Histopathologic Excision Margin Affects Local Recurrence Rate

Autor: Richard A. Scolyer, Emma C. Starritt, William H. McCarthy, J. Gregory McKinnon, John F. Thompson
Rok vydání: 2005
Předmět:
Zdroj: Annals of Surgery. 241:326-333
ISSN: 0003-4932
Popis: The appropriate margin of excision for cutaneous melanoma has been the subject of argument for many years. Modern recommendations are governed by data from prospective randomized clinical trials. The first, published by Veronesi et al1 and sponsored by the World Health Organization (WHO) Melanoma Group, was a randomized trial for patients with melanomas ≤2 mm thick. Six hundred twelve patients were randomized to a surgical excision margin of either 1 cm or 3 cm. There were no significant differences in either local recurrence (LR) or survival rates after 8 years of follow-up. The Intergroup Melanoma Study, by Balch et al,2 randomized patients with melanomas from 1 to 4 mm in thickness between a 2-cm margin of excision and a 4-cm margin. Again, there were no significant differences in either LR or survival rates. A Swedish trial, published by Ringborg et al,3 also confirmed the safety of a 2-cm margin. Recently, Khayat et al4 reported a randomized trial of patients with melanomas ≤2 mm thick that compared a 2-cm margin to a 5-cm margin. No differences in outcome were found. Finally, a recent trial reported by Thomas et al5 compared a 1-cm surgical margin to a 3-cm surgical margin in patients with melanomas that were >2 mm thick. An increase in locoregional recurrence was found, but there was no difference in overall survival. Most authorities therefore recommend that melanomas 2 mm thick should be excised with surgical margins of 2 cm.6,7 Despite these prospective data, there are many unanswered questions in relation to excision margins for melanoma. For example, it has been noted that in the WHO trial, there were 4 patients who developed LR, all from the group who had a 1-cm margin of excision and who had primaries between 1 and 2 mm thick.1 This observation has led to concern among some surgeons who consider that a 1-cm margin may be inadequate for melanomas from 1 to 2 mm thick, particularly since there is a high mortality among patients who suffer a LR.6 Others accept the finding that a 1-cm margin is adequate treatment of all patients with 1- to 2-mm-thick melanomas because of the lack of a significant difference in LR or survival between the 2 groups in the WHO trial.8 Although the 1-cm difference between 1- and 2-cm excision margins might be relatively trivial on the back or thigh, it can have significant implications for wound management, cosmetic outcome, and functional result on areas like the face or hands.9 Furthermore, melanomas arising in the head and neck region or on distal extremities were not randomized in these trials. The adequacy of margins of less than 1 cm has not been tested in a randomized trial, but for cosmetic reasons they are commonly accepted on the face and distal extremities.9 It is not known whether this practice increases the risk of LR. Most fundamentally, it is not known whether there is a relationship between the size of the excision margin and the risk of LR. It has been argued, for example, that a histologically clear margin may be adequate treatment of most melanomas and that LR is actually a form of systemic metastasis.10 The question of whether LR is due to surgical failure or to the biology of the tumor remains unanswered. It is unlikely that any further prospective trials will take place for patients with melanomas
Databáze: OpenAIRE
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