Reply: Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment.

Abstract

Sir: Surgical excision of melanoma with histologically negative margins remains the standard goal of treatment for cutaneous malignant melanoma. The reported incidence of positive margins following wide local excision varies between 5 and 22 percent.1–6 Previous studies have demonstrated that certain tumor and patient characteristics can predict positive margins following resection of cutaneous melanoma, which include advanced age and locally recurrent, ulcerated, T4 tumors.3,7 The results of our study8 demonstrate lower positive margins rate, which can be explained by our patient cohort, which excluded patients with recurrent or metastatic disease. In addition, at the time of the initial biopsy, the majority of patients had either melanoma in situ (n = 194, 37 percent) or T1 stage melanoma (n = 209, 40 percent). Although primary closure or skin grafting may be considered the ideal oncologically safe method of reconstruction following melanoma extirpation, reconstruction with adjacent tissue transfer offers a versatile alternative, and can improve functional and aesthetic results. A study by Sullivan et al.7 demonstrated that melanoma reconstruction with local flaps does not delay detection of local recurrence and may even decrease the incidence of local failure after wide local excision of head and neck melanomas. At our institution, in select cases with positive margins following local flap reconstruction, we work closely with the surgical oncologist to determine the original tumor location, aided by knowledge of the original flap design and use of preoperative photographs. Flaps are returned to their original location and reoperative margins are drawn at the proposed original site of tumor by the surgical oncologist to allow for adequate reexcision. The absence of the delayed reconstruction group does affect the accuracy of healthcare cost estimations at the time of the reexcision and reconstruction. However, the theoretical cost savings that were generated by our billing department, after reviewing hospital charges for the single-stage melanoma extirpation and reconstruction and comparing them to the theoretical costs for two-stage reconstruction, demonstrated significant cost savings. We also acknowledge that our follow-up of 1.2 years is a limitation of the study and may be too short to detect the local recurrence. In the future, a prospective study with 5-year follow-up and disease-free recurrence rates will be useful to determine our long-term recurrence rates. At the time of definitive excision, we adhere to the current National Comprehensive Cancer Network guidelines, which dictate surgical margins based on tumor thickness: 0.5 to 1 cm for melanoma in situ, 1 cm for tumors less than or equal to 1 mm in thickness, 1 to 2 cm for tumors 1.01 to 2 mm thick, and 2 cm for tumors greater than 2 mm in thickness.9 The mean margins of excision in Table 1 appear to be below the recommended National Comprehensive Cancer Network guidelines because in select patients narrower margins of excision were taken in the cosmetically and functionally sensitive head and neck region at the discretion of the surgical oncologist following extensive preoperative discussion with the patient and family regarding possible functional deficits. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Irena Karanetz, M.D.Neil Tanna, M.D., M.B.A.Division of Plastic and Reconstructive SurgeryNorthwell HealthHofstra Northwell-School of MedicineNew York, N.Y.