Primary Cutaneous Melanoma

Published Date: 19th July 2016

Publication Authors: Brackley P,

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Question: 

Most current international guidelines for the management of primary cutaneous melanoma stage pT2 and above recommend excisional surgery with a minimum of 2 cm radial margins. However recent systematic reviews suggest that wider excision margins offer no better local disease control than narrow ones. The latest Cochrane review recommended a prospective RCT comparing 1 cm versus 2 cm margins for pT2-4 cutaneous melanomas. We have investigated the potential benefits to be gained by a reduction in margins to 1 cm, if oncologically safe.

Methods: 

We collected and analysed activity from seven melanoma centres across the UK and Australia, totalling 3213 patients with primary cutaneous melanoma.

Results:  

The overall requirement for reconstruction in the UK centres was 16.4% compared to 32.2% in the wider excision group (15.8% difference, p = 0.0001). Similar results were found in the Australian data (difference 14.7%, p = 0.0001). We found a significant difference in the use of skin grafting in the head and neck area from 30.1% to 9.5% and in the extremities from 18.5% to 6.4% (p < 0.0001, both) for 1 cm excision margins compared to 2 cm. It has been shown previously that avoiding reconstruction reduces inpatient stay and it’s resulting costs but this would also free up the services required for graft checks and dressing changes in tertiary care. We have previously shown in other studies that neuropathic

pain is more prevalent and quality of life is significantly reduced in patients that require reconstruction after wide excision for melanoma.

Conclusion:  

A reduction in wide excision margins for pT2-4 cutaneous melanoma to 1 cm, if oncologically safe, would have a major impact on post-op morbidity, procedural costs, final cosmesis and quality of life. A randomised control trial is merited to verify these important secondary outcomes from narrower excision margins.

Macdonald, C; Goodenough, J; Brackley, P et al. (2013).  The impact on quality of life and reconstructive need of wider excision margins >1 cm for primary cutaneous melanoma . Journal of the German Society of Dermatology. 11 (Supplement S7), 6

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