Collectively, surgeons have incorporated evidence-based practices increasingly over the last decades. The meta-analysis on 5 clinical trials involving melanoma surgical excision margins by Lens et al in this issue of the Archives provides an opportunity to review the evolution of our current standard of care for melanoma surgery and exemplifies a continuing shift from empirically based to evidence-based surgery.
Readers of the Archives might recall that just 25 years ago the standard of care was to excise melanomas with 4-cm to 5-cm radial margins of skin (Yes, that would be 5 to 6 inches across!), with disfiguring, morbid closures and large skin grafts. Historically, the approach of using radical margins has been ascribed to the anecdotal experience of Handley,1 who in 1907 reported his treatment of locally advanced melanomas and his finding of “centripetal lymphatic spread” of disease. Sustaining this practice of wide excision was the known association of local recurrence with a high risk of distant metastases and fear that undertreatment of the primary melanoma with a narrow excision might contribute to increased risk of local recurrence and patient death. Almost 70 years later, a Commission on Cancer national survey on the treatment of melanoma in the United States showed that most patients underwent radical excision of primary melanomas.2 Furthermore, there was no clear correlation of the excision margin selected with either tumor thickness or level of invasion2 despite published reports that local recurrence rates are low in thinner, nonulcerated melanomas.3 The radical excision standard was the same elsewhere in the world. In 1988, Veronesi and colleagues wrote that “For decades, wide excision (with margins of 3 to 5 cm) has been universally accepted as the treatment of choice . . . the belief has been so strong that among more than 800 patients in the WHO Melanoma Registry, we found only 40 who had been treated with a margin of less than 2 cm.”4(p1159) During these middle decades of the 20th century, the natural history of melanoma was profoundly changing. The incidence of melanoma was increasing dramatically, but most of these melanomas were both thinner and more superficially invasive and were associated with a low risk of local recurrence.5
Balch CM, Ross MI, Cascinelli N, Soong S. Excision Margins for Primary Cutaneous Melanoma—Invited Critique. Arch Surg. 2007;142(9):891-893. doi:10.1001/archsurg.142.9.891