Surgical excision margins for primary cutaneous melanoma. Melanoma of the hand requires special attention because the skin of the hand is structurally unique to allow for fine sensibility, mobility for complex motor skills, and durability. Melanoma is classified by the clark level and the breslow thickness. Apr 06, 2012 excision of melanoma in situ remains more art than science. Melanoma in situ of nonlentigo maligna type is likely to be completely excised with 5mm margins whereas. Treatment options for stage 0 melanoma aim at melanoma. Melanoma in situ stage 0 is localized to the outermost layer of skin the epidermis. What are the recommended safety margins for radical excision. In some cases, an excision biopsy will have removed the melanoma entirely.
The authors work from the reasonable conceit that mohs surgery with. More common at age 3050 years, often on the trunk, and in women often on the legs. P l a i n l a n g u a g e s u m m a r y whilst melanoma accounts for only 5% of skin cancers, it is important because it is the cause of 75% of all skin cancer deaths. To obtain a 97% clearance rate, both lentigo maligna and melanoma in situ required a 12mm margin on the head and neck and a 9mm margin on the trunk and extremities. After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 510 mm measured with good lighting and magnification with the aim of achieving complete histological clearance. The lentigo maligna lm subtype of melanoma in situ mis develops on chronically sunexposed skin, with indistinct clinical margins corresponding to single melanocytes trailing along the epidermaldermal junction figure 1a,c,e. After surgery, they found the the margins were not clean and it has melanoma in situ. A main component of the treatment of primary melanoma involves wide local excision wle of the primary lesion or of the biopsy scar with adequate margins 18. For a stage iesion, you typically want 1cm clear margins. Wide excision is the standard surgical procedure for melanoma stage 0 in situ, stage i, stage ii, and most stage iii melanomas. However, a melanoma in situ mis is located in the most superficial layer of skin, the epidermis, so the prognosis is very good. The clark level is defined by the depth of the melanoma. Melanoma surgery code guidelines worksheet with tables. A in situ subungual melanoma on the left second toe.
Objective to calculate the proportion of patients requiring 5 mm margin. Surgical treatment of melanoma is the standard of care for all primary melanomas and consists of en bloc excision of the tumor or biopsy site with a margin containing normalappearing skin and underlying subcutaneous tissue. In the case of melanoma, the purpose of a wide excision is to remove local micrometastases and otherwise phenotypically normal tissue that might be harbouring genotypically abnormal cells located in either the surrounding cutis or superficial lymphatics, while at the same. The frequently recommended 5mm margin for melanoma is inadequate. Mohs excision is a good alternative where the margins. I am going in for more biopsies the end of the month to see if this has changed. Melanoma in situ skin cancer and reconstructive surgery. Surgical management of melanoma cutaneous melanoma ncbi. Those who use conventional excision are prepared for a high rate of local recurrence after standard 5mm margins, and even after mohs, some surgeons employ adjuvant therapies along the periphery e. The surgeon removes the tumor, including the biopsy site, as well as a surrounding area of normalappearing skin and underlying subcutaneous tissue, to make certain the whole tumor has been removed. Surgical excision remains the first line of defence in most patients with a. Waikoloa, hawaii the widely utilized 5mm surgical margins for excision of melanoma in situ are inadequate in many cases, christopher b.
The recommended margins vary depending on the thickness of the tumor. The margins can also vary based on where the melanoma. Surgery remains the cornerstone of cutaneous melanoma treatment. Minimum clearances from all margins should be statedassessed. Surgery at this stage is the very best cure for melanoma and having adequate margins is. A melanoma discovered in situ, therefore, is routinely awarded the prognosis of malignancy requiring prompt intervention. Sep 14, 2016 mohs micrographic surgery was used effectively to treat melanoma in situ exceeding traditional excision margins of 5 mm, according to published study results. Another recent study found that in situ melanoma lesions that were not lentigo maligna type, were unlikely to recur if completely removed, even with narrow margins figure 2. Mohs micrographic surgery and other staged excision techniques can provide exhaustive peripheral margin histologic assessment for melanoma in situ. Stage i melanoma has invaded the second layer of skin the dermis. On the other hand, a significantly higher incomplete excision rate was found in the lentigo maligna group figure 2. A randomized controlled trial of patients with stage iiac cutaneous melanoma thicker than 2mm found that a 2cm surgical resection margin is sufficient and is as safe for patients as a 4cm margin. Excision margins for melanoma in situ on the head and neck.
Fitzpatricks color atlas and synposis of clinical dermatology, 6th edition. The lentigo maligna lm subgroup of mis carries upto a 4. Melanoma in situ macro and dermoscopic image pairs. Excision margins for intermediatethickness melanoma. The amount of tissue removed depends on the position and depth of the melanoma, and whether the surgery will affect your movement afterwards. This singlecenter retrospective study assessed 1cm excision vs 2cm excision margins in matched cohorts of patients with melanoma with breslow tumor thickness 1. As melanoma in situ has no associated mortality, early detection of melanoma in an in situ phase increases survival from melanoma. The american joint committee on cancer ajccs skin melanoma. Excision margins in highrisk malignant melanoma nejm.
Melanoma is a form of cancer which causes death if it spreads or metastasizes to other locations in the body including internal organs. Study suggests smaller melanoma excision margins may be. The melanoma intergroup trial compared 2cm with table 81 recommended wide local excision margins for primary melanoma based on breslow thickness thickness of melanoma mm measured surgical margin width cm strength of recommendation evidence melanoma in situ. Standard surgical excision of melanoma in situ should include 9 mm of normalappearing skin, similar to that recommended for early invasive melanoma. Depending on the stage, size and depth of the melanoma a wide local excision may be recommended which involves the removal of a larger area of skin around the melanoma. Cutaneous melanoma accounts for 75% of skin cancer deaths. Melanoma in situ is an early form of primary melanoma in which the malignant cells are confined to the tissue of origin, the epidermis.
So the wide excision had clear margins, but the 69 oclock margin only had 4mm margins from the residual melanoma in situ. It is also known as in situ melanoma and level 1 melanoma. Risk factors for positive or equivocal margins after wide local. Melanoma wide excision margins after initial excision biopsy recommended in the clinical practice guidelines for the management of cutaneous melanoma in australia and new zealand 3. The margins of the final excision are determined with the tumor. Zelen zelen 1979 proposed this novel randomised consent design. Surgery for melanoma skin cancer melanoma surgery options. A controversy in the treatment of melanoma in situ is the required width of surgical margin. Mohs surgery vs wide local excision for melanoma in situ.
A patient video guide early stage melanoma part 1 of 4. This novel finding does not indicate that multiple biopsies. Those who use conventional excision are prepared for a high rate of local recurrence after standard 5mm margins. This procedure may be done in a doctors office under local anesthetic. Stage 0 tisn0m0 melanoma in situ lentigo maligna iowa. Surgical margins for melanoma in situ sciencedirect. Furthermore, in contrast to lentigo maligna, melanoma in situ is unlikely to recur after a total excision, even with narrow margins, which reduces the need for wider second excision 2. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin excision margins. The biopsy margins were positive in only 16 specimens 11 shaves, 5 punches, and in none of the 6 excisional biopsies. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. Consideration should be given to further excision if necessary. Mohs micrographic surgery versus wide local excision for melanoma in situ. The currently accepted 5mm margin is based on a 1992 consensus opinion, despite data since then showing this is inadequate. Jan 30, 2020 after initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 12 cm.
What are the recommended safety margins for radical. Those who use conventional excision are prepared for a high rate of local recurrence after standard 5mm margins, and even. Comparison of surgical margins for lentigo maligna versus. National comprehensive cancer network nccn evidencebased. Jan 30, 2020 after initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 510 mm measured with good lighting and magnification with the aim of achieving complete histological clearance. In both stage 0 and stage i melanoma cases, the physician uses a scalpel to remove any remaining tumor plus a safety margin of surrounding normal tissue. Malignant melanoma in situ is clinically defined as a thin but spreading patch of. The icd9 diagnosis codes for malignant melanoma of skin 172. The standard of treatment for stage 0 melanoma in situ is re excision of the original site with a surrounding area of normallooking skin being taken. Excision of melanoma in situ remains more art than science. Principles of surgical margins for wide excision of primary melanoma meb the recommended clinical margin for in situ changed from 0. Standards are well established for peripheral margins of excision table 1. Margin involvement after the excision of melanoma in situ.
Jan 11, 2016 the main aim of surgery in treating any cancer is to completely excise the tumour, thereby preventing local recurrence. Red and black dotted lines indicate lateral margins. The authors work from the reasonable conceit that mohs surgery with repeated. Complete surgical excision of melanoma in situ mis is curative. Alternatively, the less common nonlentiginous mis nonlm mis typically occurs in more sunprotected areas with distinct clinical margins. Melanoma in situ mis is a noninvasive lesion accounting for up to 27% of all melanomas by coory et al. Standard treatment is surgical excision with a safety margin some distance from the. The standard treatment for cutaneous melanoma in situ is surgical excision followed by standard pathologic. Consider 9mm surgical margins for mis mdedge dermatology. Re excision may be done by your family doctor if the melanoma is in situ stage 0. Excision margins for patients with meltumps clinical. The prevalence of melanoma is rapidly increasing 1,2 and therefore more patients are being evaluated by surgeons for treatment of this tumor.
Focal residual melanoma in situ, close to inked epidermal margin. Study suggests smaller melanoma excision margins may be option for some patients adapted from the nci cancer bulletin. Unanswered questions about margin recommendations for. However, in contrast to invasive melanomas, there has been an increase in the recommended margins for in situ melanoma from 0. Excision margins for melanoma redefined melanoma institute. Whilst melanoma accounts for only 5% of skin cancers, it is important because it is the cause of 75% of all skin cancer deaths. The treatment for melanoma in situ mis, including lentigo maligna, should be complete surgical excision with clear margins.
For primary cutaneous melanoma, standard treatment is complete surgical removal of the melanoma with a safety margin some distance from the visible edges of the primary tumour. Aadacmsasdsaasms 2012 appropriate use criteria for mohs micrographic surgery. If the re excision occurs during the same session as the initial excision, report a single code to describe the greatest area removed. Melanoma precursers and primary cutaneous melanoma. Surgical margins for melanoma in situ nejm journal watch.
Melanoma in situ mis is a noninvasive lesion accounting for up to 27% of all melanomas. The effect on melanoma specific survival in the swedish melanoma study group trial 9 was similar, with a hazard ratio of 1. Mohs excision has also been used for treatment of melanoma in situ, but even with mohs excision clear margins are still uncertain due to difficulty of seeing atypical melanocytes on frozen sections. Only 3 of the 16 19% biopsy specimens with positive margins demonstrated residual melanoma on re excision, and none of the specimens with negative biopsy margins demonstrated residual tumor on re excision. Jul 22, 20 excision on neck, melanoma in situ duration. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6mm margin. Need help reading a pathology report melanoma research. Pdf melanoma in situ mis is a noninvasive lesion accounting for up to 27% of all melanomas by coory et al. In panel c, there were 128 deaths from melanoma in the group with 1cm margins of excision, as compared with 105 in the group with 3cm margins of excision hazard ratio, 1. B nail apparatus excision including the periosteum of the distal phalanx. Request pdf margin involvement after the excision of melanoma in situ background. Our dermatologist reexcised a melanoma with an area that was 12 cm long and 3.
Surgery is the current recommended treatment for patients with melanoma in situ. Nonamputative wide local excision followed by skin grafting for in situ subngual melanoma. A 5mm margin is often taken as the standard primary excision margin despite increasing evidence that this is frequently inadequate for tumor clearance. This study is a major contribution to the establishment of standard margins for excision of melanoma in situ. In addition, combination of surgery with novel immuno, and targeted therapies, may result in. Pdf surgical excision margins for melanoma in situ researchgate. Reexcision may be done by your family doctor if the melanoma is in situ. In order to be successful, a margin of clinically normal skin must be included because it is welldocumented that invisible tumor exists at the margins. Sometimes it is difficult to achieve recommended margins in sites such as the midface. Useful techniques for the resection of foot melanomas. Melanoma is melanoma manage all types aggressively melanoma in situ. If standard excision of melanoma in situ is performed, a 9mm margin should be used, which will clear 98. I would want the complete 1cm margins and i would most definitely have another excision. Melanoma surgery mount zion1600 divisadero 1600 divisadero st.
We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ. Melanoma in situ of nonlentigo maligna type is likely to be completely excised with 5mm margins whereas lentigo maligna may require wider excision. This novel finding does not indicate that multiple biopsies cause positive margins. Positive or equivocal margins after wide local excision wle complicate. Melanomainsitu and lentigo malignas are treated with narrower surgical margins, usually 0. Confusion regarding excision margin for acral lentiginous melanoma which has in situ lesion.
The margins are wider because the diagnosis is already known. The recommendations for definitive wide local excision of primary cutaneous melanoma in the new guidelines are. A randomized controlled trial of patients with stage iiac cutaneous melanoma thicker than 2mm found that a 2cm surgical resection margin is sufficient and is as safe for patients as a 4cm margin in terms of overall. Blue dotted line indicates the peripheral border of the in situ lesion. The dermatologist excised down to but not including the fascia. In addition to more specificity in body location for example, different icd10 codes for melanoma. Current surgical management of acral lentiginous melanoma. These recommendations for melanoma in situ are similar to those for early. The size of the re excision margin depends on the breslow thickness measured by the pathologist and the site of the melanoma. Mohs micrographic surgery may be used for melanoma in situ. Local coverage determination for excision of malignant. The commonly recommended 5mm surgical margin for melanoma in situ may yield a clearance rate less than 86%, and is therefore inadequate.
Lentigo maligna lm is a sub group of melanoma in situ occurring most commonly in sun damaged skin and is rarely seen in young patients. No difference was found in either melanoma specific survival or relapsefree survival after a median followup of 41 months. The melanoma intergroup trial compared 2cm with table 81 recommended wide local excision margins for primary melanoma based on breslow thickness thickness of melanoma mm measured surgical margin width cm strength of recommendation evidence melanoma in situ 0. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6mm margin p. Malignant melanocytes are confined to the epidermis.