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Recurrence Rate of Melanoma In Situ Excised With a 5-mm Excisional Margin

Jama Dermatology

The recommendations for treating invasive melanoma have evolved dramatically during the past century. The surgical practices of radically wide margins and amputations were abandoned when evidence from randomized clinical trials (RCTs) showed that surgical margins as narrow as 1 cm were safe for most melanomas. In contrast, the recommendations for surgical margins for melanoma in situ (MIS) are not based on RCTs and exist with some controversy. The earliest recommendations of a 5-mm surgical margin for MIS was suggested by the National Institutes of Health by a panel of dermatologists in 1991 based on their experience rather than scientific evidence, and this became the recommended excision margin adopted by many national and international groups writing clinical guidelines. At the same time, the experience of Mohs surgeons and others looking carefully at the width of surgical margins necessary to achieve negative histologic margins led to a different conclusion. Multiple studies from various institutions showed that MIS often extends beyond a 5-mm clinical margin, and wider margins were necessary to avoid local recurrence and tumor progression. Although no RCTs were performed to my knowledge, the preponderance of evidence from these sources came to the same conclusion that margins wider than 5 mm for MIS are necessary to provide negative histologic margins in 97% of real-world lesions of MIS. However, the controversy continued about surgical margins for subgroups of MIS based on histology (MIS vs lentigo maligna), location (head and neck vs trunk and extremity), and other clinical parameters. Today, most clinical guidelines recommend a range of margins of 0.5 to 1 cm for all MIS, noting that the goal of excision is negative histologic margins.

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Agosto 2024
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