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

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 logic", 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 "recesses"! 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!

Introduction

The melanoma surgery is based on certain guidelines according to which the main therapeutic steps are: 1) primary excision of melanoma with margins of surgical safety of 0.5 in all directions, 2) histological examination of the removed lesion and determination of the tumor thickness according to the Breslow method, on the basis of which follows 3) determination of the necessity of reexcision with extended margins of surgical safety with or without removal of the draining lymph nodes [1]. The current recommendations of the American Academy of Dermatology are: for melanoma in situ excision with margins of safety from 0.5 -1.0 cm in all directions; for tumor thickness <1 mm, 1.0 cm in all directions, by thickness 1.01 and 2.0 mm: 1.0-2.0 cm and by tumor thickness >2 mm: 2.0 cm (1). This variability in the centimeters of surgical safety (0.5-1.0 cm for melanoma in situ and 1.0-2.0 cm for tumor thickness between 1.01 and 2 cm) can be often confusing for the clinician and often this comprehensiveness or to some extent definitiveness (without specification or personalization depending on the clinical and dermatoscopic characteristics of the lesion) leads to the loss of the individual approach towards the patient [2]. One step of melanoma surgery is an approach which corrects this drawback of the guidelines and considers each patient as an individual set of characteristics [3].

Case report

We present a sixty-three-year-old patient in good general condition. He is admitted to the clinic for the first time due to surgical removal of a melanocytic lesion located in regio abdominalis sinistra and many year duration. From the dermatological examination was established the presence of oval hyperpigmented lesion (Figure 1a). This discovery met the requirements for a malignant melanocytic lesion clinically and dermatoscopically. Additional tests were performed and from the paraclinic was noticed the light form of dyslipidemia and PSA- 13.900 (< 4.0). The apparat diagnostic was without indication for process dissemination.

Figure 1

a) Clinical manifestation of melanoma and preoperative surgical skin marking with 1.0 cm filed for safety in all directions; b, c) Elliptical surgical excision of the lesion under local anaesthesia; d) Wound closure with simple interrupted sutures

A conversation with the patient about the advantages and disadvantages of the one step melanoma surgery was conducted, and accordingly, preoperative informed consent of its execution in outpatient conditions was signed.

The suspected for malignant melanoma lesion was radically removed under local anaesthesia (Figure 1 b, d). By clinical and dermatoscopic data (indicative for melanoma under 1mm), the operation was performed with a field of surgical safety of 1cm in all directions (Figure 1 b, c). The closure of the surgical defect followed via an expandable plastic (Figure 1d). The histological test confirmed the originally clinically and dermatoscopically set diagnosis: melanoma in situ, clear resection lines.

Discussion

In that case, if the therapeutic approach was based on the current guidelines, the treatment should start with a primary excision of the melanocytic lesion with a field of safety of 0.5 cm in all directions followed by postoperative measurement of the tumour thickness [4]. Depending on the histologically established thickness, during the so-called second stage, an assessment of the reexcision necessity with othe r without removal of the draining lymph nodes has to be performed [4]. In the case of our patient, the decision for only one initial excision of 1cm in all directions was taken by clinical experience and dermatoscopic data. Both indicated malignant melanoma < 1 mm. The described case is a vivid consecutive example of how, with only one surgical intervention, diagnosis and surgical treatment are achieved simultaneously without the patient is subject to a second surgical session [3].

In given cases, the determination of the surgical margins can be supported by preoperative ultrasonographic examination of the tumour thickness [5]. This should not be a prerequisite by patients with thin melanomas (determined by definitive clinical and dermatoscopic criteria), and in that case, the many year’s clinical experiences are enough. Although one step melanoma surgery does not follow the guidelines, it provides a radical removal of the melanoma via adequately respecting the surgical safety margins for the respective tumour thickness by considering the recommended by the guidelines resection fields [6].

The main advantages of this one-stage model are 1) melanocytic lesion removal with one operative (surgical) session, instead of two, in cases of thin melanomas which inevitably 2) decreases the risk of complications which every additional surgical intervention contains and 3) leads to significant financial relief.

It should be noted though that this method is applicable only to certain groups of patients. This fact should be considered critically and individually assessed for each patient.

It is not clear why, for the time being, these innovative opportunities are overlooked? It is not the good perception of innovations (but namely the lack of any arguments available against them) that would determine to a certain extent the current surgical approach conducted in melanoma patients (albeit it is too extreme as a definition) to a certain extent as „populistic, unconsidered and deliberate”.

The conformism is (sickness and weakness) spread not only in politics, fashion and the social sphere but also in medicine. The human desire to perceive him/herself, or to be falsely accepted or perceived as a part of a large, a whole, „complete society”, not to be isolated, misunderstood, ignored-this is the perpetual generator of energy for the conformism (Figure 2) [7] [8] [9]! This gives rise to and “feeds” the conformism, or otherwise said: our fears lead us to the loss of our individuality and identity:” To be afraid to be wrong! Not to break the “basic, accepted norms” that are created by someone and for a certain purpose? In order not to be isolated and understood in a wrong way?! (Figure> 2c)”.

Figure 2

a), b) The conformism leads to depersonalization and loss of individualisation. When the respective person does not understand the group’s ideas but notices that the latter has an influence, then that person seeks to join it. The reason for this affiliation is the most often the fear of isolation and the lack of competence on certain issues or topics. Uniting with the group solves this problem and the individuals in question enter their area of comfort as they do not want to be disturbed. They make themselves equal (I would say them descent too) with the group’s ideas and problems only within the pseudo-identification. They attend congresses and have 20 years of work experience, but they are not aware of what the fields of surgical security in melanoma patients are or should be!? They nod assent approvingly on themes that are totally unclear to them!? They make presentations on topics they do not understand. They strive for the group to solve all the problems. They implicitly obey. This is the so-called or the “flock” in question. This situation is analogous and identical in medicine, politics and the social sphere. That is why we use it as a model for determining a given individual in a given situation and under certain conditions. The conformism is a 100% model for problem generation but also a model within which we find solutions too! And we present them in “all their glory”!; c) Fluctuations and differences are not tolerated if they are noticed. The reason is that they can break the status quo and cause turmoil, doubt, and so on. And the turmoil creates anxiety, revolution, and dissent. The turmoil leads to the provocation of questions, and hence inevitably explanations should also be given. The turmoil leads to a loss of capital in certain lobbies. And this eventually ends up remodelling the “artificially created landscape!” “To become sober from the heavy hangover!”. To the public shame of the revealed unconventional approaches that have been applied by the recent references of imitation. Therefore, it must be suppressed and destroyed. The turmoil is harmful; d), e) At the basis of conformism is the manipulation, brainwashing, and the intrusion of the intrusive ideas, that you feel good, that you are most appreciated that it is also so for all your friends and relatives and that you should be pleased. But actually, you live in a pseudo-realism, you have pseudo-desires, have pseudo-ideas (knowing nothing about them), do pseudo-actions (not knowing what they will bring), pseudo-family, pseudo-sensations, even pseudo-therapy? And all the desires and messages directed to you have one, though a “slightly or softly transmitted” form of order, which is meant to “pacify and tame” you! To put you into the “right order” of the law or the guideline! Given from the top” finely and elegantly, or a little bit “roughly and insensitively”. But instructive and threatening! Or in the form of party assemblies, secret societies, international guidelines, symposia, congresses, dinners, romantic walks in Venice or the Greek islands, etc.? However, the stimulation of independent thinking is again strictly prohibited. It is defined as risky. That is why it should be turned in the right direction

It could be summarised as follows: “When you have nothing to offer when you are afraid to be different then you are allowed to be cowardly, to have no face and go against yourself (Figure 2 a, b). You’re even allowed to put a bell on your neck and to shout. You are allowed to be conformist and to be a part of the society which probably does not care for you, as long as you are quieter than the grass. The advantage is that you are allowed to graze from time to time (Figure 2 a)”.

It is a paradox that even the sheep beware themselves of the wolf for all their life but are slaughtered and eaten by the shepherd? The one who supposedly takes care of them? And preserves them from the monsters’ evil (which 98% of them will never even meet)? That’s the idea-not to be eaten by the wolf. Finally, however, they are eaten by the shepherd, their guardian!

Isn’t it analogically in medicine-the question is only rhetorical.

If we optimise the baseline positions for diagnosis and treatment of melanoma, …if we smooth out the possibilities for a wrong or inadequate primary approach? Then an enormous number of patients would not reach a terminal stage where the means for innovative treatments are sometimes out of control? Out of limits? Out of reason?

The individualisation of the therapy in the early stages of melanoma should be our duty and priority as clinicians. The rough arithmetic indicates that a change of the baseline conditions or the treatment rules for melanoma would result in an inimitable optimisation of amounts (grossly or grosso modo) of no less than 300 to 500 million dollars (worldwide). For some units of the “food chain”, these would not be advantages (saved fates), but simply- losses! We are letting readers guess who they are! These are the ones, who would be interested in the pharmaceutical industry to flourish and to take care of carefully prepared innovations!

Is it also interesting what feeds the conformism? The manipulations of the people around us (mainly), the inferiority complex within us (a necessary condition), the weakness of our characters (often an available condition), the fear of being ourselves (often an available condition)? And in fact, it turns out that our differences, …. this is our biggest advantage? Differences, this is the progress! “Vivere militare est”-“To live means to fight“.

Since ancient times, the progress has been made with fire and sword (Figure 3 a, b, c)! The lack of acceptability and discutability of the proposed innovation necessitates their application (as if you are certain in your actions-you do not wait for approval), which is successful as already shown by us. And when the results are indicative, then also the “gods” are silent! That is why the one step of melanoma surgery is successful. It is because of this-it takes place without the need for the consent of certain circles and lobbies. That is why we meet the silence of these circles, but also the smiles of the satisfied patients!

Figure 3

a), b) and c) Duplicity and manipulation are characteristic of human traits. They have accompanied humanity since prehistoric times and have been the cause of countless wars and losses of human lives. Unfortunately, even today, we are again in a continuous state of war as well as a complete information blackout. The reason is again in the fact that the changes and the different thinking give rise to the revolutions. They should not be allowed, although they provide or could provide benefits to certain groups. Manipulation and disinformation are the main cause of the decay of the society and human civilisation as a whole. A civilization that does not learn from its mistakes! A civilization that does not allow the innovation unless it originates from certain circles or is refracted through certain prisms. Regardless of the fact that this would cost human fates. That is why innovation in all spheres should not be subject to control. But to debates, proof and quick perception. However, the important thing is: Innovations can be carried out without the consent of certain circles, whether it is “the Pacific influences” or “Some Western European trends!” But then the first step should be made by ourselves. And then - we should not expect approval from the “strongest of the day” or from the “pseudo-reality”! We just have to be ourselves: “Vivere militare est!”

We must not forget that the conformism, aided by the manipulations of the people around us or those surrounding us, and the “flock mental make-up” -these are the factors that are mutually potentiated, are stuck in a diabolical circle and are inevitably linked with severe consequences to us and to others (especially in medicine), namely: 1) the loss of individuality, 2) the inability to progress in general, and sooner or later, though it sounds cruel, selfish and extreme … and 3) the loss of a human life (Figure 2d).

The ability to simplify means to eliminate the unnecessary so that the necessary may speak (Figure 4a). This is the reason why we have opened the way for one step melanoma surgery (OSMS) for our patients. Because simple ideas as the OSMS could solve (in a high per cent of the cases) complex problems (Figure 4b).

Figure 4

Simplicity and geniality? Probably connected?