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Establishing a Standard of Care for the Patient with Melanoma

From the Department of Surgery, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida.

Correspondence: Address correspondence to: Douglas Reintgen, MD, Program Leader, Cutaneous Oncology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL; Fax: 813-979-7211; E-mail: reintgds{at}moffitt.usf.edu

Malignant melanoma is an extensively investigated tumor due to the fact that it is easily diagnosed with simple techniques, prognostic factors have been well-described for the disease, and it seems to be an immune reactive tumor, making melanoma a favorite model system for immunotherapy programs. The report by Balch and the Intergroup Melanoma Trial¹ in this issue of the Annals of Surgical Oncology adds to this body of literature that defines the standard of surgical care for melanoma. This trial investigates two questions. The first is the proper margin of excision for intermediate thickness melanoma (tumor thickness between 1–4 mm) and the second is the efficacy of elective lymph node dissection. The appropriate margin of excision is the basis of this report. Now with 10 years of follow-up, it is apparent that patients initially treated with a 2.0 cm wide local excision (WLE) had similar survival rates as those treated with a 4.0 cm WLE. Patients that were unfortunate enough to suffer a local recurrence had a uniformly poor survival, but the higher local recurrence rate was associated more with the biology of the primary melanoma (ulcerated lesions) and location (head and neck) than with the margin of excision.

There are a number of remarkable points to make about this study. The principal investigator and other co-investigators need to be congratulated, as it is not every day that the surgical literature publishes a national prospective randomized study with 10 years of follow-up.

The second point worth emphasizing is the poor survival of anyone who suffers a local recurrence. In the new proposed AJCC staging system,² a local recurrence is shifted from Stage II to Stage III to reflect this poorer survival. Local recurrence combines with in-transit metastases in the Stage III grouping to reflect the biology of the disease, that both recurrences reflect cutaneous lymphatic spread of the melanoma. With such a poor survival, every attempt should be made to obtain the proper margin of resection around the primary melanoma. The readers are reminded that this margin is a gross margin measured around the pigmented lesion or the excisional biopsy scar, and not a microscopic margin as measured from the histologic examination. In addition, because of this high rate of recurrence and death in melanoma patients who have a local recurrence, this group should be considered for adjuvant therapy or included in adjuvant therapy trials.

Finally, because melanoma is a well study tumor, consensus standards of care are more possible with this tumor. In my opinion, these are as follows:

Concerning the margin of excision:

1. For a melanoma-in situ–a 0.5-1.0 cm WLE

2. For an invasive melanoma < 1.0 mm in thickness—a 1.0 cm WLE as established by the World Health Organization study³

3. For an intermediate thickness melanoma (1–4 mm)—a 2.0 cm WLE as established by this Intergroup study

4. For a deep melanoma (>4.0 mm in thickness)—a 2.0 cm WLE as established in a retrospective study at the MD Anderson/Moffitt Cancer Centers⁴

Concerning the regional lymphatic basin:

1. Perform preoperative lymphoscintigraphy to define all basins at risk for metastases

2. Complete lymphatic mapping and sentinel lymph node biopsy for staging, prognosis, clinical trial work and to determine which patients are candidates for adjuvant therapy

Now, if the research community could just find a better treatment and perhaps cure for Stage IV melanoma!

Received for publication November 10, 2000. Accepted for publication November 27, 2000.

REFERENCES

1. Balch C, Soong S-J, Smith T. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. 2001; 8: 101–8.
2. Balch C, and the members of the AJCC Melanoma staging committee. A new AJCC staging system for Cutaneous melanoma. Cancer (2001), in press.
3. Veronesi U, Cascinelli N. Narrow excision (1.0 cm margin): A safe procedure for thin cutaneous melanoma. Arch Surg 1991; 126: 438.[Abstract]
4. Heaton KM, Sussman J, Gershenwald J, Lee J, Reintgen DS, Mansfield P, Ross M. Surgical margins and prognostic factors in patients with thick (>4mm) primary melanoma. Ann Surg Oncol 2001, in press.

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