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Boost Radiation Therapy after Breast Conserving Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO

Boost radiation therapy is an additional dose of radiation delivered to the tumor bed after whole-breast irradiation (WBI) in patients who undergo breast-conserving surgery (BCS). The goal is to reduce local recurrence rates. The decision to give a boost is typically based on patient-specific risk factors.

Indications for Boost Radiation after BCS

1. Age < 50 years (especially < 40 years)

Data: The EORTC 22881–10882 trial (Bartelink et al., 2001; 2007 update) Population: 5,318 women with stage I/II breast cancer who received BCS + WBI (50 Gy) ± boost (16 Gy). Results: 10-year local recurrence (LR): Without boost: 10.2% With boost: 6.2% (Absolute reduction: 4%, p < 0.0001) Age stratification: < 40 years: LR reduced from 24% to 14% with boost (10% absolute benefit) 41–50 years: LR reduced from 11.7% to 6.4% (5.3% absolute benefit) 50 years: Less pronounced benefit

2. Positive or Close Surgical Margins

Rationale: Tumor cells may remain near the excision cavity, increasing recurrence risk. Guideline Support: NCCN recommends a boost for positive margins (even if re-excised) or if final margins are close, particularly in young patients.

3. High-Grade Tumors (Grade 3)

Data: High-grade tumors are more biologically aggressive and associated with higher LR rates. Boost helps reduce recurrence in these patients, especially when combined with other risk factors (young age, close margins).

4. Lymphovascular Invasion (LVI)

LVI is a marker for higher local and regional recurrence risk. While not an absolute indication, it adds weight to the decision in a patient with other risk factors.

5. Extensive Intraductal Component (EIC)

Especially in younger patients, an EIC increases the risk of residual disease and LR.

6. Triple-negative or HER2-positive subtypes (in younger patients)

While molecular subtype alone isn’t a formal indication for boost, aggressive biology may influence the decision when combined with other features (e.g., young age, LVI, close margins).

Guidelines

ASTRO 2016: Endorses boost in patients <50 years or with high-risk features. NCCN 2024: Recommends consideration of boost based on age, margin status, histology, grade, and LVI.

Clinical Takeaway

Boost radiation significantly reduces local recurrence in high-risk patients following breast-conserving surgery. The greatest benefit is seen in younger women and those with adverse pathological features.

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Diagnosis of Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The choice of biopsy technique:
    • Varies according to the anatomical site as well as the size and shape of the lesion
  • Particular attention should be placed on the impact of the biopsy:
    • On definitive surgical treatment
  • Either an excisional biopsy or an incisional biopsy using a scalpel or punch is acceptable
  • Punch biopsies can be performed for most lesions:
    • They should generally be performed at the most raised or darkest area of the lesion to sample the most aggressive area of the potential melanoma
  • Full-thickness biopsy into the subcutaneous tissue:
    • Should be performed to ensure accurate staging of the lesion
  • An excisional biopsy allows the pathologist to accurately determine the thickness of the lesion, since the entire lesion is available for evaluation:
    • Excisional biopsies should be performed when the lesion is too large for a punch:
      • But still can be removed without excessive surgical intervention
    • For excisional biopsies, a narrow margin of normal-appearing skin (1 to 2 mm) is generally taken with the specimen:
      • An elliptical incision is often used to facilitate closure
      • The biopsy incision should be oriented to facilitate later wide excision (e.g., axially on extremities) and minimize the need for a skin graft to provide wound closure at the time of wide excision
  • Shave biopsy:
    • Is generally discouraged if a diagnosis of melanoma is being considered since incomplete assessment of tumor thickness may result if the deep margin is not cleared
    • If a shave biopsy is performed, a deep shave /saucerization is preferable to obtain full-thickness biopsy of the suspect lesion
  • In general, I submit all pigmented lesions for permanent section examination and perform definitive surgery later
  • I generally prefer image-guided fine-needle aspiration or core biopsy as an initial diagnostic maneuver to document nodal or other melanoma metastases, but not to diagnose primary melanomas

Diagnosis of Cutaneous Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The choice of biopsy technique:
    • Varies according to the anatomical site as well as the size and shape of the lesion
  • Particular attention should be placed on the impact of the biopsy on definitive surgical treatment
  • Either an excisional biopsy or an incisional biopsy using a scalpel or punch is acceptable
  • Entire removal of the lesion is generally preferred to allow for accurate pathologic evaluation
  • Punch biopsies:
    • Can be performed for most lesions:
      • Generally, they can be performed when lesions are located on areas where maximum preservation of surrounding skin is important, or can be completely excised with a punch
    • Punch biopsies:
      • Should be performed at the most raised or darkest area of the lesion to sample the most aggressive area of the potential melanoma
  • Full-thickness biopsy:
    • Into the subcutaneous tissue should be performed to ensure accurate staging of the lesion
  • An excisional biopsy:
    • Allows the pathologist to accurately determine the thickness of the lesion, since the entire lesion is available for evaluation
  • Excisional biopsies:
    • Should be performed when the lesion is too large for a punch but still can be removed without excessive surgical intervention
  • For excisional biopsies:
    • A narrow margin of normal-appearing skin (1 to 3 mm) is taken with the specimen
  • An elliptical incision:
    • Is often used to facilitate closure
  • The biopsy incision should be oriented to facilitate later wide excision (e.g., axially on extremities) and minimize the need for a skin graft to provide wound closure at the time of wide excision
  • Shave biopsy:
    • Is generally discouraged if a diagnosis of melanoma is being considered since incomplete assessment of tumor thickness may result if the deep margin is not cleared
    • If a shave biopsy is performed:
      • A deep shave is preferable
  • In general, I submit all pigmented lesions for permanent section examination and perform definitive surgery at a later time
  • I generally prefer image-guided fine-needle aspiration biopsy as an initial diagnostic maneuver to document nodal or other melanoma metastases:
    • But not to diagnose primary melanomas
Excisional Biospy
Punch Biopsy

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Clinical Presentation of Cutaneous Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Clinical features of melanoma often include:
    • Variegated color
    • Irregular raised surface
    • Irregular perimeter
  • A biopsy should be performed on a:
    • Pigmented lesion that changes in size, configuration, or color
  • The so-called ABCDEs are a mnemonic device to help clinicians and laypersons remember potential early signs of melanoma:
    • A denotes lesion asymmetry
    • B border / surface irregularity
    • C color variegation
    • D diameter greater than 6 mm
    • E a lesion that is elevating, evolving, or enlarging
  • When a patient presents with a lesion suggestive of melanoma, in addition to biopsy:
    • A thorough physical examination must be performed:
      • With particular emphasis on the skin (including the scalp, interdigit webspace, and intertriginous areas), nodal basins, and subcutaneous tissues
  • Clinical Features:
    • Appearance:
      • Melanomas typically present as pigmented lesions, often with irregular borders and color variations
      • They can be black, brown, tan, or even red, white, or blue
      • Amelanotic melanomas:
        • Which lack pigment, can appear pink or flesh-colored, making them more challenging to diagnose
    • ABCDE Criteria:
      • The American Cancer Society recommends using the ABCDE criteria for early detection:
        • Asymmetry:
          • One half of the mole does not match the other
        • Border:
          • Edges are irregular, ragged, notched, or blurred
        • Color:
          • Color is not uniform and may include shades of brown, black, pink, red, white, or blue
        • Diameter:
          • The spot is larger than 6 mm across (about the size of a pencil eraser), although melanomas can be smaller
        • Evolving:
          • The mole is changing in size, shape, or color
  • References:

Surgical Margins in Cutaneous Melanoma: Summary of the Six Major Randomized Trials

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • WHO Melanoma Trial No. 10 (1988):
    • Citation:
      • WHO Melanoma Programme. Lancet. 1988
    • Population:
      • 612 patients with melanomas ≤ 2 mm
    • Arms:
      • 1 cm vs 3 cm surgical excision margins
    • Results:
      • No significant difference in:
        • Local recurrence (LR):
          • ~ 2.3% (1 cm) vs ~2.2 % (3 cm)
        • Overall survival (OS):
          • Similar in both groups
        • Complication rates:
          • Similar
    • Conclusion:
      • 1 cm margins are safe and adequate for melanomas ≤ 1 mm in thickness
      • Wider excisions did not improve outcomes
  • Swedish Melanoma Study Group Trial (1996):
    • Citation:
      • Ringborg U, et al. Cancer. 1996.
    • Population:
      • 989 patients with melanomas 0.8 to 2.0 mm
        • Arms:
      • 2 cm vs 5 cm margins
      • Results:
        • No significant difference in:
          • LR:
            • 3.8% (2 cm) vs 3.6% (5 cm)
          • OS:
            • 65% (2 cm) vs 68% (5 cm) at 10 years
        • Higher rates of skin grafting and wound complications in the 5 cm group
      • Conclusion:
        • 2 cm margins are sufficient
        • 5 cm excision is excessive, with no survival benefit but increased morbidity
  • UK Melanoma Study Group Trial (2004):
    • Citation:
      • Thomas JM, et al. Lancet. 2004.
    • Population:
      • 900 patients with melanomas > 2 mm
    • Arms:
      • 1 cm vs 3 cm margins
    • Results:
      • Local recurrence:
        • 4.6% (1 cm) vs 1.2% (3 cm), p < 0.01
      • 5-year melanoma-specific survival:
        • 65% (1 cm) vs 69% (3 cm), not statistically significant
      • More wound closure problems and skin grafts in the 3 cm group
    • Conclusion:
      • 1 cm margins are inadequate for thick melanomas (> 2 mm)
      • 3 cm margins reduce local recurrence, but without a survival benefit
  • French Cooperative Group Trial (2002, updated 2007):
    • Citation:
      • Veronesi U, et al. NEJM. 2002; Gallardo A, et al. J Clin Oncol. 2007.
    • Population:
      • 742 patients with melanomas > 2 mm
    • Arms:
      • 2 cm vs 5 cm margins
    • Results:
      • LR:
        • 3.7% (2 cm) vs 3.3% (5 cm)
      • Melanoma-specific survival at 10 years:
        • 67% (2 cm) vs 65% (5 cm)
      • Skin grafting more frequent in the 5 cm group
    • Conclusion:
      • 2 cm margins are equivalent to 5 cm margins for thick melanomas
      • 5 cm offers no additional benefit but increases morbidity
  • Intergroup Melanoma Surgical Trial (US, 2001):
    • Citation:
      • Balch CM, et al. Ann Surg Oncol. 2001
    • Population:
      • 740 patients with melanomas 1 to 4 mm thick
      • Arms:
        • 2 cm vs 4 cm margins
      • Results:
        • LR:
          • 1.3% (2 cm) vs 0.9% (4 cm), not significant
        • DFS and OS:
          • No significant difference
        • More skin grafting and delayed healing in the 4 cm group
    • Conclusion:
      • 2 cm margins are sufficient for melanomas 1 to 4 mm in thickness
      • 4 cm margins do not improve outcomes and increase surgical morbidity
  • MelMarT Pilot Trial (2016; Full Results Pending)
    • Citation:
      • Haydu L, et al. Ann Surg. 2016
    • Population:
      • 400 patients with melanomas > 1 mm (pilot phase)
      • Arms:
        • 1 cm vs 2 cm margins
      • Results (pilot):
        • LR, DFS, OS not significantly different (short follow-up)
      • Fewer complications in the 1 cm group
    • Conclusion (preliminary):
      • The 1 cm margin may be sufficient for select patients with intermediate-thickness melanomas
      • Full results from the larger trial (~2,000 patients) are pending and may influence future guidelines

Melanoma Margins Trial II (MelMarT-II)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The Melanoma Margins Trial II (MelMarT-II):
    • Is a pivotal phase III, multicenter, randomized controlled trial:
      • Designed to evaluate the safety and efficacy of narrower surgical margins:
        • For primary cutaneous melanomas that are stage T2b or higher
    • This trial specifically compares 1-cm margins with the standard 2-cm margins:
      • To determine if the narrower margin can provide equivalent outcomes in terms of local control and survival
    • The trial includes patients with primary melanomas thicker than 2 mm (T2b or higher):
      • It aims to assess whether a 1-cm margin can achieve similar rates of local recurrence, disease-free survival, and overall survival compared to the traditional 2-cm margin
    • The rationale for this study:
      • Is based on the hypothesis that narrower margins may reduce surgical morbidity and improve cosmetic outcomes without compromising oncologic safety
  • The MelMarT-II trial:
    • Is significant because it addresses the ongoing debate about the optimal surgical margin for thicker melanomas
  • Previous studies have established that a 2-cm margin is safe for melanomas thicker than 2 mm:
    • But the potential benefits of a 1-cm margin in terms of reduced morbidity and improved quality of life warrant further investigation
  • References:

Morphogenetic Correlates and Mutations in Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • In addition to the classical descriptions of melanomas:
    • The ability to perform molecular profiling on tumors has added to our understanding of this complex and often heterogeneous disease
  • Although currently not generally reported as part of the primary staging of melanoma:
    • Genetic profiling has been widely employed in advanced disease:
      • With advances in technology, mutational analysis is routinely performed from formalin-fixed paraffin-embedded archival tissue
    • This has led to new insights into the pathogenesis of this disease as well as actionable treatment strategies against specific molecular aberrations:
      • Especially in the setting of unresectable and advanced disease
    • Recent studies demonstrate that most melanomas have one or more mutations in essential kinase signaling pathways
  • Important in melanoma is the:
    • RAS-RAF-MEK-ERK kinase-signaling pathway
  • Studies have consistently found that 40% to 50% of cutaneous melanomas (particularly superficial spreading melanoma):
    • Harbor mutations in a particular member of the RAF family known as BRAF
      • Although multiple BRAF mutations have been identified:
        • Approximately 90% consist of a point mutation at V600E:
          • That leads to an approximately 400-fold increase in the activity of the BRAF protein
      • Interestingly, 70% to 80% of benign nevi also harbor BRAF mutations:
        • Suggesting that genetic alterations alone cannot fully explain the aggressive biology of melanoma
    • In the same kinase pathway, approximately 15% to 26% of melanomas:
      • Are found to have an activating NRAS mutation
    • A comprehensive molecular analysis of cutaneous melanoma by The Cancer Genome Atlas (TCGA) melanoma project has provided new insights into the roles and frequency of mutated cancer genes and other genomic signatures
    • These findings helped to establish that cutaneous melanoma can be grouped into one of four subtypes:
      • BRAF mutant (most common)
      • RAS mutant
      • NF1 mutant
      • Triple-WT (wild type)
    • Interestingly, BRAF and NRAS mutations:
      • Are rarely identified simultaneously in the same melanoma tumor
  • The phosphatase and tensin homolog (PTEN) protein is widely expressed throughout the human body:
    • PTEN acts as a phosphatase to dephosphorylate phosphatidylinositol (3,4,5)-trisphosphate
    • The PI3 kinase-AKT pathway:
      • Is the most common kinase pathway mutated in cancer
    • PTEN inhibits the activation of AKT:
      • Therefore, loss of PTEN results:
        • In the constitutive activation of the AKT pathway
    • Often, PTEN loss is found concurrently with NRAS mutations
    • Mutations in AKT have also been identified in melanoma
  • While MAP kinase signaling pathway mutations:
    • Have been commonly found in cutaneous melanomas:
      • Arising in sun-exposed areas:
        • They are infrequent in mucosal and acral lentiginous melanomas
  • A missense mutation in the c-KIT gene:
    • Has been found in more than 20% of mucosal melanomas and more than 10% of acral lentiginous melanomas

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Risk Factors for Cutaneous Melanoma II

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The increasing incidence rates of cutaneous melanoma in the United States projected for 2025 are influenced by several key risk factors:
    • With ultraviolet (UV) exposure and demographic changes playing significant roles
  • Ultraviolet (UV) Exposure:
    • UV radiation from sunlight and artificial sources like tanning beds is the primary risk factor for melanoma
    • Both intermittent intense exposure (e.g., sunburns) and chronic cumulative exposure contribute to melanoma risk
    • The American Cancer Society emphasizes that reducing UV exposure through protective measures such as:
      • Sunscreen use, wearing protective clothing, and avoiding tanning beds can mitigate this risk
  • Demographic Factors:
    • Skin Type:
      • Individuals with fair skin, light hair, and light eye color are at higher risk:
        • Due to lower melanin levels:
          • Which provide less natural protection against UV radiation
    • Age:
      • Melanoma incidence increases with age, particularly in older adults:
        • Due to cumulative UV exposure over a lifetime
      • However, it is also common in younger adults, especially women:
        • Likely due to higher use of tanning beds and intentional sun exposure
    • Gender:
      • Men have higher melanoma incidence rates than women, particularly after age 40:
        • This may be due to differences in sun exposure behaviors and lower rates of skin self-examination among men
    • Genetic Factors:
      • A family history of melanoma increases risk, as does the presence of numerous or atypical nevi (moles)
      • Genetic predispositions, such as mutations in the CDKN2A gene:
        • Also contribute to higher melanoma risk
    • Other Factors:
      • Immunosuppression, whether due to medical conditions like HIV or medications post-organ transplantation:
        • Increases melanoma risk
      • Additionally, socioeconomic factors, such as higher income and access to dermatologic care, can lead to higher diagnosis rates due to increased diagnostic scrutiny
  • In summary, the rising incidence of cutaneous melanoma in the United States is driven by UV exposure, demographic changes, genetic predispositions, and other factors:
    • Effective prevention strategies focusing on reducing UV exposure and early detection are crucial to managing this growing public health concern
  • References:

Risk Factors for Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Estimating an individual’s risk of developing melanoma:
    • Can be clinically useful in determining primary prevention strategies and in directing the level of screening
  • Patients identified as being at high risk for melanoma:
    • May also be recruited to prevention trials
  • Multiple factors are associated with risk for developing melanoma:
    • Some factors are modifiable while others are inherent to the individual
  • Skin type:
    • Caucasians have at least 20 times the melanoma incidence of African Americans and five times the melanoma incidence of American Hispanics
    • In addition, white patients with red or blond hair, fair complexion, or blue eyes:
      • Are at increased risk for melanoma
  • Age and Gender:
    • The incidence of melanoma increases with age
    • The incidence of melanoma is:
      • 1.7-fold higher for women than men before 49 years of age
      • Over age 70:
        • The incidence of melanoma is 2.4-fold higher for men than women
    • In general, the incidence of melanoma is:
      • Higher in men than in women:
        • Specifically, a man’s lifetime risk of melanoma development is approximately:
          • 1.5 times greater than a woman’s risk
  • Overexposure to ultraviolet radiation (UVR) from the sun:
    • Overexposure of UVR from the sun:
      • Has been associated with an increased risk of melanoma
    • Genetic sequencing data:
      • Also support the role of UV melanomagenesis
    • Known to be a tumor with one of the highest mutational loads:
      • A seminal report of the melanoma effort within The Cancer Genome Atlas Program:
        • Revealed that most somatic mutations in melanoma indeed have a “UV signature”
    • Data support that damage from sunburns in childhood or even in adulthood are associated with increased risk:
      • A correlation has been identified between the number of severe and painful sunburn episodes and the risk of melanoma:
        • Individuals who have a history of more than 10 severe sunburns are more than twice as likely to develop a melanoma compared those who have no history of sunburns
  • Use of indoor tanning devices:
    • Multiple studies support that indoor tanning device use is strongly associated with increased risk of melanoma
    • A systematic review by the International Agency for Research on Cancer (IARC):
      • Demonstrated a 15% increased relative risk of melanoma in individuals who had ever used a sunbed versus those who had never (RR 1.15; 95% CU 1.00 to 1.31)
    • The dangers of indoor tanning have been corroborated by subsequent U.S. and Australian groups
    • Young age of onset and higher frequency of use are key risk factors that are associated with even greater risk of melanoma
    • Indeed, a well-designed Minnesota case–control study showed increased risk with number of years, hours, and sessions of indoor tanning, independent of outdoor sun exposure:
      • These researchers also found that 97% of women diagnosed with melanoma before age 30 had indoor tanned
    • Young patients who use indoor tanning devices more than 10 times annually have more than 7 times the melanoma risk compared to individuals who do not indoor tan
    • A meta-analysis estimated a 1.8% increased melanoma risk for each additional tanning bed session
    • Since 2009, the World Health Organization lists tanning beds as a Class I carcinogen
  • Previous melanoma:
    • Individuals with a personal history of melanoma have an increased risk of developing a second melanoma of approximately:
      • 3% to 7%
  • Benign nevi:
    • Although a benign nevus is most likely not a precursor of melanoma:
      • The presence of large numbers of nevi has been consistently associated with an increased risk of melanoma:
        • Persons with ≥ 50 nevi, all of which are > 2 mm in diameter:
          • Have 5 to 17 times the melanoma risk of persons with fewer nevi
  • Individuals who tend to develop freckles:
    • Also have an increased risk of melanoma
  • Family history:
    • Approximately 10% of individuals diagnosed with melanoma:
      • Have a family member with a history of melanoma
    • A family history of melanoma:
      • Increases an individual’s risk of melanoma three- to eightfold
    • Furthermore, persons who have two or more family members with melanoma:
      • Are also at a particularly high risk
    • When available, these patients should be referred to genetic counseling
  • Genetic predisposition:
    • Approximately 8% to 12% of melanomas:
      • Occur in individuals with a genetic predisposition
    • Specific genetic alterations have been implicated in the pathogenesis of melanoma
  • Atypical mole and melanoma syndrome:
    • Previously known as dysplastic nevus syndrome, atypical mole and melanoma syndrome:
      • Is characterized by the presence of multiple, large (> 5 mm) atypical dysplastic nevi generally in nonexposed areas of skin that represent a distinct clinicopathologic type of melanocytic lesion
      • Melanomas can originate from either normal skin or from a dysplastic nevus
      • Since the actual frequency of an atypical mole progressing to melanoma is small:
        • Resection of all dysplastic nevi is not indicated
      • However, new, changing, or symptomatic lesions that appear suspicious for melanoma on clinical and / or dermoscopic examination should be evaluated histologically

Surgical Margins in Melanoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The standards set for wide excision of melanoma:
    • Are well-studied and are the result of:
      • Five randomized, prospective trials
  • Randomized trials:
    • The French Cooperative Group Trial and the Swedish Melanoma Trial Group:
      • Analyzed melanomas 2 mm in depth
      • Comparing 2-cm and 5-cm margins
      • The findings of these studies demonstrated:
        • No increased risk of local or distant recurrence associated with the smaller margin
  • The World Health Organization (WHO) Melanoma Trial number 10:
    • Analyzed patients with melanomas 2 mm in thickness:
      • But compared 1-cm and 3-cm margins
    • It also demonstrated no difference in overall survival:
      • Although among the patients with a melanoma of 1- to 2-mm thickness:
        • The rate of local recurrence was slightly higher when a 1-cm margin was used:
          • The difference was not statistically significant, however:
            • And the recommendation from this trial was that a 1-cm margin was safe for lesions 2 mm Breslow thickness:
              • Although the rate of local recurrence in the 1- to 2-mm subgroup may be higher with this margin
  • The Intergroup Melanoma Trial:
    • Analyzed all patients with a melanoma of intermediate thickness (1 to 4 mm)
    • The authors compared 2-cm and 4-cm margins and, despite the inclusion of patients with melanomas 2 mm thick:
      • No difference was seen in overall survival or local recurrence
    • This trial demonstrated that a 2-cm margin of excision was safe for patients with a melanoma of up to 4 mm thick:
      • But did not address patients who had a lesion greater than 4 mm thick
  • The British Cooperative Group Trial:
    • Analyzed patients with lesions greater than 2 mm in thickness and randomly assigned them to 1-cm margins or 3-cm margins
    • This trial demonstrated a greater risk of recurrence among patients who had a 1-cm margin of excision:
      • However, importantly, this trial did not include SLN biopsy, and the greatest incidence of recurrence was regional:
        • When accounting for regional recurrence, the differences between groups were no longer statistically significant
      • Given this limitation, the application of these results to the standards in regions where SLN is routinely applied becomes somewhat ambiguous
      • Finally, the overall survival in both arms was not statistically different
  • Margins are measured grossly, not microscopically:
    • Therefore pathologic analysis after resection does not require repeat resection (except in the setting of positive margins) to ensure the appropriate distance
    • There is no role for compromise of these standards, i.e., biopsy margins cannot be added to planned surgical margins to obtain a total excision margin (i.e., 5 mm plus 5 mm):
      • Therefore, wide excision is planned around the biopsy site or the known primary lesion with the appropriate margin at the time of definitive wide excision:
        • In areas of anatomic or functional constraint, such as the hand or the face:
          • Margins may be compromised from the set standards:
          • In settings where margins must be compromised:
            • Local recurrence does not appear to have an impact on overall survival
  • Sentinel lymph node biopsy:
    • Should be discussed and offered for patients with melanoma greater than or equal to 0.8 mm in thickness
    • Melanomas less than 0.8 mm thick with the presence of high-risk features such as:
      • The presence of ulceration
  • Ultrasound surveillance of the regional lymph node basin(s):
    • Would be indicated only in the instance of a primary tumor that failed to localize on preoperative lymphoscintigraphy
  • Reference
    • Balch CM, Houghton AN, Sober AJ, et al, eds. Cutaneous Melanoma. 5th ed. St. Louis, MO: Quality Medical Publishing; 2009.
    • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Melanoma. Available at http://www.nccn.org.
    • Morton DL, Cochran AJ, Thompson JF, et al. Sentinel node biopsy for early stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg. 2005;242:302-311.