Mayo Clinic Consensus Recommendations for the Depth of Excision in Primary Cutaneous Melanoma

Primary cutaneous melanoma of the scalp: Patterns of recurrence

“…The galea (aponeurotica) of the scalp is equivalent to the panniculus carnosus of lower mammals and it serves as a layer of “superficial fascia”—dividing a superficial lobular fatty compartment from a deep areolar fibrous compartment . When extrapolating the most recent Mayo Clinic guidelines on melanoma excisional depth in the extremities/trunk, satisfactory clearance should be acquired from a sub‐galeal resection and our results logically corroborate this. This method of excision also conveniently permits direct skin grafting to the periosteum and aside from several patients reported in this cohort, a sub‐galeal resection is our routine practice.…”

Excision of fascia in melanoma thicker than 2 mm: no evidence for improved clinical outcome

“…Following excision for diagnosis and measurement of microscopic Breslow depth, a wide and deep margin is taken to ensure complete removal of the primary lesion and to remove any micrometastases . The fact that tumour thickness, being associated with local, regional and distant involvement, has an important effect on the prognosis and outcome of patients with melanoma leads to the consideration that the depth of surgical excision could also influence local recurrence . Although the depth of the melanoma excision has conventionally been to the muscle fascia or deeper, there is currently no sound scientific evidence for or against excision of fascia .…”

“…Correspondingly, the peripheral margin of primary melanoma excision has become more conservative over the last few decades. Nevertheless, the optimal depth of excision remains unknown, although it is possible that the depth of excision may be as important as the width of excision for primary melanoma . Unfortunately, these guidelines do not make direct recommendations about the depth of excision .…”

“…Unfortunately, these guidelines do not make direct recommendations about the depth of excision . Lack of evidence‐based data therefore results in significant variations among surgeons regarding removal or preservation of the deep muscular fascia at the time of wide local excision for primary cutaneous thick melanomas …”

Is a Wider Margin (2 cm vs. 1 cm) for a 1.01–2.0 mm Melanoma Necessary?

“…There have been several large prospective trials which have studied resection margins in melanomas ranging from 0.8 to 4 mm in thickness as summarized in Table 1 [2–7]. These studies were unable to demonstrate a significant difference in overall survival (OS), disease-specific survival (DSS) or local recurrence when a wide margin of 4 or 5 cm was compared to narrow margin of 2 cm [8]. One of the earliest studies to report on margins of resection and recurrence was done by Veronesi et al The authors showed a higher rate of recurrence when a 1 cm margin was used compared to a 3 cm margin for melanomas < 2 mm in thickness, although this was not statistically significant.…”