Melanoma In Situ: A Critical Review and Re-Evaluation of Current Excision Margin Recommendations

Friedman, Erica B.; Scolyer, Richard A.; Williams, Gabrielle; Thompson, John F.

doi:10.1007/s12325-021-01783-x

Cited by 14 publications

(12 citation statements)

References 56 publications

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“…2 Reported recurrence rates vary from 6% to 20% following wide local excision (WLE) using the guideline-recommended 5 mm surgical margins for melanoma in situ. 3,4 As a result, international LM guidelines acknowledge larger margins (i.e. 5-10 mm) may be necessary to achieve local control, while for LMM the larger surgical margins are defined according to the tumour thickness.…”

Section: Introductionmentioning

confidence: 99%

“…Consequently, the optimal surgical management and margins for LM/LMM are still a matter of debate. 3 Mohs' micrographic surgery (MMS) allows intra-operational en face assessment of the surgical margins. Unfortunately, MMS is not only limited by requiring extensive training, but more importantly, the use of frozen sections is not universally accepted in the treatment of melanocytic lesions as it can result in artefactual and fixational changes in the excisional specimens.…”

Section: Introductionmentioning

confidence: 99%

“…These recurrences are the result of incomplete resections due to the often poor clinical demarcation likely because of clinically undetectable field cancerization 2 . Reported recurrence rates vary from 6% to 20% following wide local excision (WLE) using the guideline‐recommended 5 mm surgical margins for melanoma in situ 3,4 . As a result, international LM guidelines acknowledge larger margins (i.e.…”

Section: Introductionmentioning

confidence: 99%

“…Consequently, the optimal surgical management and margins for LM/LMM are still a matter of debate 3 . Mohs' micrographic surgery (MMS) allows intra‐operational en face assessment of the surgical margins.…”

Section: Introductionmentioning

confidence: 99%

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Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Elshot

Tio

With

et al. 2023

Acad Dermatol Venereol

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Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non‐Randomized Studies instrument. Meta‐analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline‐recommended margin was insufficient in 21.6%–44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%–1.9%), and highest for WLE (13%; 95% CI, 7.2%–21.6%). The mean follow‐up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld‐RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma‐associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH‐RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Elshot

Tio

With

et al. 2023

Acad Dermatol Venereol

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“…Friedman et al performed a review of current excision margin recommendations for melanoma in situ in 2021. 13 The authors reported that the rate for a complete excision with a 5 mm margin was variable, ranging from 42% to 70%, according to the studies. The present study observed a rate of 84%.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of imiquimod in the management of lentigo maligna

Daude

Dinulescu

Nguyen

et al. 2023

Acad Dermatol Venereol

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BackgroundLentigo maligna (LM) is a melanocytic proliferation occurring on photo‐exposed skin that may progress to LM melanoma. Surgery is recommended as first‐line treatment. Excision margins of 5–10 mm remain, without international consensus. Several studies have shown that imiquimod, an immunomodulator, induces LM regression. This study investigated the effect of imiquimod versus placebo in neoadjuvant settings.Patients and MethodsWe performed a prospective, randomized, multicentre, phase III clinical study. Patients were randomly assigned in 1:1 ratio to receive imiquimod or placebo for 4 weeks, followed by LM excision 4 weeks after the last application of imiquimod or placebo. The primary endpoint was extra‐lesional excision, with a 5 mm margin from the residual pigmentation after imiquimod or vehicle. Secondary endpoints included the gain on the surface removed between the two groups; number of revision surgeries to obtain extra‐lesional excisions; relapse‐free time; and number of complete remissions after treatment.ResultsA total of 283 patients participated in this study; 247 patients, 121 patients in the placebo group and 126 in the imiquimod group, accounted for the modified ITT population. The first extralesional extirpation was performed in 116 (92%) imiquimod patients and in 102 (84%) placebo patients; the difference was not significant (p = 0.0743). Regarding the surface of LM, imiquimod reduced the LM surface (4.6–3.1 cm2) significantly (p < 0.001) more compared to the placebo (3.9–4.1 cm2).ConclusionImiquimod reduces the lentigo maligna surface after 1 month of treatment, without a higher risk of intralesional excision and with a positive aesthetic outcome.

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Recurrence Rate of Small Melanoma In Situ on Low-Risk Sites Excised With 5-mm Excisional Margin

Sun,

Lim,

De’Ambrosis

et al. 2024

JAMA Dermatol

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ImportanceThe incidence of melanoma in situ (MIS) has increased significantly over the past decades, and traditional guidelines for treatment of MIS have been excision with a 5-mm clinical margin; however, current Australian and other guidelines now recommend 5- to 10-mm margins. This changed recommendation was largely driven by the outcomes of studies using Mohs micrographic surgery, and recent studies using Mohs micrographic surgery are advocating for even wider excisions up to 18 mm for clearance.ObjectiveTo assess the rate of recurrence of MIS excised with a 5-mm margin.Design, Setting, and ParticipantsThis case series studied all MIS lesions from a single private dermatology clinic between January 1, 2011, and November 30, 2018. The criteria for inclusion were a documented 5-mm excisional margin on operation report and more than 5 years of site-specific follow-up after wide local excision. Lesions were excluded if the excisional margin was more than 5 mm or undocumented, there was less than 5 years of follow-up, or they required more than 1 wide local excision. Data analysis was performed January 30 to February 25, 2024.InterventionWide local excision with 5-mm margin.ResultsA total of 351 MISs were identified from 292 patients (mean [SD] age, 60.3 [11.8] years; 162 females [55.5%]). Superficial spreading melanoma was the most common subtype diagnosed (177 lesions [50.4%]), followed by lentigo maligna (107 lesions [30.5%]) and lentiginous MIS (67 lesions [19.1%]). The trunk was the most common location of lesions (168 lesions [47.9%]), followed by upper limb (96 lesions [27.4%]) and lower limb (59 lesions [16.8%]). Scalp was the least common location (2 lesions [0.6%]). Most of the lesions were small, with 274 lesions (78.1%) having a length less than 10 mm and 312 lesions (88.9%) having a width less than 10 mm. A total of 348 lesions (99.1%) did not have clinical recurrence after excision with a 5-mm clinical margin following then current guidelines. A total of 3 lesions (0.9%) experienced local recurrence with no metastatic spread.Conclusions and RelevanceThis case series found that excision with a 5-mm margin for MIS of smaller size (&lt;10 mm) on low-risk body sites had a low rate of recurrence. Conservative 5-mm excisional margin is likely to be suitable for small MIS on lower-risk body sites.

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Melanoma In Situ: A Critical Review and Re-Evaluation of Current Excision Margin Recommendations

Cited by 14 publications

References 56 publications

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Efficacy of imiquimod in the management of lentigo maligna

Recurrence Rate of Small Melanoma In Situ on Low-Risk Sites Excised With 5-mm Excisional Margin

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