Risk Factors Predicting Positive Margins at Primary Wide Local Excision of Cutaneous Melanoma

Abstract

Positive margins after WLE are uncommon. When a patient has multiple risk factors for positive margins at WLE, histologically clear margins should be obtained through mapped serial excision or Mohs micrographic surgery.

How Much We Follow Guidelines in Surgery of Melanoma: It's Time to Reflect!

“…Finally, as in previous reports 3,6 , also in this study it is confirmed an important percentage of recurrences in thin melanomas ࣘ1.00 mm (21.6% among melanomas with a recurrence) and that 8.6% of patients with thin melanoma did not regularly follow the guidelines. As reported above, all these findings stress the importance of follow guidelines, also in thin lesions 9 .…”

“…3 In another study, Mangold et al found that, interestingly, patients with positive margins at WLE had positive margins on initial biopsy and a higher rate of melanoma in situ component on initial biopsy. 6 In a wider study of 11.290 thin melanomas (ࣘ1.00 mm), MacKenzie Ross et al confirmed that a ࣙ1 cm clinical excision margin for thin (T1) primary melanomas reduces significantly the risk of local recurrences. 7 All these findings, stress the importance to follow surgical guidelines for melanomas, starting also from early stages.…”

Considerations for Timing of Defect Reconstruction in Cutaneous Melanoma of the Head and Neck

“…The reported incidence of positive margins ranged from 6 to 20.9% (►Table 1). 4,[7][8][9][10][11][12][13][14] The average rate of positive margins on wide local excision specimens across all studies was 10.1% (170/1,690). Biopsy modality, multiple biopsies at tumor site prior to wide local excision, ulceration, tumor thickness, locally recurrent tumors, increasing patient age, melanoma in situ (MIS) component, noncompliance with recommended margins, histological regression, and the desmoplastic subtype were identified as risk factors for positive margins in these studies.…”

“…Biopsy modality, multiple biopsies at tumor site prior to wide local excision, ulceration, tumor thickness, locally recurrent tumors, increasing patient age, melanoma in situ (MIS) component, noncompliance with recommended margins, histological regression, and the desmoplastic subtype were identified as risk factors for positive margins in these studies. [7][8][9]11,12,14 Namin Zitsch found that the diagnosis of melanoma by shave biopsy or punch biopsy was associated with positive margins on wide local excision, and Miller et al found that multiple biopsies at the tumor site before wide local excision were associated with positive margins on wide local excision. 8,11 Ulceration was associated with positive margins on wide local excision in one of the studies included.…”

Frequency of and risk factors for tumor upstaging after wide local excision of primary cutaneous melanoma

“…However, excisional biopsies were less likely to have negative margins (both deep and lateral) for melanomas on the head, neck, hands, feet, genitals, or pretibial leg (26%, 8/31) versus those on the trunk and proximal extremities (54%, 54/100). The increased risk for upstaging, whatever the method of biopsy, adds to the well-documented challenges of positive margins [30][31][32][33] and local recurrence 16,[33][34][35][36][37][38][39][40][41][42][43][44][45][46] after wide local excision of melanomas on the head, neck, hands, feet, genitals, or pretibial leg. An explanation for the significance of the risk factors old age (OR 1.03, 95% CI 1.01-1.06, P = .002) and non-LM histopathologic subtype (OR 0.28, 95% CI 0.12-0.64, P = .002) is unclear.…”