The Novel Surgical Margin for One Step Melanoma Surgery (OSMS) (Without Using Ultrasonography Preoperatively): The End of Conformity! ʺVivere militare est!ʺ

Abstract

BACKGROUND: Innovations in medicine are often due to the simplicity of a certain activity, interaction, even counteraction, or a mistake leading to a subsequent final optimal outcome. Innovations could also be due to conclusions based on targeted clinical or sporadic, as well as completely random observations. The genius of an approach or statement is often based on the “iron logicâ€, which in turn is based on irrefutable data or facts. These are often observations or results from actions that happen right before our eyes and provide advantages or prerequisites for the better future development of things (in this case, disease) concerning certain groups of people (in these case-patients). When the clinical results achieved following an inevitable introduction of certain methods or innovations speak eloquently of a number of advantages in terms of 1) spearing effect on the patients, 2) better control or prevention of possible local and/or distant metastatic spread 3) better financial balance for the health institutions and patients, ..., then even the "Gods of certain latitudes" should be silenced. We at this moment present a completely new method or approach for surgical treatment of cutaneous melanoma that once again proves the effectiveness of one-step melanoma surgery, which was successfully first officialised in the world literature again by the Bulgarian Society of Dermatologic Surgery, (BULSDS). In some cases, this method does not even require the preoperative use of a high-frequency ultrasound for determining the tumour thickness.

CASE REPORT: In patients with advanced stage of cutaneous melanoma, removal of a primary draining lymph node and/or locoregional lymph nodes is often performed simultaneously. However, it remains unclear why in patients with early-stage (or intermediate, with moderately thick melanomas) disease high-frequency ultrasound is not applied as a routine method of determination of tumour thickness? Meanwhile, re-excision is required following histopathological verification? Is it necessary to have 2 surgical interventions? The two surgical interventions are a burden for the patients and create prerequisites for contradicting opinions, statements, and subsequent results, which ultimately slows down the patient’s staging and the introducing more precise treatments. Based on the logic (and further aided by the clinical picture and dermatoscopy), we decided to operate selected cases of patients with cutaneous melanomas with a field of surgical security of 1cm in all directions when clinical, and dermatoscopic data are indicative of melanoma in situ or thin melanomas (less than 1 cm). Optimal results were achieved, with one surgical intervention and subsequent rehospitalisation spared for the patient.

CONCLUSIONS: An answer to the question whether it is better not to follow the guidelines strictly (since, as a rule, they are generally recommended and somewhat misleading in certain circles of specialists, and as we have already found, also lead to unjustified logical secondary excisions), or update them at least annually when data for better tumor control is available (using a new method such as the one we mentioned above), should be searched for. This is a method not derived from AJCC/USA or other similar/equal or equivalent organisation’s “recessesâ€! Acceptability of innovations depends to a large extent on the latitude or territory where they originated?! Something that should be changed! Or in other words, something that has already been changed! The End of Conformity, and the beginning of a New Era!