Surgical excision margins for primary cutaneous melanoma

Abstract

BACKGROUND: Cutaneous melanoma accounts for 75% of skin cancer deaths. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin. Excision margins are important because there could be trade-off between a better cosmetic result but poorer long-term survival if margins become too narrow. The optimal width of excision margins remains unclear. This uncertainty warrants systematic review. OBJECTIVES: To assess the effects of different excision margins for primary cutaneous melanoma. SEARCH STRATEGY: In August 2009 we searched for relevant randomised trials in the Cochrane Skin Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2009), Medline, Embase, Lilacs, and other databases including Ongoing Trials Registers. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs) of surgical excision of melanoma comparing different width excision margins. DATA COLLECTION AND ANALYSIS: We assessed trial quality, and extracted and analyzed data on survival and recurrence. We collected adverse effects information from included trials. MAIN RESULTS: We identified five trials. There were 1633 participants in the narrow excision margin group and 1664 in the wide excision margin group. Narrow margin definition ranged from 1 to 2 cm; wide margins ranged from 3 to 5 cm. Median follow-up ranged from 5 to 16 years. AUTHORS' CONCLUSIONS: This systematic review summarises the evidence regarding width of excision margins for primary cutaneous melanoma. None of the five published trials, nor our meta-analysis, showed a statistically significant difference in overall survival between narrow or wide excision. The summary estimate for overall survival favoured wide excision by a small degree [Hazard Ratio 1.04; 95% confidence interval 0.95 to 1.15; P = 0.40], but the result was not significantly different. This result is compatible with both a 5% relative reduction in overall mortality favouring narrower excision and a 15% relative reduction in overall mortality favouring wider excision. Therefore, a small (but potentially important) difference in overall survival between wide and narrow excision margins cannot be confidently ruled out. The summary estimate for recurrence free survival favoured wide excision [Hazard Ratio 1.13; P = 0.06; 95% confidence interval 0.99 to 1.28] but again the result did not reach statistical significance (P < 0.05 level). Current randomized trial evidence is insufficient to address optimal excision margins for primary cutaneous melanoma.

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

“…Similarly, several meta-analyses showed no significant difference in overall survival, disease-free survival, and in-transit, regional, or local recurrence. 9,22,23 No significant difference was noted in overall (hazard ratio, 1.04; 95% confidence interval, 0.95-1.15; P>.05) or recurrence-free (hazard ratio, 1.13; 95% confidence interval, 0.99-1.28; P=.06) survival in the Cochrane meta-analysis for wider margins. A recent meta-analysis evaluated disease-specific survival in the 3 randomized controlled trials (N=2357); the pooled metaanalysis revealed an increased risk of death from melanoma for patients undergoing narrow vs wide surgical excision of their primary melanoma (hazard ratio, 1.28; 95% confidence interval, 1.07-1.53; P=.01).…”

“…24 This improvement came at the expense of increased short-term morbidity and patient dissatisfaction with scar appearance. 9 These studies have led to the current widely accepted standard treatment guidelines supported by the National Comprehensive Cancer Network, which recommend 1-cm margins for thin melanoma (<1-mm thick), 1-to 2-cm margins for 1-to 2-mm melanomas, and 2-cm margins for intermediatethickness melanomas (2-4 mm).…”

Optimal follow-up for melanoma

“…In the current treatment of melanoma, the indications for excision margins and staging with SLNB are widely accepted and based on well-designed trials [3,49]. Only clinical stage III melanoma patients should be staged with whole-body FDG-PET, PET-CT or spiral-CT as well as using the serum biomarker S100-B [95,113].…”

“…Guidelines for the treatment of primary melanoma considering excision margins are well defined and widely accepted [3]. There is evidence that nonadherence to these guidelines can be harmful for the patient [4,5].…”

Pigmented Pre-malignant and Malignant Lesions of Skin with Special Reference to Atypical Presentations

“…Malignant melanoma accounts for only 4% of all skin cancers however it is responsible for >75% of all skin cancer related deaths world-wide [1,2]. It is mostly seen in adults with only 2% melanomas occurring in persons younger than 20 years of age and 0.3% in children <14 years old [3].…”