Author reply

Abstract

We thank Dr. Lens and colleagues for their comments on our work.1 We agree completely with their pertinent observations. The results of their extensive review,2 which pooled data from our study and the Intergroup and Swedish trials, are consistent with our conclusion. Dr. Lens and colleagues discuss the use of smaller margins for lesions measuring < 2 mm in thickness. We agree that for lesions measuring < 1 mm in thickness, more limited resection (1 cm margins, compared with 2 cm margins in our study) is recommended; this finding is supported by Balch et al.3 and by Veronesi and Cascinelli.4 Nonetheless, for 1–2 mm thick lesions, we believe that 2 cm margins remain appropriate. In the World Health Organization study, although there was no difference in survival between patients with 1 cm surgical margins and those with 3 cm margins, there was a slightly greater risk of recurrence in the 1 cm cohort;3 however, in the latter subgroup (1 cm margins), margin size could be adjusted for each patient based on other prognostic factors, such as ulceration and location (foot, hand, or scalp). Ulceration data were not available in our study. We await the definition of a surgical consensus by trials examining procedures for lesions that measure > 2.1 mm in thickness. The results of those trials will be combined with biologic analysis (involving genomic, proteomic, and other serum molecular markers) to define the pattern of recurrence and to avoid the use of unnecessarily large excision margins for biologically predicted metastatic evolution.