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Updated Practice Guidelines for Melanoma Management
The 2008 evidence-based clinical practice guidelines for the management of melanoma are currently being revised and updated in a staged process by a multidisciplinary working party established by Cancer Council Australia. The guidelines for definitive excision margins for primary melanomas have been revised as part of this process.
Definitive management of primary cutaneous melanoma consists of surgical excision of the melanoma with the aim of curing the patient. The melanoma is widely excised together with a safety margin of surrounding skin and subcutaneous tissue, after the diagnosis and Breslow thickness have been established by histological assessment of the initial excision biopsy specimen.
Sentinel lymph node biopsy should be discussed for melanomas ≥ 1 mm thickness (≥ 0.8mm if other high risk features) in which case lymphoscintigraphy must be performed before wider excision of the primary melanoma site.
The recommendations for definitive wide local excision of primary cutaneous melanoma are:
- melanoma in situ: 5–10mm margins
- invasive melanoma (pT1) ≤ 1mm thick: 1cm margins
- invasive melanoma (pT2) 1.01–2mm thick: 1–2cm margins
- invasive melanoma (pT3) 2.01–4mm thick: 1–2cm margins
- invasive melanoma (pT4) > 4mm thick: 2cm margins
Changes in management as a result of the guidelines
Based on currently available evidence, excision margins for invasive melanoma have been left unchanged compared with the 2008 guidelines. However, melanoma in situ should be excised with 5–10mm margins, with the aim of achieving complete histological clearance. Minimum clearances from all margins should be assessed and stated. Consideration should be given to further excision if necessary; positive or close histological margins are unacceptable.
Michael J Sladden, Omgo E Nieweg, Julie Howle, Brendon J Coventry and John F Thompson. Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma. Med J Aust 2018; 208 (3): 137-142. Published online: 19 February 2018. doi: 10.5694/mja17.00278