Table 1, recommended margins for surgical excision cutaneous. Melanoma in situ mis accounts for up to 27% of all melanomas. Excision margins for melanoma redefined melanoma education. Excision of facial tumors was first described in the indian compendium of sushruta back in 600 bc. Researchers suggested that the safe margin during melanoma surgery is between 8 and 16 mm. This singlecenter retrospective study assessed 1cm excision vs 2cm excision margins in matched cohorts of patients with melanoma with breslow tumor thickness 1. Jan 30, 2020 a few nonrandomised trials suggest that excision margins on the head and neck can be safely reduced but the results must be interpreted with caution given the nature of the studies.
The recommendations for the width of melanoma excision margins are based on the breslow thickness of the primary melanoma at its thickest depth of invasion, as determined by histological assessment of the initial excision biopsy. For example, you report 11603 excision, malignant lesion including margins, trunk, arms or legs. Most surgeons accept these recommendations at face value, rarely considering the many situations in which questions remain. The margins can also vary based on where the melanoma is on the body and other factors. Medical director, melanoma and skin center coleader melanoma moon shot chair, ajcc melanoma expert panel 2 february 2018 ajcc physician to physician 8th edition ajcc melanoma staging system no materials in this presentation may be repurposed in print or online without the express written permission of the american joint committee on cancer. A metaanalysis and bayesian probability evaluation. Standard wide local excision margin recommendations also apply to melanomas of the skin of the digits. Study suggests smaller melanoma excision margins may be. Surgery for melanoma memorial sloan kettering cancer center.
Those who use conventional excision are prepared for a high rate of local recurrence after standard 5mm margins, and even. Pdf determination of melanoma lateral and depth margins. Surgical excision remains the first line of defence in most patients with a primary melanoma of the skin, and 85%90% of patients will be cured at this stage of treatment. What are the recommended safety margins for radical. If the width of the melanoma is 1 cm, then the total diameter is 5 cm. One of the major controversies in the treatment of melanoma is the width of the surgical margin that is necessary for complete excision. Apr 29, 2019 surgical margins of 5 mm are currently recommended for melanoma in situ, and margins of 1 cm are recommended for melanomas less than or equal to 1 mm in depth lowrisk primaries. In addition, combination of surgery with novel immuno, and targeted therapies. Melanoma is melanoma manage all types aggressively melanoma in situ.
In some settings of melanoma in situ, tissue sparing may be critical, and mohs margincontrolled excision may be appropriate. In their article about excision margins for melanoma, thomas et al. For excision to be successful, a margin of clinically normal skin must be included because macroscopically invisible tumour often exists at the margins. If the diagnosis is melanoma, the doctor needs to learn the extent, or stage, of the disease before planning treatment.
Standards are well established for peripheral margins of excision table 1. Wide excision margins are then based on reported tumour thickness. You will find blank pages at the back of the book to use for questions, appointments or other notes. Of these patients 9758% underwent wider excision, which reflected a change in practice in keeping with the 2006 melanoma guidelines, 22 which recommended excision margins of 25 mm for mis. The recommended margins vary depending on the thickness of the tumor. Even when a confident clinical diagnosis of melanoma is made, excision biopsy rather than immediate wide excision should be performed.
Sometimes it is difficult to achieve recommended margins in sites such as the midface. This open access article is licenced under creative commons attribution 4. Although its incidence is increasing, survival rates are improving due to early detection and treatment. Red and black dotted lines indicate lateral margins of 0. More common at age 3050 years, often on the trunk, and in women often on the legs. Blue dotted line indicates the peripheral border of the in situ lesion. Malignant melanoma is one of the most common cancers in the usa, australia and europe. An assessment of histological margins and recurrence of. In the case of melanoma, the purpose of a wide excision is to remove local micrometastases and otherwise phenotypically normal tissue that might be harbouring genotypically abnormal cells located in either the surrounding cutis or superficial.
Im unclear if i can use 24076 or have to use 11603. Melanoma in situ of nonlentigo maligna type is likely to be completely excised with 5mm margins whereas lentigo maligna may require wider excision. The wide excision aims to reduce the rate of tumor recurrence at the site of the original lesion. None of the five published trials, nor our metaanalysis, showed a statistically significant difference in overall survival between narrow or wide excision. Melanoma in situ stage 0 is a melanoma localized to the outermost layer of skin the epidermis. Treatment of choice for primary cutaneous melanoma of any thickness is surgical excision with histologically negative margins.
The size of the re excision margin depends on the breslow thickness measured by the pathologist and the site of the melanoma. In the case of permitted digital reproduction, please credit the national cancer institute as the source and link to the original nci product using the original products title. Confusion regarding excision margin for acral lentiginous melanoma which has in situ lesion. The main aim of surgery in treating any cancer is to completely excise the tumour, thereby preventing local recurrence. Surgical excision margins in primary cutaneous melanoma. Our melanoma surgeons, including mary sue brady shown here, provide compassionate care to people with all stages of the disease. Melanoma wide excision margins after initial excision biopsy recommended in the clinical practice guidelines for the management of cutaneous melanoma in australia and new zealand 3. One of the topics addressed in the new guidelines is excision margins for primary cutaneous melanoma. This study was designed to determine the minimum safe pathologic excision margin for primary cutaneous melanomas 1.
What are the recommended safety margins for radical excision. Many patients diagnosed with melanoma skin cancer may require additional xray diagnostic testing, immunodiagnostic testing, or lymphnode biopsy of the tissue. Principles of surgical margins for wide excision of primary melanoma meb the recommended clinical margin for in situ changed from 0. This confirms the diagnosis and allows rational planning of definitive treatment width and orientation of excision margins, and whether or not to recommend sentinel lymph node sln biopsy. Surgical margins for invasive melanoma should be a t least 1 cm and no more than 2 cm clinically measured around primary tumour. Through underlying subcutaneous tissues down to and included underlying muscular fascia. Melanoma in situ of nonlentigo maligna type is likely to be completely excised with 5mm margins whereas. Surgical excision margins for primary cutaneous melanoma. This is a common pattern of treatment failure in melanoma. We aimed to assess the relation of histological excision margins of mis to recurrence and progression to invasive. Jan 30, 2020 after initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 510 mm measured with good lighting and magnification with the aim of achieving complete histological clearance. Whats the cpt for wide excision malignant melanoma, upper arm2. The authors work from the reasonable conceit that mohs surgery with repeated narrow. Thicker tumors need larger margins both at the edges and in the depth of the excision.
Consideration should be given to further excision if necessary. Malignant of melanoma surgical treatment ncbi bookshelf. Considerable research has aimed to elucidate appropriate margins for excision with a general trend toward less aggressive treatment during the last decades. Chang, md1 1division of surgical oncology, university of michigan comprehensive cancer center, ann arbor, michigan 2department of dermatology, university of michigan, ann arbor, michigan introduction the prevalence of. A main component of the treatment of primary melanoma involves wide local excision wle of the primary lesion or of the biopsy scar with adequate margins 18. A biopsy, a shaving of a lesion, or destruction of a benign, premalignant, or malignant lesion excision of a pilonidal cyst excision of a pressure ulcer 8. After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 510 mm measured with good lighting and magnification with the aim of achieving complete histological clearance. This study investigated the safe margin the tissue removed around the tumor during surgery for stage 2 melanomas tumors with 12 mm in thickness. In general, wider excision is favoured for tumours with a less favourable prognosis, such as increased breslow thickness. Current treatment statusdid not start treatment yet, treatments now being consideredsurgical excision, locationskin melanoma, melanoma.
If the re excision occurs during a subsequent session, however, base your code selection on the diameter of the new excision. Pathology indicates inadequate margins to remove all malignancy. No difference was found in either melanoma specific survival or relapsefree survival after a median followup of 41 months. National comprehensive cancer network nccn evidencebased. Mayo clinic consensus recommendations for the depth of. Mohs micrographic surgery was used effectively to treat melanoma in situ exceeding traditional excision margins of 5 mm, according to published study results. Optimal surgery margins in stage 2 melanomas medivizor. Staging is a careful attempt to learn how thick the tumor is, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. Surgery for melanoma skin cancer melanoma surgery options. In the case of melanoma, the purpose of a wide excision is to remove local micrometastases and otherwise phenotypically normal tissue that might be harbouring genotypically abnormal cells located in either the surrounding cutis or superficial lymphatics, while at the same. Wide excision malignant melanoma, upper arm general. Introduction the doctors and nurses at the university of michigan surgery oncology clinic.
What are the recommended definitive margins for excision. Several studies have shown previously that narrow clinical excision margins 12 cm in vivo are as safe as wide excision margins 45. Current surgical management of acral lentiginous melanoma. Procedure description excision excision full thickness through the dermis removal of a lesion, including margins and simple repair these codes are notused for. As for invasive melanoma, the treatment for melanoma in situ, including lentigo maligna lm, is complete surgical excision with clear margins. The size of the reexcision margin depends on the breslow thickness measured by the pathologist and the site of the melanoma. When would the radical resection code 24077 be appropriate. Surgical excision margins for melanoma in situ sciencedirect. Excision margins in highrisk malignant melanoma nejm. The authors work from the reasonable conceit that mohs surgery with repeated. Howidoit useful techniques for the resection of foot melanomas robert a. Excision margins for melanoma redefined melanoma institute. Wide local excision with 1 cm or 2 cm margins in treating.
No difference was found in either melanomaspecific survival or relapsefree survival after a median followup of 41 months. Fortunately, if you have been receiving regular skin checks, most melanoma can be addressed with a wide excision by your forefront boardcertified dermatologist. Surgical treatment of melanoma is the standard of care for all primary melanomas and consists of en bloc excision of the tumor or biopsy site with a margin containing normalappearing skin and underlying subcutaneous tissue. If the reexcision occurs during the same session as the initial excision, report a single code to describe the greatest area removed. Excision of facial tumors are, as most other skin excisions, most often performed to remove tissue that is either suspected of malignancy e. When discussing margins, one is talking about the distance from the edge of the melanoma in centimeters. This study is a major contribution to the establishment of standard margins for excision of melanoma in situ. Stage i melanoma is a melanoma that has invaded the second layer of skin the dermis. Guidelines of care for the management of primary cutaneous melanoma. Excision margins for intermediatethickness melanoma.
Background controversy exists concerning the necessary margin of excision for cutaneous melanoma 2 mm or greater in thickness. Surgical management of melanoma cutaneous melanoma ncbi. A randomized controlled trial of patients with stage iiac cutaneous melanoma thicker than 2mm found that a 2cm surgical resection margin is sufficient and is as safe for patients as a 4cm margin in terms of overall survival, according to a report published online october 21, 2011 in the lancet. The prevalence of melanoma is rapidly increasing 1,2 and therefore more patients are being evaluated by surgeons for treatment of this tumor. There are no rct data that demonstrate whether narrower excision margins impact on mortality or recurrence rates in head and neck melanoma. Surgical margins of 5 mm are currently recommended for melanoma in situ, and margins of 1 cm are recommended for melanomas less than or equal to 1 mm in depth lowrisk primaries. Re excision may be done by your family doctor if the melanoma is in situ stage 0. Malignant melanocytes are confined to the epidermis. The margins are wider because the diagnosis is already known. Minimum clearances from all margins should be statedassessed. P l a i n l a n g u a g e s u m m a r y surgical excision margins for primary cutaneous melanoma whilst melanoma accounts for only 5% of skin cancers, it is important because it is the cause of 75% of all skin cancer deaths. Mohs micrographic surgery may be used for melanoma in situ. Unanswered questions about excision margins excision margin recommendations are based on the results of randomized controlled trials conducted in different patient populations comparing various margins.
Wide local excision with 1 cm or 2 cm margins in treating patients with melanoma nct03034395. Recommendations regarding the width of the surgical margin of excision are. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. Excision of melanoma in situ remains more art than science. Current treatment statusdid not start treatment yet, treatments now being considered. Surgery remains the mainstay of treatment of primary melanoma, and in the majority of. Surgery to remove a larger area of healthy skin from around where the melanoma was, is known as a wide local excision. The site of the melanoma had the expected distribution. Request pdf surgical excision margins for primary cutaneous melanoma whilst melanoma accounts for only 5% of skin cancers, it is important because it is. Nov 14, 2016 this study investigated the safe margin the tissue removed around the tumor during surgery for stage 2 melanomas tumors with 12 mm in thickness. The oncologic adequacy of narrow resection margins vs more traditional wide margins has been compared in 5 randomized controlled trials enrolling 3297 patients with a robust 5 to 16year median followup.
Surgery is often the best option to cure earlystage melanoma melanoma that hasnt spread to other areas of the body. Excision is one treatment option for basal cell carcinoma bcc and squamous cell carcinoma scc. Cutaneous melanoma accounts for 75% of skin cancer deaths. Study suggests smaller melanoma excision margins may be option for some patients adapted from the nci cancer bulletin. Sentinel lymph node biopsy provides important prognostic information and a probable. Confusion regarding excision margin for acral lentiginous melanoma which has.
The average final excision margin for those patients who underwent a. Mis has no metastatic potential and the aim should be to excise the lesion completely with a clear histological margin, although margin clearance remains undefined. Thus, if the goal is to obtain a 2 cm margin for a 2 mm thick melanoma, then the diameter of the specimen is at least 4 cm. Jan 11, 2016 the main aim of surgery in treating any cancer is to completely excise the tumour, thereby preventing local recurrence. How much skin is removed depends on whether any melanoma cells might have been left behind in the surrounding skin, how deep the melanoma is and the position of the melanoma on the body. Surgical margins for excision of primary cutaneous melanoma. Useful techniques for the resection of foot melanomas. Until recently, margins of 5 cm or more were standard, but these were based more on personal bias and surgical dogma than scientific evidence. Subungual melanoma frequently requires amputation of a distal phalanx.
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