Acral Melanoma

Acral melanomas present particular challenges in management, including:
- The location, which makes reconstruction more difficult:
  - Lesions on non-weight bearing areas of the sole, such as the arch:
    - May be reconstructed with skin grafts with good functional results:
      - However, this option is less acceptable for lesions on the ball of the foot or the heel:
        
        In those areas coverage with thicker tissue, for example an acral skin flap from the arch, is preferable
      - If skin graft must be used, it should be full thickness
SLN biopsy is an effective staging tool for melanoma, including thick lesions:
- Several retrospective studies and the first Multicenter Selective Lymphadenectomy Trial (MSLT-I):
  - Have confirmed the prognostic significance of nodal metastases, even in high-risk lesions:
    - However, SLN biopsy was not found to confer a melanoma-specific survival advantage in the MSLT-I trial:
      - Any potential survival advantage of early nodal treatment:
        
        Appears to be limited to lesions thinner than 3.5 mm
Neoadjuvant treatment of resectable melanoma:
- Is not a standard approach at this time for any resectable melanoma, primary or metastatic:
  - However, some investigation and clinical use of a neoadjuvant approach in BRAF-mutated melanomas with borderline resectable metastases has been suggested
  - A mutation in c-kit may be present in some acral melanomas:
    - But preoperative systemic therapy targeted to that mutation (e.g., imatinib) is not recommended
References:
- Balch C, Soong S, Ross MI, et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0-4.0 mm). Ann Surg Oncol. 2000;7:87-97.
- Bello DM, Ariyan CE, Carvajal RD. Melanoma mutagenesis and aberrant cell signaling. Cancer Control. 2013;20:261-281.
- Gershenwald JE, Mansfield PF, Lee JE, Ross MI. Role for lymphatic mapping and sentinel lymph node biopsy in patients with thick (or = 4 mm) primary melanoma. Ann Surg Oncol. 2000;7:160-165.
- Gillgren P, Drzewiecki KT, Niin M, et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: A randomised, multicentre trial. Lancet. 2011;378:1635-1642.
- Morton DL, Thompson JF, Cochran AJ, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370:599-609.
- Nahabedian M, Wagner JD. Complex closures of melanoma excisions. In: Balch CM, Houghton AN, Sober AJ, Soong S-J, eds. Cutaneous Melanoma. 4th ed. Saint Louis, MO: Quality Medical Publishing; 2003:231-256.
- Thomas JM, Netwon-Bishop J, A Hern R, et al. Excision margins in high-risk malignant melanoma. N Engl J Med. 2004;350:757-766.