Primary Excision Margins, Sentinel Lymph Node Biopsy, and Completion Lymph Node Dissection in Cutaneous MelanomA: A Clinical Practice Guideline

Abstract

Background For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (SLNB), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck.Methods Using Ovid, the MEDLINE and EMBASE electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of SLNB for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017.Results Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ SLNB should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection.Conclusions Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Prognostic factors for in-transit metastasis in patients with malignant melanoma

“…The principles of a complete surgical resection are well defined, as resection margins should be appropriate in order to avoid and also decrease the risk of local recurrence. The conclusions of several randomized clinical trials helped define a consensus regarding the appropriate surgical margins according to the stage of the tumor [24,[34][35][36]. Moreover, a hypothesis was raised whether to perform a sentinel lymph node biopsy (SLNB) or complete lymph node dissection (CLND) to avoid a higher risk of developing in-transit metastasis.…”

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

“…3 ) with the goal of obtaining complete histologic clearance and thereby minimizing the risk of local recurrence (Table 1 ). However, the most recent guidelines from the USA [ 7 , 8 ], Australia [ 9 ], and Canada [ 10 ] recommend clinical margins of 5–10 mm for MIS. These guidelines recognize the high incidence of subclinical extension of MIS [ 11 ], especially LM, and suggest that these lesions often require clinical clearance margins greater than 5 mm to achieve histologically clear margins.…”

“…Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable Level 4 (case series, poor quality cohort and case–control studies) Cancer Care Ontario [ 10 ] Canada 2019 Margin; 5–10 mm Not stated European Society for Medical Oncology (ESMO) [ 52 ] Europe 2019 Margin; 5 mm All margins; level II (RCT), grade B (strong or moderate evidence generally recommended) Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF [ 53 ] Germany 2019 A complete excision with histopathological control should be performed Consensus 88% Italian Association of Medical Oncologists [ 54 ] Italy 2019 Margin; 5 mm Low Regional Cancer Centre [ 55 ] Sweden 2019 Margin; about 5 mm Not stated American Academy of Dermatology [ 8 ] USA 2019 Margin; 5–10 mm Lower level (not further explained) National Comprehensive Cancer Network (NCCN) [ 7 ] USA 2019 Margin; 5–10 mm Level 2B (lower level evidence, NCCN consensus) European CanCer Organisation (ECCO) [ 56 ] Europe 2018 Margin; 5 mm Not stated Finnish Melanoma Group [ 57 ] Finland …”

Near-Infrared Fluorescence Imaging for Sentinel Lymph Node Identification in Melanoma Surgery

“…Melanoma represents only 3% of the skin cancers diagnosed each year; however, the disease is accountable for approximately 65% of skin cancer-related deaths [1]. Standard management for patients with clinically node-negative melanoma includes evaluation of regional lymph nodes by means of a sentinel lymph node (SLN) biopsy [2]. SLN biopsy is classically performed using a blue dye (isosulfan or patent blue) and a radioactive tracer (Technetium ) in order to identify the first lymph node or nodes that drain the primary melanoma site [2].…”

“…Standard management for patients with clinically node-negative melanoma includes evaluation of regional lymph nodes by means of a sentinel lymph node (SLN) biopsy [ 2 ]. SLN biopsy is classically performed using a blue dye (isosulfan or patent blue) and a radioactive tracer (Technetium [Tc-99]) in order to identify the first lymph node or nodes that drain the primary melanoma site [ 2 ]. Despite advances in medical technology, pathologic analysis, and surgical techniques, false-negative SLN biopsy is still reported to occur in 13% of cases [ 3 ].…”