Surgical Management of Cutaneous Melanoma of the Head and Neck

Surgical Management of Cutaneous Melanoma of the Head and Neck

Oral Maxillofacial Surg Clin N Am 17 (2005) 191 – 204 Surgical Management of Cutaneous Melanoma of the Head and Neck Christopher Harris, DMD, MDa, Jo...

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Oral Maxillofacial Surg Clin N Am 17 (2005) 191 – 204

Surgical Management of Cutaneous Melanoma of the Head and Neck Christopher Harris, DMD, MDa, Jonathan Bailey, MD, DMD, FACSb,*, Remy H. Blanchaert, Jr, MD, DDSc a

Department of Oral and Maxillofacial Surgery, University of Missouri – Kansas City, Truman Medical Center, Kansas City, MO, USA b Division of Oral and Maxillofacial Surgery, Carle Clinic Association, Urbana, IL, USA c Private Practice, Kansas City, MO, USA

Malignant melanoma accounted for 4% of all cancer cases diagnosed in the United States in 2004. Approximately 55,100 diagnoses of malignant melanoma will be made and 7910 deaths will result from this particular malignancy [1]. The frequency of the presentation of this malignancy in the head and neck (estimated at 20%) requires that oral and maxillofacial surgeons be well educated in its recognition and management [2]. Of all deaths from skin cancer, 75% result from malignant melanoma. This rate occurs although only 5% of all skin cancers are malignant melanoma. Most skin cancers are seen in persons of advanced age. Currently, 25% of persons who develop malignant melanoma are younger than 40 years of age at presentation. The incidence of this malignancy is alarming. In women aged 25 to 29, malignant melanoma is the most common malignancy. In women aged 30 to 34, the incidence of malignant melanoma is second only to breast cancer [3] (Figs. 1 – 4). The most successful form of therapy available to date has been early detection and surgical treatment before local-regional or systemic dissemination of disease. Diagnosis of melanoma at an earlier stage is more common in the last few decades then it was

* Corresponding author. E-mail address: [email protected] (J. Bailey).

in the distant past, probably because of increased awareness in the medical community and the public. The data are also likely affected by the diagnosis of additional melanomas in an early stage in patients who were previously successfully treated and were undergoing comprehensive surveillance. This article provides the reader with a thorough understanding of the surgical management of cutaneous malignant melanoma of the head and neck. The article reviews the topics of the clinical features of malignant melanoma, proper biopsy and excision technique, appropriate resection margins, an update on the management of the regional lymphatics, and understanding of the current staging system. A series of clinical cases supplements the discussion in the text of the article.

Clinical features Incidence and etiology In 1935, lifetime individual risk for the development of malignant melanoma was 1:1500. This risk increased to 1:105 by 1991and is expected to continue to increase to 1:50 by the year 2010 [4]. The incidence rate of malignant melanoma is rising faster than that of any other cancer in this country. The percentage of cutaneous melanoma occurring in the head and neck is approximately 20% [2]. Men are

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Fig. 1. (A) An 80-year-old man with a T2a N0 M0 melanoma of the nasal tip. (B) Close-up view of T2 N0 M0 melanoma of the nasal tip. (C) Preoperative PET scan demonstrates an area of increased uptake in the left supraclavicular level IV region. No palpable or CT evidence of enlarged cervical lymph nodes. (D) Technetium scan demonstrates a right level I sentinel lymph node. (E) Intraoperative view after injection of isosulfan blue dye with planned excision using 1-cm margins. (F) Wide local excision specimen oriented for permanent pathology. (G) Full-thickness skin graft reconstruction. (H) The right level I sentinel lymph node biopsy was negative for melanoma; however, the left supraclavicular biopsy identified metastatic malignant melanoma. The patient underwent a left modified radical neck dissection. (I) Postoperative view demonstrates a well-healed, full-thickness skin graft of the nasal tip and left neck incision.

well known to present more commonly than women with truncal and head and neck melanoma, whereas women are more likely to present with extremity (especially lower leg) melanoma. There is clear evidence that genetic makeup and environmental influences are important in the devel-

opment of melanoma. This evidence is exemplified by the alarmingly high rates of this disease in northern Europeans who populate regions of Australia. In general, the closer to the equator peoples such as these live, the greater the risk. Contrasting this is the rare occurrence of melanoma in light-skinned

surgical management of cutaneous melanoma

Fig. 1 (continued).



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surgical management of cutaneous melanoma


Fig. 3. (A) Intraoperative view of T2a N0 M0 melanoma of the right temporal region. Wide local excision margins are marked. (B) Technetium 99 sulfur colloid scan performed immediately preoperatively identifies the sentinel node in the right parotid gland. (C) The sentinel lymph node position is identified transcutaneously with gamma probe corresponding with Tc 99 scan. (D) Cervicofacial rotation advancement flap is marked out. (E) Wide local excision specimen. (F ) Cervicofacial flap elevated for exposure of parotid bed and for defect closure. (G) Superficial parotidectomy specimen. Final pathologic results were negative for metastatic disease. (H ) Cervicofacial flap inset. (I ) Postoperative frontal view. (J ) Postoperative lateral view.

people of northern Italy. These people apparently have a genetic resistance to the environmental influence of ultraviolet radiation [5]. Although cumulative ultraviolet radiation exposure has been linked conclusively to the development of non-melanoma skin cancer, there is no clear correlation with melanoma, with the exception of lentigo maligna melanoma [6]. It seems that intermittent, brief, high-dose ultraviolet exposure results in the development of malignant melanoma.

Risk factors Accepted risk factors for malignant melanoma were identified by Friedman et al [3], who evaluated 43 separate risk factors in 208 patients with malignant melanoma. The identified risk factors are red or blond hair color, family history, actinic keratosis, pronounced freckling of the upper back, three or more blistering sunburns before age 20, and 3 or more years of outdoor summer jobs during the teen years.


Fig. 2. (A) A 74-year-old man with a T2a N0 M0 melanoma of the right nasolabial fold. (B) Close-up view of T2a melanoma of the right nasolabial fold. (C) Technetium scan demonstrates sentinel lymph node in the right level I region. (D) Intraoperative view of wide local excision of the lesion with superiorly based melolabial flap elevated. Note closed incision in the right level I after sentinel node biopsy. (E) Flap inset.


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Fig. 3 (continued).

surgical management of cutaneous melanoma


Fig. 4. (A) 77 year old male with T4N0M0 melanoma of left cheek. Pre-operative frontal view. The patient had no clinical or radiographic evidence of metastatic disease. The patient refused elective neck dissection and parotidectomy and was treated with wide local excision of the lesion and observation of the neck and regional lymphatics. (B) Pre-operative lateral view. (C) Intraoperative view of the planned excision with 2 cm. margins. Note additional excision of synchronous basal cell carcinoma of the left temporal region. (D) Intraoperative view of excision and supraclavicular full-thickness skin graft donor site. (E) Intraoperative view of defect repaired with full-thickness skin graft prior to placement of bolster. (F) Approximately 2 weeks post-operative lateral view demonstrating 100% take of full-thickness skin graft. (G) 6 months post-operatively, the patient developed a palpable parotid node. CT scan was obtained and the patient underwent superficial parotidectomy. The patient refused to undergo a concurrent selective neck dissection. Final pathology identified metastatic melanoma in 4 lymph nodes. (H) 12 months s/p wide local excision of his T4 melanoma, and 6 months s/p superficial parotidectomy, the patient developed a mass in the level 2 adenopathy. A left modified radical neck dissection was performed. (I) Intraoperative view of left modified radical neck dissection. Final pathology demonstrated metastatic melanoma in 2 lymph nodes. (J) Post-operative frontal view. Patient is currently well without any evidence of metastatic disease. (K) Post-operative lateral view.


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Fig. 4 (continued).

surgical management of cutaneous melanoma


association with lentiginous melanocytic proliferation was greater in the patients of advanced age. A family history of melanoma results in a two- to eightfold higher risk for the development of melanoma in the relative [10]. Immunosuppression for transplantation and patients with lymphoma or leukemia are also at increased risk for the development of malignant melanoma [11,12]. The benefit of identifying all of these risk factors is the potential positive effect of public education on reducing the incidence of malignant melanoma through reduction of exposure and the formation of effective screening programs. Diagnostic characteristics and challenges

Fig. 4 (continued).

Possessing one or two of these risk factors was found to correlate with a three- to fourfold increase in incidence of developing malignant melanoma. Identification of three or more of these risk factors correlated with a 20-fold increased individual risk. Additional risk factors have been identified by other researchers. The presence of pre-existing pigmented cutaneous lesions of the head and neck is well correlated with the development of malignant melanoma. Approximately 70% of cutaneous melanomas of the head and neck develop in existing pigmented lesions [7]. The lifetime risk of the development of melanoma within the lesion for patients with large (>20 mm) congenital nevi is 20% [8]. The risk of malignant melanoma in patients with dysplastic nevus syndrome is accepted as 100%. The association between benign melanocytic lesions and malignant melanoma was demonstrated in a paper by Skender-Kalnenas et al [9]. The article evaluated 289 cases of thin (<1 mm) malignant melanoma for the presence of histologic association with benign melanocytic lesions. Thin lesions were selected to avoid the obliteration of associated lesions by the growth of melanoma. A nevus was found in association with 51% of the melanoma cases. Of these cases, 82 (56%) were dysplastic nevi, 61 (41%) were common acquired nevi, and 4 (3%) were congenital nevi. Lentiginous melanocytic proliferation was present in the epidermis adjacent to 219 (75%) of the melanomas with a coexisting nevus in 97 (44%) of the melanoma specimens. The

Characteristics commonly ascribed to most malignant melanomas include asymmetry, border irregularity, color variegation, and a diameter larger than 6 mm. Any growth or significant characteristic change in an existing pigmented lesion also should be evaluated carefully and a high index of suspicion should be maintained. The four types of melanoma are superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. Superficial spreading melanoma is the most common type of melanoma. Superficial spreading melanoma accounts for approximately 70% of all melanoma diagnoses. A prolonged radial growth phase may predate the development of actual invasion. Nodular melanoma is diagnosed in approximately 15% of all cases. This particular form has an immediate vertical growth phase and is commonly seen later in life (fifth to sixth versus fourth to fifth decades) than is superficial spreading melanoma. Amelanotic melanoma is a rare variant of the nodular form of melanoma. Despite the name, these lesions may range from flesh tone to pink and even red. Acral lentiginous melanomas are seen approximately 10% of the time. These cases are seen in greatest numbers in blacks and Asians and are commonly seen on the hands and the soles of the feet [13]. A few lesions can be mistaken for melanoma: seborrheic keratosis, dermatofibroma, pigmented basal cell carcinoma, lentigines, and melanocytic nevi. With great care, these lesions can be differentiated from malignant melanoma. One always should maintain a high level of suspicion, however, and if the clinician remains doubtful, excision is warranted.

Biopsy and excision technique Evidence suggests that wide excision of a lesion suspicious for malignant melanoma is the best


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possible biopsy technique. Austin et al [14] reported a statistically significant difference in survival for patients who initially underwent excision of the lesion versus incisional or other biopsy. In this study, only 8.9% of patients who underwent excisional biopsy died of disease, whereas 25% of patients who had incisional biopsy and 31.3% of patients who had some other form of biopsy died of melanoma. One possible reason for such a striking difference is that there may be a treatment delay between incisional, punch, or shave biopsy and definitive excision of the lesion, which allows time for local or distant dissemination of disease. Another plausible explanation for such a striking difference is that the incisional and other techniques may alter the local defense mechanism and allow easier dissemination. Whenever possible, excision should be the selected method of biopsy. Complete excision of the suspect melanoma, the underlying subcutaneous tissue, and an appropriate margin of uninvolved normal-appearing tissue is recommended. Selection of an appropriate surgical margin requires considerable thought. In general, the wide margins recommended in extremity and truncal melanoma are inappropriate on the face because of the differences in clinical behavior and the proximity to adjacent vital structures. Such a large excision would, however, be recommended for a scalp melanoma because of the high incidence of satellites and in-transit metastases [15]. Excisions should be performed within facial esthetic units wherever possible without direct infiltration of local anesthetic fluid because it could distort tissue planes. Either field block technique or general anesthesia should be used. Diagnosis should be made on permanent histopathology. Accurate assessment of the margins requires that the specimen be oriented properly. Excision of the primary lesion is based on the thickness of the lesion, which often is not known at the time of initial treatment. When this is the case, a 1-cm margin of normal tissue should be obtained down to the level of the fascia. There has been considerable disagreement in the past regarding the appropriate width of excision. The primary reason for this debate is the attempt to obtain local control of disease. The World Health Organization recommends excision of 1 cm for lesions less than 1 mm thick and 3 cm for lesions more than 1 mm thick [16]. The actual margin of excision was noted by Cruse et al [17] to be of no significance in the rate of local recurrence. Local recurrence seems to correlate more strongly with thickness. The study reported 0 to 2% recurrence in lesions less than 0.76 mm thick and 3% to 5% in lesions thicker than 0.76 mm. Surgical

management of the primary malignant melanoma of the head and neck is generally accomplished with 1- to 2-cm margins, with exceptions made to avoid the involvement of adjacent anatomic structures (ie, eyes). Appreciation of esthetic facial units is also required of the ablative head and neck surgeon with respect to the management of malignant melanoma of the face. Many head and neck melanoma resection sites can be closed directly (eg, ear, cheek, brow), whereas other areas may require full-thickness skin graft or local flaps (eg, nose, eyelid, scalp). When a parotidectomy, neck dissection, or sentinel node biopsy is planned, the access incision design for that procedure must be determined and taken into consideration early in surgical planning. This is necessary so that alterations to standard incision design can be made to facilitate local flap closure. Access incision design for sentinel node biopsy also should be a portion of the incision required for comprehensive neck dissection. It is often best to outline the incision design for comprehensive cervical lymphadenectomy and then select the portion of the design to open for the sentinel node biopsy procedure based on the signal obtained with the intraoperative use of the gamma probe.

Management of regional lymphatics Surgical management of the regional lymphatics is also an issue of considerable debate in the setting of the absence of palpable disease. Thin melanoma management requires no treatment of the regional lymphatics because the prognosis for cure approaches 100%. Patients with intermediate thickness (0.76 – 1.49 mm) melanoma of the head and neck develop regional lymph node metastases in approximately 25% of cases and distant metastases in less than 10% of cases [18]. In the absence of ominous histologic features such as nodular configuration, ulceration, or Clark level IV depth or presentation on the scalp, some clinicians decide not to remove the regional lymphatics electively [19]. Avoidance of complications associated with neck dissection is generally why lymphadenectomy is not performed in this setting. The emergence of the concept of the ‘‘sentinel node’’ and selective sampling of this node has impacted clinical decision making most in regard to thin and intermediate thickness lesions [20,21]. Identification of the primary nodal drainage basin first must be performed using lymphoscintigraphy. Wells et al [22] documented variation between the predicted and

surgical management of cutaneous melanoma

actual lymphatic nodal drainage of melanoma lesions of the head and neck in a study of 25 patients with clinical stage I and stage II melanoma of the head and neck, 18 of whom underwent selective lymphadenectomy based on preoperative lymphoscintigraphy. Because of discordant lymphoscintigraphy, alteration of neck dissection occurred in 13 of 21 patients (62%). In 2 of these patients, dissection of a nodal group that was not predicted clinically but was demonstrated by the lymphoscintigraphy resulted in the detection of metastatic nodal disease [22]. The principle involved in sentinel node biopsy is the intraoperative staining of the first node or nodes that receive lymphatic flow from the area of the primary lesion. These nodes are then removed via a conservative incision that is well planned to allow extension should the nodes prove positive for metastatic disease that necessitates comprehensive lymphadenectomy. Increasingly, a combination of vital dye and radionucleotide technique is used [23 – 25]. With this technique, the surgeon has two means of detecting the most appropriate node or nodes for intraoperative sampling. The radionucleotide is collected and stays longer in the appropriate lymph nodes than the vital dye. The use of a gamma probe is believed to enhance accuracy. Readers are encouraged to explore a point-counterpoint discussion penned in the British Journal of Dermatology [26,27] regarding the role of sentinel node biopsy. These articles provide an excellent historical background and thorough discussion of the advantages and disadvantages of the technique in an easily read format. The immediate analysis of the removed sentinel node or nodes is performed using hematoxylin and eosin staining and immunohistochemistry assay [28,29]. Staining of the sentinel nodes is accomplished by the injection of blue-V or isosulfan blue dye, 0.5 mm, intradermally every 20 minutes with gentle massage of the tumor excision site. If the node is found to be positive for melanoma, cervical lymph node dissection is performed in the standard fashion. If the results of the report are negative for the presence of melanoma cells in the sentinel node, the surgeon must decide whether to proceed with lymphadenectomy. If the surgeon would perform neck dissection in the setting of a negative sentinel node biopsy, then the sentinel node biopsy procedure was an academic exercise at best. The only setting in which such a procedure should be planned is if the clinician is attempting to gain experience with the technique. Early data showed that patients with intermediate thickness melanomas (1.5 – 3.99 mm) of the head and


neck have a 57% incidence of regional nodal metastases and exhibit systemic dissemination in 15% of cases [18]. Elective neck dissection in the absence of clinically evident nodal disease was widely accepted for this group of patients [19,30]. Lymph node dissection for lesions of the temporal scalp, lateral forehead, preauricular skin, and anterior ear most often involved parotidectomy and removal of the preauricular lymph nodes. The nodal drainage pattern can be determined more precisely through the use of lymphoscintigraphy. Patients with melanoma of the head and neck that is 4 mm thick or more develop distant metastases in more than 70% of cases [18]. Patients with thick melanoma without clinically evident regional metastases should consider elective neck dissection to decrease tumor burden and avoid regional recurrence in ‘‘anticipatory palliation’’ [31].

Unknown primary The presence of cervical or parotid lymph node metastases without an identifiable primary lesion is said to occur in up to 5% of all cases of melanomas. These lesions occur disproportionately in the head and neck and in men. The proper management of the regional lymphatics in the setting of no identifiable primary lesion has been under debate for some time. Comprehensive cervical lymphadenectomy or parotidectomy with facial nerve preservation is the most commonly recommended treatment. The total number of reported cases remains small, however, and the therapy used in these cases has not been standardized. Coordination of care with radiation therapy and oncology for consideration of adjuvant radiotherapy or immunotherapy is recommended. The focus is clearly on preservation of function. There seems to be an improved survival by stage alone in these cases of unknown primary melanoma. Nasri et al [32] documented 46 cases of head and neck malignant melanoma with unknown primary. The evident metastases were present in the cervical lymphatics 74% of the time and in the parotid lymph nodes 26% of the time. Neither the location of the metastases nor the method of neck dissection (radical versus modified radical) seemed to impact survival. The only apparent predictor of outcome was the presence of four or more involved lymph nodes at the time of surgery. This group exhibited distant metastases 80% of the time versus 20% in the group of patients with less then four positive cervical lymph nodes. Overall survival rate in the 46 patients of the study was 54%, which is markedly better than the reported rates for sur-


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Table 1 The T classification of melanoma

Table 3 M classification of melanoma

Tumor thickness

Tumor ulceration

Metastasis site

LDH elevation

T1  1.0 mm

Nonulcerated and level II – III Ulcerated or level IV – V Nonulcerated Ulcerated Nonulcerated Ulcerated Nonulcerated Ulcerated

M1a Distant skin, subcutaneous tissue, or node metastasis M1b Lung metastases M1c Any other visceral metastases Any distant metastasis


T2 1.01 – 2.0 mm T3 2.01 – 4.0 mm T4 > 4.0 mm


None Elevated

Adapted from Balch CM, Buzaid AC, Soong SJ, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004;54:131 – 49.

Adapted from Balch CM, Buzaid AC, Soong SJ, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004;54:131 – 49.

vival in patients who exhibit metastases with known primary malignancies.

American Joint Committee on Cancer staging system for melanoma, the Melanoma Staging Committee of the American Joint Committee on Cancer was formed in 1998. It is composed of experts from all relevant medical specialties and includes leaders from most of the major melanoma treatment centers and cooperative groups. The group proposed a modification of the existing staging by 2001 for inclusion in the sixth edition of the American Joint Committee on Cancer staging manual in their paper published in 2001 [34]. The final version of the staging system subsequently was validated in an article from this group that was published in 2004 (Tables 1 to 3) [35]. The resultant staging system proved that thickness and ulceration are the predominant predictors

Staging Staging of melanoma is important to clinicians for many reasons. It is important that all providers use the same criteria and definitions in conversations and studies. Staging provides stratification of therapy and prognostication of outcome and assists clinical decision making considerably. Researchers recognized that improvements in the staging of melanoma could be made by applying evidencebased methods to create and then validate a staging system for melanoma. After the publication of a paper by Buzaid et al [33], which criticized the existing

Table 4 Clinical staging groups for melanoma Table 2 N classification of melanoma

Clinical stage T classification N classification M classification

Nodal metastases

Nodal mass

N1 One node N2 2 – 3 nodes N3 4 nodes, matted nodes, intransit or satellite(s) with (+) nodes

Micrometastasisa Macrometastasisb Micrometastasisa Macrometastasisb Micrometastasisa Macrometastasisb Intransit/satellite(s) with () nodes


Micrometastasis diagnosed after sentinel node biopsy or elective lymphadenectomy. b Macrometastasis with clinically detectable nodes, confirmed with therapeutic lymphadenectomy or with gross extracapsular spread. Adapted from Balch CM, Buzaid AC, Soong SJ, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004;54:131 – 49.


T in situ T1a T1b T2a T2b T3a T3b T4a T4b Any T Any T

N0 N0 N0 N0 N0 N0 N0 N0 N0 Any N Any N

M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 Any M

Includes microstaging of primary melanoma and metastasis evaluation after completed primary excision and clinical evaluation for metastasis. Adapted from Balch CM, Buzaid AC, Soong SJ, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004;54:131 – 49.

surgical management of cutaneous melanoma Table 5 Pathologic staging of melanoma Pathologic stage T classification N classification M classification 0 IA IB IIA IIB IIC IIIA IIIB



T in situ T1a T1b T2a T2b T3a T3b T4a T4b T1 ! 4a T1 ! 4a T1 ! 4b T1 ! 4b T1 ! 4a T1 ! 4a T1 ! 4a T1 ! 4b T1 ! 4b T1 ! 4b Any T Any T

N0 N0 N0

M0 M0 M0





N0 N1a N2a N1a N2a N1b N2b N2c N2c N1b N2b N3 Any N

M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 Any M

Includes microstaging of primary melanoma and nodes after lymphadenectomy. Stage 0 and IA do not require pathologic evaluation of nodes. Adapted from Balch CM, Buzaid AC, Soong SJ, et al. An evidence-based staging system for cutaneous melanoma. CA Cancer J Clin 2004;54:131 – 49.

of survival and that level or depth of invasion matters only in thin (1 mm) lesions [36 – 38]. Thickness proved meaningful in whole numbers groups (1 mm, 1.01 – 2 mm, 2.01 – 4 mm, >4 mm) [39]. Ulceration was a separate and meaningful predictor of survival throughout all groups [40]. The number of metastatic lymph nodes also was prognostic for survival. Site of distant metastasis (nonvisceral versus lung versus all other visceral sites) and the presence of elevated LDH also were prognostic and are included in the staging system (Tables 4 and 5).

Summary Surgical management of cutaneous malignant melanoma of the head and neck requires careful assessment of the primary lesion, use of appropriate biopsy and excision technique, and assessment of the regional lymphatics in all but the thinnest of lesions. Sustained disease-free survival can be achieved with appropriate initial intervention


and serial follow-up. The major significant differences between current and past management are the advent and acceptance (or not) of sentinel node biopsy technique for intermediate thickness lesions without evidence of lymphadenopathy and an improved, validated, staging system. Early diagnosis and management are crucial to improving patient survival. They are best achieved through education of patients and clinicians.

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