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Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma

Michael J Sladden, Omgo E Nieweg, Julie Howle, Brendon J Coventry and John F Thompson
Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00278
Published online: 19 February 2018

Abstract

Introduction: Definitive management of primary cutaneous melanoma consists of surgical excision of the melanoma with the aim of curing the patient. The melanoma is widely excised together with a safety margin of surrounding skin and subcutaneous tissue, after the diagnosis and Breslow thickness have been established by histological assessment of the initial excision biopsy specimen. Sentinel lymph node biopsy should be discussed for melanomas ≥ 1 mm thickness (≥ 0.8 mm if other high risk features) in which case lymphoscintigraphy must be performed before wider excision of the primary melanoma site. The 2008 evidence-based clinical practice guidelines for the management of melanoma (http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/ClinicalPracticeGuidelines-ManagementofMelanoma.pdf) are currently being revised and updated in a staged process by a multidisciplinary working party established by Cancer Council Australia. The guidelines for definitive excision margins for primary melanomas have been revised as part of this process.

Main recommendations: The recommendations for definitive wide local excision of primary cutaneous melanoma are:

  • melanoma in situ: 5–10 mm margins
  • invasive melanoma (pT1) ≤ 1.0 mm thick: 1 cm margins
  • invasive melanoma (pT2) 1.01–2.00 mm thick: 1–2 cm margins
  • invasive melanoma (pT3) 2.01–4.00 mm thick: 1–2 cm margins
  • invasive melanoma (pT4) > 4.0 mm thick: 2 cm margins

 

Changes in management as a result of the guideline: Based on currently available evidence, excision margins for invasive melanoma have been left unchanged compared with the 2008 guidelines. However, melanoma in situ should be excised with 5–10 mm margins, with the aim of achieving complete histological clearance. Minimum clearances from all margins should be assessed and stated. Consideration should be given to further excision if necessary; positive or close histological margins are unacceptable.


  • 1 University of Tasmania, Launceston, TAS
  • 2 Melanoma Institute Australia, Sydney, NSW
  • 3 University of Sydney, Sydney, NSW
  • 4 Westmead Hospital, Sydney, NSW
  • 5 Royal Adelaide Hospital, Adelaide, SA


Correspondence: m.sladden@doctors.org.uk
Acknowledgements: 

The guidelines were developed by Cancer Council Australia and Melanoma Institute Australia with financial support from Skin Cancer College Australasia. We acknowledge the Cancer Council Australia and Melanoma Institute Australia project staff, in particular Lani Teddy and Jackie Buck, who were involved in the systematic review.

Competing interests:

No relevant disclosures.

  • 1. Gyorki DE, Barbour A, Hanikeri M, et al. When is a sentinel node biopsy indicated for patients with primary melanoma? An update of the ‘Australian guidelines for the management of cutaneous melanoma’. Australas J Dermatol 2017. https://doi.org/10.1111/ajd.12662. [Epub ahead of print]
  • 2. Cancer Network Melanoma Guidelines Revision Working Party. Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, Wellington, 2008. https://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/ClinicalPracticeGuidelines-ManagementofMelanoma.pdf (viewed Mar 2017).
  • 3. Sladden M, Nieweg O, Howle J, et al. What are the recommended definitive margins for excision of primary melanoma? In: Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. Sydney: Cancer Council Australia, 2016. http://wiki.cancer.org.au/australia/Guidelines: Melanoma (viewed Sept 2017).
  • 4. Khayat D, Rixe O, Martin G, et al. Surgical margins in cutaneous melanoma (2 cm versus 5 cm for lesions measuring less than 2.1-mm thick). Cancer 2003; 97: 1941-1946
  • 5. Cohn-Cedermark G, Rutqvist LE, Andersson R, et al. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0 mm. Cancer 2000; 89: 1495-1501
  • 6. Cascinelli N. Margin of resection in the management of primary melanoma. Semin Surg Oncol 1998; 14: 272-275
  • 7. Balch CM, Soong SJ, Smith T, et al. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. Ann Surg Oncol 2001; 8: 101-108.
  • 8. Gillgren P, Drzewiecki KT, Niin M, et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: a randomised, multicentre trial. Lancet 2011; 378: 1635-1642.
  • 9. Hayes A, Maynard L, Coombes G, et al. Wide versus narrow excision margins for high-risk, primary cutaneous melanomas: long-term follow-up of survival in a randomised trial. Lancet Oncol 2016; 17: 184-192.
  • 10. Haigh PI, DiFronzo LA, McCready DR. Optimal excision margins for primary cutaneous melanoma: a systematic review and meta-analysis. Can J Surg 2003; 46: 419-426.
  • 11. Lens MB, Dawes M, Goodacre T, Bishop JA. Excision margins in the treatment of primary cutaneous melanoma: a systematic review of randomized controlled trials comparing narrow vs wide excision. Arch Surg 2002; 137: 1101-1105.
  • 12. Lens MB, Nathan P, Bataille V. Excision margins for primary cutaneous melanoma: updated pooled analysis of randomized controlled trials. Arch Surg 2007; 142: 885-891 (discussion 891-3).
  • 13. Mocellin S, Pasquali S, Nitti D. The impact of surgery on survival of patients with cutaneous melanoma: revisiting the role of primary tumor excision margins. Ann Surg 2011; 253: 238-243.
  • 14. Sladden MJ, Balch C, Barzilai DA, et al. Surgical excision margins for primary cutaneous melanoma. Cochrane Database Syst Rev 2009 Oct 7; (4): CD004835.
  • 15. Wheatley K, Wilson J, Gaunt P, Marsden J. Are narrow surgical excision margins for primary cutaneous melanoma safe? An updated systematic review and meta-analysis. J Dtsch Dermatol Ges 2013; (Suppl 7): 1-23.
  • 16. MacKenzie Ross AD, Haydu LE, Quinn MJ, et al. The association between excision margins and local recurrence in 11,290 thin (T1) primary cutaneous melanomas: a case-control study. Ann Surg Oncol 2016; 23: 1082-1089.
  • 17. McKinnon JG, Starritt EC, Scolyer RA, et al. Histopathologic excision margin affects local recurrence rate: analysis of 2681 patients with melanomas < or = 2 mm thick. Ann Surg 2005; 241: 326-333.
  • 18. Haydu LE, Stollman JT, Scolyer RA, et al. Minimum safe pathologic excision margins for primary cutaneous melanomas (1-2 mm in thickness): analysis of 2131 patients treated at a single center. Ann Surg Oncol 2016; 23: 1071-1081.
  • 19. Hudson LE, Maithel SK, Carlson GW, et al. 1 or 2 cm margins of excision for T2 melanomas: do they impact recurrence or survival? Ann Surg Oncol 2013; 20: 346-351.
  • 20. Lamboo LG, Haydu LE, Scolyer RA, et al. The optimum excision margin and regional node management for primary cutaneous T3 melanomas (2-4 mm in thickness): a retrospective study of 1587 patients treated at a single center. Ann Surg 2014; 260: 1095-1102.
  • 21. Hunger RE, Seyed Jafari SM, Angermeier S, Shafighi M. Excision of fascia in melanoma thicker than 2 mm: no evidence for improved clinical outcome. Br J Dermatol 2014; 171: 1391-1396.
  • 22. Pasquali S, Haydu LE, Scolyer RA, et al. The importance of adequate primary tumor excision margins and sentinel node biopsy in achieving optimal locoregional control for patients with thick primary melanomas. Ann Surg 2013; 258: 152-157.
  • 23. Grotz TE, Glorioso JM, Pockaj BA, et al. Preservation of the deep muscular fascia and locoregional control in melanoma. Surgery 2013; 153: 535-541.
  • 24. Tzellos T, Kyrgidis A, Mocellin S, et al. Interventions for melanoma in situ, including lentigo maligna. Cochrane Database Syst Rev 2014 Dec 19; 12: CD010308.
  • 25. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012; 66: 438-444.
  • 26. Akhtar S, Bhat W, Magdum A, Stanley PR. Surgical excision margins for melanoma in situ. J Plast Reconstr Aesthet Surg 2014; 67: 320-323.
  • 27. Hazan C, Dusza SW, Delgado R, et al. Staged excision for lentigo maligna and lentigo maligna melanoma: a retrospective analysis of 117 cases. J Am Acad Dermatol 2008; 58: 142-148.
  • 28. Felton S, Taylor RS, Srivastava D. Excision margins for melanoma in situ on the head and neck. Dermatol Surg 2016; 42: 327-334.
  • 29. Jejurikar SS, Borschel GH, Johnson TM, et al. Immediate, optimal reconstruction of facial lentigo maligna and melanoma following total peripheral margin control. Plast Reconstr Surg 2007; 120: 1249-1255.
  • 30. Abdelmalek M, Loosemore MP, Hurt MA, Hruza G. Geometric staged excision for the treatment of lentigo maligna and lentigo maligna melanoma: a long-term experience with literature review. Arch Dermatol 2012; 148: 599-604.
  • 31. Pralong P, Bathelier E, Dalle S, et al. Dermoscopy of lentigo maligna melanoma: report of 125 cases. Br J Dermatol 2012; 167: 280-287.
  • 32. Guitera P, Moloney FJ, Menzies SW, et al. Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy. JAMA Dermatol 2013; 149: 692-698
  • 33. Marsden JR, Newton-Bishop JA, Burrows L, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. Br J Dermatol 2010; 163: 238-256
  • 34. Bichakjian CK, Halpern AC, Johnson TM, et al. Guidelines of care for the management of primary cutaneous melanoma, American Academy of Dermatology. J Am Acad Dermatol 2011; 65: 1032-1047
  • 35. Thomas JM, Newton-Bishop J, A’Hern R, et al (United Kingdom Melanoma Study Group, British Association of Plastic Surgeons, Scottish Cancer Therapy Network). Excision margins in high-risk malignant melanoma. N Engl J Med 2004; 350: 757-766.
  • 36. Moncrieff M. 2016. Excision margins for melanomas: how wide is enough? Lancet Oncol 2016; 17: 127-128.
  • 37. Möhrle M, Schippert W, Garbe C, et al. [Prognostic parameters and surgical strategies for facial melanomas] [German]. J Dtsch Dermatol Ges 2003; 1: 457-463.
  • 38. Harish V, Bond JS, Scolyer RA, et al. Margins of excision and prognostic factors for cutaneous eyelid melanomas. J Plast Reconstr Aesthet Surg 2013; 66: 1066-1073.
  • 39. Jahn V, Breuninger H, Garbe C, Moehrle M. Melanoma of the ear: prognostic factors and surgical strategies. Br J Dermatol 2006; 154: 310-318.
  • 40. Pockaj BA, Jaroszewski DE, DiCaudo DJ, et al. Changing surgical therapy for melanoma of the external ear. Ann Surg Oncol 2003; 10: 689-696.
  • 41. Rawlani R, Rawlani V, Qureshi HA, et al. Reducing margins of wide local excision in head and neck melanoma for function and cosmesis: 5-year local recurrence-free survival. J Surg Oncol 2015; 111: 795-799.
  • 42. Furukawa H, Tsutsumida A, Yamamoto Y, et al. Melanoma of thumb: retrospective study for amputation levels, surgical margin and reconstruction. J Plast Reconstr Aesthet Surg 2007; 60: 24-31.
  • 43. Cohen T, Busam KJ, Patel A, Brady MS. Subungual melanoma: management considerations. Am J Surg 2008; 195: 244-248.

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