone) or for local recurrences. 5. BCG and other immunostimulants: BCG injected into intradermal metastases may result in tumor regression. However, BeG has been disappointing for visceral metastases. Other immune stimulators such as levamisole, transfer factor,and DN CBhave also had generally disappointingresults. 6. Evolving therapies a) Biologic response modifiers: May include but are not limited to interferons, interleukins, and tumor necrosis factor b) Melanoma vaccines c) Adoptiveimmunotherapy:May include but are not limited to Iymphokine-activated killer (LAK) cells; tumor .infiltrating.lymphocytes (TIL) d) Monoclonal antibodies e) Hormonal: tamoxifen, diethylstilbestrol, melanocyte stimulating hormone (MSH) conjugated to a monoclonal antibody j} Melanin precursors: levodopa and dopamine g) Other
Journal of the American Academy of Dermatology Volume 28, Number 4
1) Azelaic acid 2) Cryosurgery followed by surgical excision 3) Hyperthermia 4) Other B. Follow-up 1.Patients who have had malignant melanoma shouldbe followed up regularly. Dependingon the need,dermatologic surveillancecan be complemented withfollow-up by the primary physician, surgeon, and/or oncologist. 2. Long-term follow-up is essential to detect recurrences and/or new primary lesions. Dermatologic follow-up generally includes completecutaneous examinations. 3. For patients who have atypical nevi, especially when numerous, some physicians recommend photographing theskintoserve as a baseline for future cutaneous examinations. C. Miscellaneous 1.Patients,especially thosewitha highriskof developing malignantmelanoma, should be educated as to what constitutes suspect lesions. They shouldbe taught self-examination as well as photoprotection. 2. Screening programs and education of the public at large need to be encouraged. VI. Supportingevidence See Bibliography (Appendix). VII. Disclaimer Adherence to these guidelines will not ensuresuccessful treatment in every situation. Further, these guidelines should not be deemed inclusive of all propermethodsof care or exclusive ofother methods of'care reasonably directed to obtaining the sameresults. The ultimatejudgmentregarding the proprietyof any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.
Drake et al. 641 Appendix. Bibliography: Malignant melanoma Breslow A,MachtSD.Optimal sizeofresection margin forthin cutaneous melanoma. SurgGynecol Obstet1977;145:691-2, Cohen MB,Saxton RE, LakeRR, etal. Detection ofmalignant melanoma with iodine-123 iodoamphetamine. J Nucl Med 1988;29:1200-6. Consensus Conference. Precursors to malignant melanoma. JAMA 1984;251:1864-6. Davis KH. Use of ga1lium-67 citrate and indium-Ill monoclonal antibodies in the detection of malignant melanoma. J Nuc1 Med Tech 1987;15:25-9. Greene MH, Clark WH Jr, Tucker MA, et at. High risk of malignant melanoma in melanoma-prone families withdysplastic nevi. Ann Intern Med 1985;102:458·65. Harris MN, Gumport SL. Total excision biopsy for primary malignant melanoma. JAMA 1973;226:354-5. Ho VC, Sober AJ. Therapy for cutaneous melanoma: an update. J AM ACAD DERMATOL 1990;22:159-76. Iscoe NA, Kersey P, Gapski J, et at.Predictive value of staging investigations inpatients with clinical stage I malignant melanoma. Plast Reconstr Surg 1987;80:233-9. Liewendahl K, Kairento AL,Pyrhonen S, etal. Localization of melanoma withradiolabeled monoclonal antibody fragments and iodoamphetamine. Eur J Nucl Med 1986;12:359-62. MacKieRM, Freudenberger T, Aitchison TC. Personal riskfactorchartforcutaneous melanoma. Lancet1989;2:487-90. NIH Consensus Conference. Diagnosis andtreatmentof early melanoma. JAMA 1992;268:1314-9. Rhodes AR,Weinstock MA,Fitzpatrick TB,et at.Riskfactors for cutaneous melanoma: a practical method ofrecognizing predisposed individuals. JAMA 1987;258:3146-54. RigelDS,KopfAW,Friedman RJ. The rateofmalignant melanoma in the United States: Are we making an impact? [Editorial] J AM ACAD DERMATOL 1987;17:1050-3. Singletary SE, Balch CM, UristMM, et al.Surgical treatment ofmelanoma. In:Balch CM,Houghton AN, Milton GW, et al, eds. Cutaneous melanoma. Philadelphia: JB Lippincott, 1992:269-74. Veronesi U, Cascinelli N. Narrow excision (l em margin): a safe procedure for thin cutaneous melanoma. Arch Surg 1991;126:438-41.
Guidelines of care for malignant melanoma Committee on Guidelines of Care: Lynn A. Drake, MD, chairman, Roger I. Ceilley, MD, Raymond 1. Cornelison, MD, William 1. Dobes, MD, William A. Dorner, MD, Robert W. Goltz, MD, Charles W. Lewis, MD, Stuart J. Salasche, MD, and Maria 1. Chanco Turner, MD Task Force on Malignant Melanoma: Maria 1. Chanco Turner, MD, chairman, David R. Arrowsmith, MD, Philip M. Catalano, MD, Calvin 1. Day, MD, Charles W. Lewis, MD, and Arthur J. Sober, MD 1. Introduction The American Academyof Dermatology's Committee on Guidelines of Care is developing guidelinesof care for ourprofession. The development of guidelines will promote the continued delivery of quality care and assist thoseoutsideour profession inunderstandingthe complexities andscope ofcare provided by dermatologists. II. Definition Cutaneous malignant melanoma is a potentially lethal tumor arising most often from epidermal melanocytes and rarelyfrom dermal melanocytes. It is rare beforepuberty. Most Cases are nonfamilial, However, there exists a small but significant number of cases that appear to be genetically determined. Somepigmented lesions may be precursors to melanoma. III. Rationale A. Scope Melanoma is the mostfrequent cause of death of diseases arising in the skin. There has been an exponential increasein its incidence during the past 50 years. The lifetimerisk of a person developing melanoma in 1935 was 1:1500; by 1985 that risk had increased to 1:150. If the current trend continues, the estimatedlifetime risk will be 1;90 by the year 2000. It is estimated that in 1992, there were approximately 32,000 new cases of melanoma and 6700 deaths in the United States alone from melanoma. Nearly half of these melanomas Reprint requests: Lynn A. Drake, MD, Department of Dermatology, Wellman-2, Massachusetts General Hospital, Boston, MA 02114, JAM ACAD DERMATOL 1993;28:638-41. Copyright@l 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00+ .10 16/1/43691
638
will occur in people younger than 40 years of age. Despitethe rapidlyincreasingincidenceof melanoma between 1940 and 1980, there has been a gradual increase in the 5-year survival rate, from 41% to 83%. Because advanced melanoma is difficult to treat successfully, this improvementin survival rate can be ascribedto early detection and surgical excision of early primary lesions. B. Issue Many malignant melanomas are potentially curableby surgicalexcision, especially in early, thin lesions. Once totally removed, melanoma in situ should have essentially no effect on a patient's longevity, and no impact on insurability. Early detection, diagnosis, and removalof such lesions is desirable. Theseeffortsshouldbe especially directed toward those who are at an increased risk of developing melanoma. Risk factors may include: 1. Family and/or personal history of melanoma 2. Light complexion 3. Tendency to freckle 4. Tendency to sunburn 5. History of severe sunburn 6. Many nevi 7. Presence of clinically atypical nevi 8. Other IV. Diagnostic criteria A. Clinical 1. Patient history a) Growth or change in size, shape, or height of a skinlesion(usuallypigmented), either preexisting or new.The time over which such change was noted to take place may be useful.
Journal of the American Academyof Dermatology Volume 28, Number 4
b) Changes in color of a skin lesion-
lightening, darkening, redness, shades of blue and/or gray to black c) A skin lesion with itching, crusting, bleeding, erosion, ulceration d) Personal and/or family history of melanoma and/or nonmelanoma cancers of the skin e) Personal and/or familyhistoryof atypical nevi j) Other 2. Physical examination a) Record location of lesion. b) Note appearance of lesion. 1) Asymmetry 2) Border irregularity 3) Color variegation-generally gray to blue-black, but may have white areas as wellas varyingshadesor red and/or brown 4) Diameter 5) Elevation c) Inspect and palpate around lesion and over lymphatic drainage area for satellites and/or in-transit metastases. d) Palpate regional lymph nodes for clinical presenceof metastases. e) Examine cutaneous surface for other melanomas,congenitaland/or atypical nevi. j) Examine pigmentation of nailfold and nail plate g) Other B. Diagnostic tests 1. Biopsy As management and prognosis is dependent on primary tumor thickness, the biopsytechniqueof choicefor suspectlesions is generally a total excisional biopsy with narrow margins. Sometimes, to establish the diagnosis a punch, saucerization, or elliptical biopsy may be performed, taking care to sample what appears to be the thickest, darkest part of the lesion. 2. Histopathology The histopathology report should indicate whether the lesion is benign or malignant. A histopathology report for melanoma should include the diagnosis, thickness of the lesion in millimeters (measured from the top of the granular cell layer to the deepestpointoftumor invasion), and status of the margins,if the nature ofthe specimen permits such evaluations. In borderline or equivocal lesions, additionaldermatopathologic consultation may be requested. Im-
Drakeet al. 639 munohistochemical stains may be helpful in doubtful cases. 3. The following may be indicated at times: a) Radiographic studies b) Hematologic and/or chemistrystudies c) CT or MRI scan d) Technetium scan e) Ultrasound j) Aspiration or open lymph node biopsy g) Scintigraphy to determine direction of lymph flow h) Other C. Inappropriate diagnostic tests Extensive diagnostic studies are generally not indicated in asymptomatic patients with early melanoma (melanoma in situ or <1.0 mm). D. Exceptions Not applicable E. Evolving diagnostic tests Radionuclide scans using gallium-67 citrate, radioactive iodinated compounds, and monoelonal antibodies are currently under investigation. F. Staging criteria A thorough history and complete physical examination is usually sufficient. Althoughother staging methods are available, a practical, clinically useful system is as follows: 1. Stage I-(localized disease)-absence of clinical and/or histologic evidence of tumor in regionalnodes or distant sites. This stage may also include rare cases of local recurrence, satellitosis, and/or in-transitmetastases. 2. Stage II-(regional node metastases)elinically and/or histologically positive regionallymph nodes. 3. Stage III-(systemic metastases}-distant metastases as determined by history, physicalexamination,radiographic studies, laboratoryexamination and/or histologic documentation at sites beyond the regional lymph node basin(s). G. Prognostic evaluation The prognosis of Stage I melanoma may be basedon Breslow thickness and can be categorized as follows: Thickness of
Risk category Minimum risk Low risk Intermediate risk High risk
primary lesion (mm)
Five-year survival (%)
<0.76 0.76-1.50 1.51-4.0 >4.0
96-99 87-94 66-77 <50
Prognosis of stage II melanomas depends on the
640 Drake et al. number of nodes involved and the extensiveness of nodalreplacementbytumor.Prognosis forstage II melanoma is guarded. For stage III melanoma prognosisis influenced bythe numberofmetastatic sites,visceraland/or nonvisceral involvement, and resectabilityof the metastases. Prognosis for stage III is usually grave. V. Recommendations A. Treatment 1. Surgery is the treatment of choice for primary melanomas and for some operable metastases.Althoughthereissomeconsensus developing amongdermatologists; these guidelines will probablyundergocontinued changes in the future. a} Surgical excision 1) For melanoma in situ: Excision of the lesion orbiopsysitewitha border ofclinically normalskinand layer of the subcutaneous tissue is currently considered adequate. This may be modified according to the anatomic location, proximity to vital structures, and other patient considerations. 2) Less than 1.0 mm thick: Approximatelya 1 em margin is usually adequate for tumors less than 1.0 mm thick. Thismay be modified according to the anatomic location, proximity to vital structures, and other patient considerations. 3) More than 1.0 mm thickness: Margins are usually larger than 1.0 em but no uniform standard exists at present. 4) Elective regional Lymph node dissection: For tumors less than 0.76 mm thick,node dissection is usually not indicated. For tumors thicker than 0.76 mm there is no uniform standard at this time. b) Mohs micrographic surgery: Occasionally used as a tissue-saving technique, especially on the face. e) Cryosurgery: Recommended by some for certain lentigo maligna lesions. d) Elective regional lymphnodedissection (ERLND); The role of this form of surgeryis controversiaLERLNDis not recommended for early melanoma,i.e., less than 1 mm thick. e) Therapeutic lymph node dissection: When clinically suspect lymph nodes
Journal of the American Academy of Dermatology April 1993
are identified, regional lymphadenectomy is generallyrecommendedexcept in patients with uncontrolled distant metastasis or other medical contraindications. j) Surgery formetastatic lesions: Effective palliative treatment for some isolated, operablemetastasesis surgicalexcision. 2. Chemotherapy a} When used as adjuvant therapy for high-riskstage I or stage II melanomas following excision and therapeutic lymph node dissection, chemotherapy has been disappointing. b) For metastatic melanoma, dacarbazine (DTIC) is currently regarded as the most effective singledrug. Combination chemotherapy's benefits are not clear and can be associated with significant morbidity. High-dose chemotherapy followed by autologous bone marrow transplantationshowssomepromisebut needs further evaluation. 3. Isolation perfusion: May be useful in selected cases of in-transit metastases on the limbs 4. Radiotherapy: May be used for large lentigo maligna in the elderly or for palliative treatment of metastases (e.g., cerebral, bone) or for local recurrences. 5. BCG and other immunostimulants: BCG injected into intradermal metastases may result in tumor regression. However, BeG has been disappointing for visceral metastases. Other immune stimulators such as levamisole, transfer factor,and DN CBhave also had generally disappointingresults. 6. Evolving therapies a) Biologic response modifiers: May include but are not limited to interferons, interleukins, and tumor necrosis factor b) Melanoma vaccines c) Adoptiveimmunotherapy:May include but are not limited to Iymphokine-activated killer (LAK) cells; tumor .infiltrating.lymphocytes (TIL) d) Monoclonal antibodies e) Hormonal: tamoxifen, diethylstilbestrol, melanocyte stimulating hormone (MSH) conjugated to a monoclonal antibody j} Melanin precursors: levodopa and dopamine g) Other
Journal of the American Academy of Dermatology Volume 28, Number 4
1) Azelaic acid 2) Cryosurgery followed by surgical excision 3) Hyperthermia 4) Other B. Follow-up 1.Patients who have had malignant melanoma shouldbe followed up regularly. Dependingon the need,dermatologic surveillancecan be complemented withfollow-up by the primary physician, surgeon, and/or oncologist. 2. Long-term follow-up is essential to detect recurrences and/or new primary lesions. Dermatologic follow-up generally includes completecutaneous examinations. 3. For patients who have atypical nevi, especially when numerous, some physicians recommend photographing theskintoserve as a baseline for future cutaneous examinations. C. Miscellaneous 1.Patients,especially thosewitha highriskof developing malignantmelanoma, should be educated as to what constitutes suspect lesions. They shouldbe taught self-examination as well as photoprotection. 2. Screening programs and education of the public at large need to be encouraged. VI. Supportingevidence See Bibliography (Appendix). VII. Disclaimer Adherence to these guidelines will not ensuresuccessful treatment in every situation. Further, these guidelines should not be deemed inclusive of all propermethodsof care or exclusive ofother methods of'care reasonably directed to obtaining the sameresults. The ultimatejudgmentregarding the proprietyof any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.
Drake et al. 641 Appendix. Bibliography: Malignant melanoma Breslow A,MachtSD.Optimal sizeofresection margin forthin cutaneous melanoma. SurgGynecol Obstet1977;145:691-2, Cohen MB,Saxton RE, LakeRR, etal. Detection ofmalignant melanoma with iodine-123 iodoamphetamine. J Nucl Med 1988;29:1200-6. Consensus Conference. Precursors to malignant melanoma. JAMA 1984;251:1864-6. Davis KH. Use of ga1lium-67 citrate and indium-Ill monoclonal antibodies in the detection of malignant melanoma. J Nuc1 Med Tech 1987;15:25-9. Greene MH, Clark WH Jr, Tucker MA, et at. High risk of malignant melanoma in melanoma-prone families withdysplastic nevi. Ann Intern Med 1985;102:458·65. Harris MN, Gumport SL. Total excision biopsy for primary malignant melanoma. JAMA 1973;226:354-5. Ho VC, Sober AJ. Therapy for cutaneous melanoma: an update. J AM ACAD DERMATOL 1990;22:159-76. Iscoe NA, Kersey P, Gapski J, et at.Predictive value of staging investigations inpatients with clinical stage I malignant melanoma. Plast Reconstr Surg 1987;80:233-9. Liewendahl K, Kairento AL,Pyrhonen S, etal. Localization of melanoma withradiolabeled monoclonal antibody fragments and iodoamphetamine. Eur J Nucl Med 1986;12:359-62. MacKieRM, Freudenberger T, Aitchison TC. Personal riskfactorchartforcutaneous melanoma. Lancet1989;2:487-90. NIH Consensus Conference. Diagnosis andtreatmentof early melanoma. JAMA 1992;268:1314-9. Rhodes AR,Weinstock MA,Fitzpatrick TB,et at.Riskfactors for cutaneous melanoma: a practical method ofrecognizing predisposed individuals. JAMA 1987;258:3146-54. RigelDS,KopfAW,Friedman RJ. The rateofmalignant melanoma in the United States: Are we making an impact? [Editorial] J AM ACAD DERMATOL 1987;17:1050-3. Singletary SE, Balch CM, UristMM, et al.Surgical treatment ofmelanoma. In:Balch CM,Houghton AN, Milton GW, et al, eds. Cutaneous melanoma. Philadelphia: JB Lippincott, 1992:269-74. Veronesi U, Cascinelli N. Narrow excision (l em margin): a safe procedure for thin cutaneous melanoma. Arch Surg 1991;126:438-41.