Margin Width in Cutaneous Melanoma

• Historically, even thin melanomas were excised with very wide margins (3 cm to 5 cm):
  • Studies have demonstrated, however, that narrower margins are often associated with the same recurrence rates as wider margins

• For thin melanomas:
  • The first randomized study involving surgical margins for melanomas less than 2 mm thick was reported by the WHO Melanoma Group:
    • In an update of the study including 612 patients randomly assigned to a 1-cm or 3-cm margin of excision:
      • There were no local recurrences among patients with primary melanomas thinner than 1 mm
  • • • There were four local recurrences among the 100 patients with melanomas 1 to 2 mm thick:
        • All four occurred in patients with 1-cm margins
      • There was no significant difference in survival between the 1- and 3-cm surgical margin groups
    • These results demonstrate that a 1-cm excision margin is safe for thin (less than 1 mm thick) melanomas
  • A multi-institutional prospective randomized trial from France:
    • Compared 2-cm and 5-cm excisional margins in 362 patients with melanomas less than 2 mm thick:
      • There were no differences in local recurrence rate or survival between the two groups
  • A randomized trial from Sweden compared 989 melanoma patients with lesions less than 2 mm thick excised with 2-cm and 5-cm margins:
    • The results were similar:
      • No differences in local recurrence rate or survival between the two groups

• For thicker melanomas:
  • A randomized clinical trial from the United Kingdom, the United Kingdom Melanoma Study Group (UKMSG) Trial:
    • Compared 1-cm and 3-cm excisional margins in 900 patients with melanomas at least 2 mm thick:
      • With a median follow-up time of 60 months:
  • • • • A 1-cm margin was associated with a significantly increased risk of locoregional recurrence:
          • 37% vs. 32% for 3-cm margins
        • However, overall survival (OS) was similar in the two groups

• For intermediate thickness melanomas:
  • A randomized prospective study conducted by the Intergroup Melanoma Committee compared 2-cm and 4-cm radial margins of excision for 1-mm to 4-mm thickness melanomas:
    • There was no difference in local recurrence rate between the two groups:
      • 46% of patients in the 4-cm group required skin grafts
  • • • Only 11% of patients in the 2-cm group:
        • P < 0.001
    • A trend for improved 10-year disease-specific survival was seen in 4-cm margins (77%) versus 2-cm margins (70%)
  • A clinical trial directly comparing 1-cm and 2-cm margins for 1-mm to 2-mm melanomas has not been performed:
    • Based upon data from the WHO Trial and the Intergroup Melanoma Trial:
      • 2-cm margins are recommended when the anatomic location is favorable and primary closure can be achieved
    • Since there is no demonstrable survival advantage for a 2-cm margin over a 1-cm margin in 1-mm to 2-mm melanomas:
      • A 1-cm margin can be justified in cases in which a 2-cm margin is not easily achievable
• Thick melanomas:
  • The optimal margin width for thick melanomas (greater than 4 mm) is still unknown
  • A retrospective review of 278 patients with thick primary melanomas from The University of Texas MD Anderson Cancer Center and Moffitt Cancer Center:
    • Demonstrated that the width of the excision margin (≤ 2 cm vs. > 2 cm):
      • Did not significantly affect local recurrence, disease-free survival, or OS rates after a median follow-up of 27 months
  • In addition, based upon data from the UKMSG Trial:
    • Investigators concluded that a 3-cm margin is better than 1-cm margin for melanomas 2 mm to 4 mm thick
  • The Intergroup Melanoma Trial:
    • 4-cm margin is not superior to a 2-cm margin for same tumor thickness):
      • A margin greater than 2 cm is not necessary for these thick melanomas

• Based in large part on the data from randomized, prospective trials, several recommendations can be made for margins of excision (Table):

• Patient with melanoma in situ:
  • A 0.5-cm to 1-cm margin is adequate
• Patients with invasive melanoma less than 1 mm thick:
  • Can be treated with a 1-cm margin of excision
• Patients with melanoma 1 mm to 2 mm thick:
  • A simple recommendation is difficult because this patient population has been studied in several trials evaluating a range of excision margins:
    • In general, a 2-cm margin is preferred if anatomically and functionally feasible
  • • In regions of anatomical constraint (e.g., the face), a 1-cm margin is sufficient:
      • This recommendation is based on the fact that OS was similar for patients with 1- and 3-cm margins in the WHO Trial
• Patients with melanoma 2 mm to 4 mm thick:
  • Can be treated with a 2-cm margin
• Patients with a melanoma thicker than 4 mm:
  • A 2-cm margin is probably safe and is generally employed:
    • Although no prospective randomized trials have specifically addressed this thickness group

Rodrigo Arrangoiz MS, MD, FACS

• He is an expert in the management of skin cancer including MELANOMA

  • If you have any questions about the management of melanoma please fill free to contact Dr. Arrangoiz.

  • Article on Melanoma published by Dr. Arrangoiz:

    • http://article.sciencepublishinggroup.com/html/10.11648.j.jctr.20160401.11.html

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

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