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The Importance of Adequate Primary Tumor Excision Margins and Sentinel Node Biopsy in Achieving Optimal Locoregional Control for Patients With Thick Primary Melanomas

Pasquali, Sandro MD*; Haydu, Lauren E. BSCHE, MIPH*,†; Scolyer, Richard A. MD, FRCPA, FRCPath*,†,‡; Winstanley, Julie B. PhD, CStat*,†; Spillane, Andrew J. MD, FRACS*,†,§,¶; Quinn, Michael J. MBBS, FRACS*,§,¶; Saw, Robyn P. M. MS, FRACS*,†,§,¶; Shannon, Kerwin F. MBBS, FRACS*,§,¶; Stretch, Jonathan R. MBBS, DPhil (Oxon), FRACS*,†,§,¶; Thompson, John F. MD, FRACS, FACS*,†,§,¶

doi: 10.1097/SLA.0b013e31828421e1
Original Articles
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Objective: This study sought to investigate the impact of histopathologically measured excision margins and SNB on local and locoregional disease control in patients with primary cutaneous melanomas more than 4 mm thick.

Background: Most current guidelines recommend at least a 2-cm surgical margin (which corresponds to a 16-mm histopathologic margin). These guidelines are based on limited evidence, mostly obtained in patients who did not have an SNB.

Methods: Histopathologic tumor excision margins for clinically lymph node-negative patients with melanomas more than 4 mm thick, treated at Melanoma Institute Australia (1992–2009), were determined. Clinicopathologic predictors of local and locoregional disease-free survival were investigated.

Results: There were 632 patients eligible for the study; of these, 397 (62.8%) had an SNB. The median histopathologic excision margin was 15 mm (interquartile range, 11.0–19.5 mm). After a median follow-up of 37 months, local and locoregional recurrences were observed in 48 (7.6%) and 159 (25.2%) patients, respectively. Excision margin as a continuous variable was a significant predictor of local [hazard ratio (HR), 0.91; P < 0.001) and locoregional (HR, 0.97; P = 0.042) tumor control on multivariate analyses. Patients with histopathologic margins 16 mm or less had worse local disease-free survival (HR, 2.41; P = 0.01). Patients who did not have an SNB were at higher risk of locoregional recurrence (HR, 1.67; P = 0.003).

Conclusions: Histopathologically determined primary tumor excision margins more than 16 mm, corresponding to 2-cm surgical margins, were associated with better local control in patients with melanomas more than 4 mm thick. Patients achieved the best local and locoregional control when SNB was coupled with a more than 16-mm histologic excision margin.

In patients with thick primary melanomas (>4 mm), guidelines for wide excision are based on low-level evidence, and the value of sentinel node biopsy (SNB) in improving locoregional control has not been adequately assessed. In a large, retrospective, single-institution series, margins more than 2 cm and SNB provided optimal local and locoregional control.

*Melanoma Institute Australia

Sydney Medical School, The University of Sydney

Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital

§The Mater Hospital

Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.

Reprints: John F. Thompson, MD, FRACS, FACS, Melanoma Institute Australia, 40 Rocklands Rd, North Sydney, NSW 2060, Australia. E-mail: john.thompson@melanoma.org.au.

Disclosure: S.P. was a Research Fellow at Melanoma Institute Australia, supported by grants from the University of Padova and the Veneto Oncology Institute (Padova, Italy). R.A.S. was supported by the Cancer Institute New South Wales Clinical Research Fellowship program. Supported by the Melanoma Institute Australia, the Melanoma Foundation of the University of Sydney, Cancer Institute New South Wales, and the Australian National Health and Medical Research Council. The authors declare no conflicts of interest.

© 2013 by Lippincott Williams & Wilkins.