Abstract
Background The incidence of melanoma in situ (MIS) is increasing faster compared to invasive melanoma. Despite varying international practice, a minimum of 5 mm surgical excision margin is currently recommended in the UK. There is no clear guidance on the minimum histological peripheral clearance margins. Aim This study compares the histological peripheral clearance margins of MIS using wide local excision (WLE) to the rate of recurrence and progression to invasive disease. Methods A retrospective single-center review was performed over a 5-year period. Inclusion criteria consisted of MIS diagnosis, ≥16 years of age, and treatment with WLE with curative intent. Those patients with a recurrence of a previous MIS or with a reported focus of invasion/regression were also included. Clinicopathological data and follow-up were recorded. Results 167 MIS were identified in 155 patients, 80% of which were lentigo maligna subtype. Of patients with completely excised MIS on histology (>0 mm), 9% had recurrence with a median time to recurrence of 36 months. Three (1.8%) cases recurred as invasive disease. Age, MIS site, MIS subtype, and histological evidence of foci of invasion/regression did not predict recurrence nor progression to invasive disease (p > 0.05). The recurrence rate of MIS with a histological excision margin ≤3.0 mm was 13% compared to 3% in those with histology margins of >3.0 mm (p=0.049). Conclusion A histological peripheral clearance of at least 3.0 mm is advocated to achieve lower recurrence rates. The follow-up duration should be reviewed due to the median recurrence occurring at 36 months in our cohort. Cumulative work on MIS needs to be collated and completed in a large multicenter study with a long follow-up period.
Highlights
Cutaneous melanoma is one of the fastest rising cancer diagnoses in recent years [1]. is is owed to an aging population and increased exposure to risk factors including sun exposure and immunosuppression [1]
There is no international consensus on the optimal excision margin. e National Institute of Health and Care Excellence (NICE) guidelines in the UK currently recommends a minimum surgical excision margin of 5 mm [7] and recommend discharging the patient at the first outpatient clinic follow-up if the lesion has been histologically excised. e most recent guidance from the American Association of Dermatology (AAD) recommends a 5 to 10 mm surgical margin, recognizing that Lentigo maligna (LM) may require a larger than 5 mm margin [8]
More robust pathways for patients with a diagnosis of Melanoma in situ (MIS) are required. is body of work supports that the histological margins, when using wide local excision (WLE) as the means to surgically remove MIS, play an important role in the surgical management of patients with MIS. is study endorses that UK guidelines should aim for a consensus for a minimum histological clearance when MIS is treated by WLE
Summary
Cutaneous melanoma is one of the fastest rising cancer diagnoses in recent years [1]. is is owed to an aging population and increased exposure to risk factors including sun exposure and immunosuppression [1]. Melanoma in situ (MIS) is a noninvasive lesion that accounts for up to 27% of all melanomas [2] and its incidence is increasing faster compared to invasive melanoma. Lentigo maligna (LM) is the most common subtype of MIS accounting for 79% to 83% of all MIS tumors [5, 6]. It is associated with chronic exposure to ultraviolet radiation and primarily affects the head and neck region. Surgical intervention by wide local excision (WLE) is the most widely used first-line therapy for MIS. There is no international consensus on the optimal excision margin.
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