Head and Neck Melanoma: Wide Local Excision and Margin Assessment

More than 100,000 cases of cutaneous melanoma will be diagnosed this year in the United States, and the incidence continues to rise worldwide. Although melanoma represents only 1% of all skin cancers, it is responsible for the majority of skin cancer deaths. Major risk factors include age, UV-light exposure, and fair skin. Surgery remains the first-line treatment for primary cutaneous melanoma with the goal of achieving histopathological clearance to reduce the risk of recurrence. Cutaneous melanoma of the head and neck (CMHN) represents about 20% of all melanoma cases and poses a unique set of challenges, given the need to balance adequate oncologic resection with significant functional and cosmetic concerns. CMHN is also more likely to present with a deeper Breslow thickness and is associated with a higher likelihood of positive margins, higher recurrence rate, and worse survival than melanoma of the trunk and extremities. Histopathological subtypes in the head and neck also differ from melanoma of the trunk, with a much higher proportion of lentigo maligna (LM) and LM melanoma subtypes, which can often have significant subclinical spread beyond the pigmented lesion. Despite these differences, current National Comprehensive Cancer Network (NCCN) guidelines for the recommended excisional margins of cutaneous melanoma are based on randomized controlled trials that mostly excluded tumors of the head and neck. Therefore, the recommended margins for CHNM remain highly controversial. While there is a paucity of controlled, prospective studies assessing wide local excision (WLE) margins in CMHN, several large retrospective studies have suggested that narrow margins lead to high rates of recurrence but also that excessively wide margins do not confer an oncologic benefit. Utilizing the Surveillance, Epidemiology, and End Results database, a large population-based study with over 3,500 cases compared narrow resection margins (1–2 cm) to wide margins (>2 cm) in CMHN and found that margins >2 cm did not confer an additional benefit in overall or melanoma-specific survival (MSS). Importantly, this study found that the use of wider margins did not result in a survival benefit in patients with more advanced disease, anatomic location, or sentinel lymph node spread. Furthermore, regardless of T-stage, patients with >2 cm surgical margins had similar disease-specific survival to patients who had 1–2 cm margins.1 As expected, patients with excessively narrow clinical margins <1 cm have poorer oncologic outcomes. In 372 patients with T2 cutaneous melanoma, one retrospective study found that those who had a pathologic margin of <0.8 cm (equivalent to <1 cm clinical margin) had worse MSS compared to the 0.8–1.6 cm group (equivalent to 1–2 cm clinical margin).2 There were no differences in disease-free survival and local recurrence between the two groups. In contrast, another single-center study on T4 CMHN found a high rate of locoregional recurrence (27%), but margins ≥2 cm failed to offer any benefit in recurrence rates or MSS.3 Alternative techniques to WLE such as Mohs micrographic surgery (MMS) and staged excision (SE) have gained acceptance due to their reliance on histopathologic rather than clinical margins. MMS and SE allows for comprehensive margin assessment which can be utilized for tumors with clinically ill-defined margins in sensitive locations such as the lip and peri-ocular area. While there are no randomized trials comparing MMS or SE with standard WLE, observational studies have shown comparable or improved local recurrence rates in early-stage disease. Furthermore, no randomized, controlled studies have demonstrated that MMS and SE ultimately have narrower clinical margins compared to WLE. In a large single-institution cohort of over 1,300 patients undergoing MMS with LM and melanoma in situ (MIS) lesions of the head and neck, a 0.6 cm margin cleared 79% of LM and 77% of MIS while a 1.2 cm margin resulted in 97% clearance rate for both.4 The 5- and 10-year local recurrence rates were less than 0.4% for both types of lesions. The authors performed a systematic review of 19 studies with 3883 patients and found that the mean margin of 1.9 cm was required to obtain a 97% clearance rate for MIS of the head and neck. The largest case series of SE for CMHN also offers similar insights. In Moyer et al., 564 MIS lesions and 270 invasive melanomas underwent “square” SEs.5 The mean margin for histologic clearance was 0.93 cm for MIS and 1.37 cm for invasive melanoma. The estimated local recurrence rates were 1.4% at 5 years and 2.2% at 10 years. In conclusion, due to the functional and cosmetic importance of the head and neck, guidelines for melanoma resection and appropriate margins should be developed separate from lesions of the trunk and extremities. However, the current literature assessing the role of margins in CMHN has significant limitations including a high risk of bias in patient and treatment selection, high heterogeneity in the measured outcomes, and a limited number of prospective studies. Current NCCN margin guidelines for WLE based on T-stage are appropriate for melanoma of the head and neck. The studies presented suggest that 1–2 cm margins for WLE are appropriate for all T-stages and that extending beyond 2 cm does not offer a survival benefit. Observational studies for MMS and SE demonstrate similarly low 5-and 10-year recurrence rates in MIS and T1 invasive melanoma, but lack evidence that they have narrower margins or are more tissue sparing compared to WLE. Future studies should prospectively investigate whether margins based upon T-stage can be reduced further without compromising disease recurrence.

Can we reduce excision margins for head and neck melanoma? A 12-year retrospective study

7552 Introduction: The utility of lymphatic mapping (LM) and sentinel lymphadenectomy (SL) in head and neck (H&N) melanoma is still debated. The purpose of this study is to determine the therapeutic efficacy of LM/SL-directed surgical clearance of tumor-involved lymph node (LN) basins in early-stage cutaneous H&N melanoma. Methods: Database query identified all cutaneous H&N melanoma patients who were seen at our institution within first 3 months of diagnosis and underwent surgery between 1974 - 2002. Inclusion criteria were stage I - III, wide local excision (WLE) only, WLE/SL ± complete lymph node dissection (CLND), and at least 1-year of follow-up. Exclusion criteria were mucosal melanoma and stage III with palpable LNs. Group 1 underwent WLE only, whereas Group 2 underwent WLE/SL + CLND if sentinel node contained metastatic tumor. Patients from each group were matched for Breslow thickness (0 - 1 mm, 1.01 - 2 mm, 2.01 - 3 mm, 3.01 - 4 mm, > 4 mm), primary site (face/nose, scalp, ear, neck), and gender. 5-year disease free survival (DFS), loco-regional recurrence (LRR), and times to LRR were measured. χ2 and log-rank tests were used to determine statistical significance. Results: Of 604 eligible patients, 176 patients from each group (total of 352) were matched for above prognostic factors. Distribution of Clark level (p = 0.16) and % of patients with ulceration (p = 0.63) were not different. 5-year DFS rates were not statistically different (65 ± 4% for Group 1 vs. 71 ± 4 for Group 2; p = 0.287). However, the difference in LRR was statistically significant (Group 1: 20% vs. Group 2: 6.3%; p = 0.0001). Despite differences in median follow-up times (99 vs. 51 months), the median/mean times to LRR were not different (Group 1: 12/26 months vs. Group 2: 13/36 months; p = 0.56). Conclusions: Our data indicate that LM/SL-directed surgical clearance of melanoma-involved LN basins decreases the incidence of LRR for early-stage cutaneous H&N melanoma. Its therapeutic superiority in controlling loco-regional disease, when compared to WLE alone, provides a de-facto evidence of validity for application of LM/SL in early-stage cutaneous H&N melanoma. No significant financial relationships to disclose.

Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision

Selective sentinel lymph node dissection (SLND) plays an important role in the staging of the regional nodal basins for head and neck (H&N) melanoma. Preoperative lymphoscintigraphy is mandatory to identify the regional nodal basin(s) accurately for a newly diagnosed H&N primary melanoma of at least 1mm or greater. A wide local excision should be delayed if SLN mapping is indicated, to minimize watershed effect and maximize accuracy in identifying the "true" SLN because of the complex lymphatic network in the H&N region. An experienced multidisciplinary team is required for optimal identification of H&N SLNs. In general, selective SLND can replace ELND to minimize the complications of a neck dissection. Completion lymph node dissection is only indicated when the SLN is positive. A nerve stimulator should be used during selective SLND in the parotid and posterior triangle to minimize the injury to the facial and spinal accessory nerve.

To assess postbiopsy pigmentation (PBP) as a prognostic feature in patients with cutaneous head and neck (H&N) melanoma. Retrospective review of patients undergoing sentinel lymph node biopsy (SLNB) for H&N melanoma (1998-2018). PBP was defined as visible remaining pigment at the scar or biopsy site that was documented on physical exam by both a medical oncologist and a surgeon at initial consultation. Variables associated with disease-free survival (DFS) and overall survival (OS) were analyzed using multivariable Cox proportional hazards models. Among 300 patients, 34.3% (n = 103) had PBP and 44.7% (n = 134) had microscopic residual disease on final pathology after wide local excision. Prognostic factors associated with DFS included advanced age, tumor depth, ulceration, PBP, and positive SLNB (p < 0.05). Patients with PBP fared worse than their counterparts without PBP in 5-year DFS [44.1% (31.1-56.3%) vs. 73.0% (64.1-80.0%); p < 0.001] and 5-year OS [65.0% (50.0-76.6%) vs. 83.6% (75.7-89.2%); p = 0.005]. After multivariable adjustment, PBP remained associated with shorter DFS [hazard ratio (HR) 1.72, 95% confidence interval (CI) 1.01-2.93; p = 0.047], but was not prognostic of OS. In patients with H&N melanoma, PBP is associated with significantly shorter DFS. Patients with PBP may warrant greater consideration for SLNB and closer postoperative surveillance.

Although previous database studies suggest that Mohs micrographic surgery (MMS) treatment is associated with improved overall survival (OS) for head and neck melanomas, outcomes for trunk and extremity (T&E) tumors have not been adequately evaluated. To assess survival outcomes for patients with melanomas of the T&E treated with MMS vs wide local excision (WLE). This retrospective cohort study examined deidentified data from the National Cancer Database between 2004 and 2015. Inclusion criteria for the analysis included diagnosis of trunk, upper extremity, or lower extremity melanoma; known Breslow depth; removal by MMS or WLE; and known last date of survival status. Five-year all-cause mortality (ACM) rates. A total of 188 862 in situ and invasive melanomas were included in the analysis (MMS, 2.3%; WLE, 97.7%); the mean (SD) age of patients included was 58.8 (16.0) years, and 52.7% were male. Multivariate analysis demonstrated no OS difference among trunk (WLE hazard ratio [HR], 1.097; 95% CI, 0.950-1.267; P = .21), upper extremity (WLE HR, 1.013; 95% CI, 0.872-1.176; P = .87), lower extremity (WLE HR, 0.934; 95% CI, 0.770-1.134; P = .49), or combined T&E (WLE HR, 1.031; 95% CI, 0.941-1.130; P = .51) tumors. Factors associated with increased risk of ACM on multivariate analysis of all tumors included increasing age (HR, 1.043; 95% CI, 1.042-1.044; P < .001), no insurance or nonprivate insurance (none: HR, 1.921 [95% CI, 1.782-2.071]; Medicaid: HR, 2.410 [95% CI, 2.242-2.591]; Medicare: HR, 1.237 [95% CI, 1.194-1.281]; other government insurance: HR, 1.279 [95% CI, 1.117-1.465]; P < .001 for all), positive surgical margins (HR, 1.609; 95% CI, 1.512-1.712; P < .001), a Charlson-Deyo comorbidity score greater than 0 (Charlson-Deyo score of 1: HR, 1.340; 95% CI, 1.295-1.385; P < .001; Charlson-Deyo score of ≥2: HR, 2.044; 95% CI, 1.934-2.159; P < .001), tumor ulceration (HR, 2.175; 95% CI, 2.114-2.238; P < .001), and increasing Breslow depth (HR, 1.002 [per 0.1 mm]; P < .001). Female sex (HR, 0.698; 95% CI, 0.680-0.716; P < .001) and nonnodular subtype (lentigo maligna/lentigo maligna melanoma: HR, 0.743; 95% CI, 0.686-0.805; P < .001; superficial spreading: HR, 0.739; 95% CI, 0.710-0.769; P < .001; other subtype: HR, 0.817; 95% CI, 0.790-0.845; P < .001; nodular: HR, 1 [reference]) were associated with improved OS. This cohort study of patients surgically treated for melanomas of the trunk and/or extremities found that, compared with WLE, MMS was not associated with significantly different OS for T&E melanomas.

Clinical and pathological analysis of dermatofibrosarcoma protuberans with long-term follow-up

# IntroductionTruncal and head and neck head and neck melanomas have a greater propensity to drain to multiple lymph node basins (MLNB) compared to extremity melanomas, which drain predominantly to a single lymph node basin (SLNB). The objective of this study was to compare the lymphatic drainage patterns and characteristics of truncal and head and neck melanoma, to assess their clinical usefulness in areas of unpredictable drainage. # MethodsA retrospective review of 143 patients with head and neck or truncal melanoma from 2014–2018 treated at the Victorian Melanoma Service, Alfred Hospital, Melbourne, Australia. Patients scheduled for a wide local excision (WLE) and SeNBx, and those whose initial biopsy results stated melanoma type, cell type and BT, were included. Patients were excluded if they underwent nodal biopsy alone.# ResultsWe identified 95 patients with truncal and 48 with head and neck melanoma. Drainage to MLNB was significantly higher in the truncal melanoma group (36.8%) compared to the head and neck group (10.4%) (_p_ = 0.001). Patients with drainage to MLNB had a higher positive sentinel node biopsy (SeNBx) rate compared to those with SLNB (40.0% verus. 12.6%, _p_ &lt;0.0001). Truncal melanomas that drained to MLNB were associated with a significantly higher Breslow thickness (2.1 versus. 1.5, _p_ = 0.02), ulceration (40.6% vs. 20.7%, _p_ = 0.043) and mitotic rate (3.0 versus. 2.0, _p_ = 0.045) compared to equivalent melanomas that drained to SLNB. # ConclusionPatients with melanomas occurring in the trunk exhibit higher rates of drainage to MLNB compared to melanomas arising in the head and neckhead and neck. Patients with drainage to MLNB also demonstrate a higher rate of positive SeNBx than those with SLNB drainage. This may represent more aggressive disease pathology or later diagnosis of lesions within these locations, or a lymphatic system that is more facilitatory of spread.

Wide local excision (WLE) is a standard component of cutaneous melanoma management, although prospective evidence supporting current margin recommendations remains limited. Surgical margins have progressively decreased. However, six randomized clinical trials comparing wider (3-5cm) vs. narrower (1-2cm) margins did not demonstrate significant reductions in local recurrence (LR) or survival benefits. Furthermore, wider margins are associated with increased morbidity and healthcare costs. We systematically reviewed relevant published studies up to and including December 2025 to compare LR and survival outcomes between standard WLE and no or narrow-margin excisions. The analysis included adult and pediatric cases of superficial spreading, nodular, acral, and desmoplastic cutaneous melanoma; lentigo maligna was excluded. No prospective studies were found comparing WLE to the omission of WLE for cutaneous melanoma. Two retrospective studies reported no significant differences in LR or overall survival (OS) in patients who did not undergo WLE (n = 453). Regarding lateral margins, 30 retrospective studies were identified. Collectively, these studies suggest that narrower margins than those currently recommended are not associated with worse LR, disease-free survival, or OS for melanoma in situ and pT1-pT3 tumors (Breslow index ≤ 4mm). However, findings for pT4 melanomas (Breslow index > 4mm) remain inconsistent. Analysis of deep margins (n = 5 retrospective studies) largely supported more superficial excision strategies than current guidelines. Regardingacral melanoma, seven retrospective studies were located, all of which reported that narrower and shallower margins-including the preservation of plantar fat-did not adversely affect LR or survival. Conversely, in cases ofdesmoplastic melanoma, two retrospective studies were found with conflicting results regarding LR. In the pediatric population, evidence remains scarce; two retrospective studies evaluating narrow excision margins revealed no adverse impact on OS. Current evidence suggests that narrower lateral margins and shallower deep excision strategies could be oncologically safe. However, the absence of an observed association with higher rates of LR or worse survival outcome should not be interpreted as proof of non-inferiority to standard WLE, given the predominance of observational data, heterogeneity across studies, and limited statistical power in smaller cohorts. High-quality prospective randomized trials are required. Ongoing randomized trials (MelMART-II, WoW, and ICEMAN) will play a key role in refining future surgical margin recommendations.

Can we reduce wide local excision margins for head and neck melanoma: a 10 year retrospective analysis of head and neck cutaneous melanoma

Head and neck melanoma often approaches critical structures. Therefore, excision is often limited, leading to positive margins, and increased local recurrence. Immediate reconstruction carries concern for rearrangement or concealment of cancerous tissues. Therefore, reconstruction is often delayed until confirming negative margins on permanent pathology. Our purpose is to identify variables associated with a positive margin and establish criteria for reconstruction timing. We reviewed 117 consecutive patients who underwent wide local excision of head and neck melanoma. Reconstruction was immediate for 107 and delayed for 10. Six percent of patients had a positive margin after wide local excision with no difference in incidence between immediate and delayed reconstruction (P = 0.11). Tumor characteristics associated with a positive margin were locally recurrent, ulcerated, and T4 tumors (P < 0.05); and delayed reconstruction should be considered in these circumstances. Immediate reconstruction is safe for the majority of head and neck melanoma and should be based on knowledge of tumor characteristics.

Knowledge of variation in diagnosis and surgery in high-risk primary melanoma patients is limited. We assessed frequency and determinants of diagnostic procedures, wide local excision (WLE) and sentinel lymph node biopsy (SLNB). People in Queensland newly diagnosed with melanoma, clinical stage 1b or 2, were recruited prospectively. Patient information was collected from questionnaires and pathology records. Differences in surgical procedures in relation to host and tumor characteristics were assessed. In 787 participants, primary melanoma was diagnosed by surgical excision (74%), shave (14%), punch (12%) or incisional (1%) biopsy. General practitioners (GPs) diagnosed 80%. Diagnostic procedure differed by remoteness of residence, health sector, treating doctor's specialty and melanoma site and thickness. 766 patients had WLE, 86% by surgeons. Of 134 residual melanomas, 13 (10%) were ≤ 1 mm at diagnosis but > 1 mm at WLE, mostly after shave biopsy. SLNB was performed in 261 (33%) patients. SLNB was more common in those under 50, in remoter locations or treated by GP initially, and less common with head and neck melanoma. Diagnostic and surgical procedures for primary melanoma vary substantially and partial biopsy can influence initial tumor microstaging. Patient, tumor and doctor characteristics influence SLNB practice.

Improved overall survival of melanoma of the head and neck treated with Mohs micrographic surgery versus wide local excision

The proximity of head and neck (H&N) melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. This study sought to determine the risk associated with reducing margins of wide local excision (WLE) in H&N melanoma and to identify risk factors of recurrence. Seventy-nine cases of primary, invasive H&N melanoma were treated by WLE and followed prospectively for local recurrence. Forty-two WLEs were performed according to current practice guidelines (1cm for lesions<1.0 mm thick, 1-2 cm for lesions 1.01-2.0 mm thick, and 2 cm for lesions >2.0 mm thick). Reduced margins (0.5 cm for lesions ≤1.0 mm thick, 0.5-1.0 cm for lesions 1.01-2.0 mm thick, and 1.0 cm for lesion >2.0 mm thick) were utilized in 37 cases to preserve critical anatomical structures such as the eyelid, nose, mouth and auricle. Overall local recurrence rate was 8.9% over a mean follow-up period of 71.3 months and a minimum of 60 months. Reducing margins of WLE did not increase local recurrence rates as demonstrated by local recurrence-free survival (90.4% vs. 91.9%, P = 0.806). Margins of WLE may be safely reduced in melanomas in close proximity to structures of the H&N without affecting local recurrence rates.