Scandinavian Journal of Plastic and Reconstructive Surgery

ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18

Excisional Biopsy and Delayed Wide Excision Versus Primary Wide Excision of Malignant Melanoma Jan Eldh To cite this article: Jan Eldh (1979) Excisional Biopsy and Delayed Wide Excision Versus Primary Wide Excision of Malignant Melanoma, Scandinavian Journal of Plastic and Reconstructive Surgery, 13:2, 341-345, DOI: 10.3109/02844317909013079 To link to this article: http://dx.doi.org/10.3109/02844317909013079

Published online: 08 Jul 2009.

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Date: 10 May 2016, At: 21:29

Scand J Plast Reconstr Surg 13: 341-345, 1979

EXCISIONAL BIOPSY AND DELAYED WIDE EXCISION VERSUS PRIMARY WIDE EXCISION OF MALIGNANT MELANOMA Jan Eldh From the Department of Plastic Surgery (Head: 8. Johanson). Sahlgrenska sjukhuset, Goteborg, Sweden

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(Submitted for publication January 8, 1979)

Abstracr. In a retrospective study of 269 cutaneous malignant melanomas in stage I the influence of biopsy on survival was studied. Sixty patients were treated with primary wide excision and 209 patients with excisional biopsy followed by wide excision. The 5-year survival rates for the two groups were 75.0% and 82.8% respectively. There was an equal distribution of prognostic factors such as thickness, level of invasion, presence of ulceration, location and maximal size of the tumours in the two groups. As excisional biopsy with subsequent wide excision gives an accurate histopathologic diagnosis and permits a more rational treatment of thin melanomas, this form of treatment is recommended.

During recent years several studies on cutaneous malignant melanoma (Hansen & McCarthen, 1974; Breslow, 1975; Eldh, Boeryd & Peterson, 1978) have demonstrated that thickness and depth of invasion of the tumour constitute excellent prognostic indices. Breslow & Macht (1977) have shown that if the melanoma has a maximum thickness of less than 0.76 mm a narrow excision with direct closure is adequate treatment and gives excellent survival. Therefore an accurate histological diagnosis is important so that the operation can be tailored to the depth of invasion and the thickness of the tumour. The aim of the present study was to ascertain whether excisional biopsy followed by wide excision at a second stage would influence the results, as compared with primary wide excision.

least 5 cm. On the trunk and extremities the resection was extended to 10-15 cm from the tumour towards the regional lymph node. On the face, the resection was limited to anatomical regions but the radius was never less than 2 cm. Full-thickness skin grafts were used on the face and split-thickness skin graft in all other cases. The regional nodes were left intact in all cases. Postoperatively, the patients were followed up at our department at intervals of 3 months for the first 3 years and then every 6 months for up to 10 years. Sixty of the patients were treated with primary wide excision (Group A) and 209 patients had an excisional biopsy followed by wide excision when the pathology report on the paraffin sections became available (Group B). The histologic sections were analysed according to the recommendations given by McGovern, Mihm Jr, Bailly, Booth, Clark Jr, Cochran, Hardy, Hicks, Levene. Lewis, Little & Milton (1973) and thickness according to Breslow (1970). The two groups were comparable concerning tumour thickness, level of invasion, presence and extent

%

,1

30 20 10

MATERIAL AND METHODS During the years 1959-73, 269 patients were treated for malignant melanoma in stage I, i.e. the patients showed no signs of metastasis at the time of operation. The operation consisted of excision down to, but not including the muscle fascia, and covering of the resulting defect with a free skin graft. The excision was performed with a radius of at

80,76

0.76-

1.51-

2.26-

1.50

2.25

3,OO

>3.00

Fig. 1. Distribution of tumor thickness in 269 patients with malignant melanoma. 69 = Group A, 60 patients with primary wide excision; 0 = Group B, 209 patients with excisional biopsy followed by delayed wide excision. S c m d J Plasr Reconstr Siirg 1.3

342

J . Eldh

%

%

4

40

40

30

30

20 20

10 111

N

m V

10

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Fig. 2. Distribution of level of invasion in 269 patients with malignant melanoma. 61 = Group A, 60 patients with primary wide excision; 0 = Group B, 209 patients with

Arm Hand

excisional biopsy followed by delayed wide excision.

of ulceration, maximum diameter and location. The distribution was such that no group had an overrepresentation of prognostically unfavourable factors (Figs. 1-5). To analyse the results of the two forms of treatment in terms of 5-year survival, cross-classification tables were constructed based on tumour thickness (Eldh et al.). In a previous study of this material the most important prognostic factor was found to be the tumour thickness. 2.25 mm of thickness was shown to be the limit between cases with favourable and unfavourable prognoses (Tables I111).

RESULTS Analysis of the various parameters showed that 32% of Group A, primary wide excision, had a maximum thickness of more than 2.25 mm compared with 28% in Group B, delayed wide excision

Head Neck

Trunk

Fool

Le 9

Fig. 4. Location of tumour in 269 patients with malignant melanoma. 61 = Group A, 60 patients with primary wide excisional; 0 = Group B, 209 patients with excisional

biopsy followed by delayed wide excision.

(Fig. 1). In Group A, 47% of the tumours were in invasion levels IV and V, compared with 45% in Group B (Fig. 2). Ulcerations greater than 6 mm were noted in 12 % in Group A and in 1 1 % in Group B. Non-ulcerated tumours were found in 58 % in Group A and in 69 % in Group B (Fig. 3). There were an equal distribution to head and neck and to trunk in both groups. Location to arm-hand-leg appeared in 28% in Group A and in 39 % in Group B. Melanomas on the foot were more common in Group A than in B, 17 % and 7 % respectively (Fig. 4). Regarding the size of the tumour,

%

80

60 40

20 None

Fig. 3. Presence and size of ulceration in 269 patients with

malignant melanoma. 19= Group A, 60 patients with primary wide excision; 0 = Group B, 209 patients with excisional biopsy followed by delayed wide excision. Scand J Plast Reconstr Surg 13

52cm

w2cm

Fig. 5. Maximum diameter of tumour in 269 patients with malignant melanoma. Q = Group A, 60 patients with

primary wide excision; 0 = Group B, 209 patients with excisional biopsy followed by delayed wide excision.

Delayed vs. primary wide excision of malignant melanoma

343

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Table I . 5-year survival rate for patients with malignant melanoma thinner than 2.25 mm according to size, location, level of invasion and ulceration of tumour A = 60 patients with primary wide excision. B = 209 patients with excisional biopsy followed by delayed wide excision

c 2 cm

>2 cm

Am, hand, leg

Level IV

Level V

Ulceration >6 mm

Group A 26/27 %.3 %

11/14 78.6%

14/14 100%

11/13 84.6%

-

212

Group B 1351142 95.1%

15/19 78.9%

58/59 98.3 %

39/45 86.6%

-

313

every third tumour in Group A was larger than 2 cm, compared with every seventh in Group B (Fig. 5 ) . The 5-year survival rate for the 60 patients in Group A was 75 % and for the 209 patients in Group B, 82.8%. The difference is not statistically significant (F50.05).On analysing the thin tumours (G2.25 mm thick) almost identical survival rates were found in both materials (Table I). These thin tumours did not infiltrate very deeply and very few showed extensive ulceration. Regarding thick tumours P 2 . 2 5 mm), there were fewer cases and the figures were less reliable. A slight tendency towards a better 5-year survival rate may be traced in Group B (Table 11). The survival rates were found to be very similar in both materials for a given tumour volume measured from the maximal diameter and the thickness of the tumour (Table 111). In Group B, 44/209 had their biopsy performed at our department and 165/209 elsewhere. All delayed

wide excisions were performed at our department. The 5-year survival rates for these two groups were 77.2 and 84.2% respectively. DISCUSSION The result of this study shows that the survival was the same, whether the definitive excision was done primarily or after a previous excisional biopsy. Olsen (1966) studied the influence of preoperative biopsy in stage I melanomas by comparing the metastatic rate in one group of 19 patients with biopsy and in another group of 304 patients without biopsy. Although the group subjected to biopsy was small, Olsen concluded that “if there was a wellfounded suspicion of melanoma, biopsy should not be done, unless operation with grafting could be carried out immediately. When the clinical diagnosis was definite, biopsy should never be done. If biopsy was undertaken, it should be performed under general anesthesia and the tumour

Table 11.5-year survival rate for patients with malignant melanoma thicker than 2.25 mm according to size, location, level of invasion and ulceration of tumour A = 60 patients with primary wide excision. B = 209 patients with excisional biopsy followed by delayed wide excision

s 2 cm

>2 cm

Arm, hand, 1%

Group A 5/13 38.5 %

316

113

5/12 41.7%

013

215

4/10 40 %

16/23 69.6%

22/36 61.1%

6/14 42.9%

4119 21.1%

Group B 19/38 50 %

Level IV

Level V

Ulceration >6 mm

~~

~~

Scand J Plast Reconstr Surg 13

344

J . Eldh

Table 111.5-year survival rate for patients with malignunt melunoma nccording to maximal thickness and size of the tiimours A = 60 patients with primary wide excision. B = 209 patients with excisional biopsy followed by delayed wide excision Thickness, mm Size, cm Group A

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Group B

. ..

...

s 2.25

>2.25

c2

12

G2

>2

26/27 96.3 % 135/ 142 95.1%

11/14 78.6% 15/19 78.9%

5/13 38.5 % 19/38 50.0%

316 50 % 4/10 40 Yo

sent for frozen-section microscopy”. Ironside, Pitt & Rank (1977) observed the 5-year survival rate for 96 patients with biopsy to be 53% compared with 70% for 413 without biopsy. They also found a better survival when the biopsy was performed by an experienced surgeon rather than by the referring doctor; this finding could not be verified in the analysis of our material. Other authors have found no evidence that biopsy affects survival. Knutsson, Hori & Spratt (1971) noted the same survival rate for 156 patients with biopsy as for 74 patients without biopsy. Epstein (1971) made a similar observation when he compared the outcome of a material of 1 I5 patients with biopsy and 55 patients where definitive surgery was performed immediately. The 5-year survival rates were 79% and 75% respectively and the 10year survival rates 65.4% and 55.8% respectively. Mattsson, Gynning, Hogeman, Jacobsson & Line11 (1976) reported a favourable 5-year survival rate of 84% for 183 patients where excisional biopsy preceded extended surgery. It should be noted that in none of the above studies has there been any examination of the distribution of the important prognostic factors in the two different groups. The clinical diagnosis of melanoma is frequently difficult to establish. Epstein, an experienced dermatologist, found that he had a personal diagnostic accuracy of 40%. Kopf, Mintzis & Bart (1975) reviewed the skin cancer registry of the New York University Medical Center, in which there were 99 melanomas. The diagnostic accuracy was found to be 64.4%. The authors emphasized the importance of having histologic verification prior to definitive radical surgery on patients with malignant melanoma. Determination of thickness and level of invasion Scond J Plast Reconstr Sitrg I3

before an extensive operation is also very important. Excellent prognosis after limited local resection of thin melanomas has been demonstrated by Hansen & McCarthen when tumour thickness is less than 1.5 mm and by Breslow & Macht with a thickness below 0.76 mm. There are two ways to achieve this goal. One is to perform an excisional biopsy for paraffin sections and then, after an interval, the definitive excision. The other way is to excise the tumour for immediate frozen-section examination. The rationale for the latter alternative is the elimination of any possible risk of dissemination of malignant cells as a result of the excision biopsy procedure (Hughes, 1975). Davis & Little (1974) also favour the frozen-section method and recommend the removal of the tumour under general anesthesia. However, many surgeons and pathologists dislike the frozen-section technique and consider it less accurate. Sometimes the pathologist is unable to give a firm diagnosis and definitive diagnosis must await examination of the paraffin sections (Hughes). In our study, however, the survival rate was not improved by primary wide excision, and accordingly we see no advantages in the frozen-section technique. Excisional biopsy, on the other hand, can be done as an outpatient procedure under local anesthesia and subsequently provide the surgeon with the vital information concerning diagnosis, depth of invasion and tumour thickness. There is no evidence in the literature suggesting that incisional biopsy of a malignant melanoma will worsen the prognosis. However, the technique is not recommended because of the difficulty of sampling a representative area within the tumour. The risk of underestimating the maximum thickness and depth of invasion is great, sometimes resulting in an

Delayed vs. primary wide excision of malignant melunoma

inconclusive diagnosis. If the tumour is so large that an excisional biopsy and direct closure cannot be performed, the patient should be referred to a facility where total excision and skin grafting can be done and the specimen sent for adequate histological examination. The only indication for incisional biopsy remains in giant naevi. Here multiple biopsies can be taken from clinically suspect areas.

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CONCLUSIONS This study concludes that excisional biopsy with subsequent wide excisions is the treatment of choice for malignant melanoma. Excisional biopsy will also permit a more sophisticated treatment of the thin melanomas where wide excision is not indicated. As the survival rate is not improved by an immediate radical excision there are no indications for frozen-section technique in the diagnosis of cutaneous malignant melanoma.

REFERENCES Breslow, A. 1970. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanomas. Ann Surg 172, 902. - 1975. Tumour thickness, Level of invasion and node dissection in stage I cutaneous melanoma. Ann Surg 182, 572. Breslow, A. & Macht, S. D. 1977. Optimal size of resec-

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tion margin for thin cutaneous melanoma. Surg Cynecol Obstet 145, 691. Davis, N. C. & Little, J. H. 1974. The role of frozen section in the diagnosis and management of malignant melanoma. Br J Surg 61, 505. Eldh, J., Boeryd, B. & Peterson, L.-E. 1978. Prognostic factors in cutaneous malignant melanoma in Stage I. A clinical, morphological and multivariate analysis. Scand J PIast Reconstr Surg 12, 252. Epstein, E. 1971. Effect of biopsy on the prognosis of melanoma. J Surg Oncol3. 25 1. Hansen, M. G. & McCarthen, A. B. 1974. Tumour thickness and lymphocytic infiltration in malignant melanoma of the head and neck. Am J Surg 128. 557. Hughes, L. E. 1975. The place of frozen section in the practical management of melanoma. Br J Surg 62, 840. Ironside, P., Pitt, T. T. E. & Rank, B. K. 1977. Malignant melanoma: Some aspects of pathology and prognosis. Aust N Z J Surg 47, 70. Knutsson, C. O., Hori, J. M. & Spratt, Jr, J. S. 1971. Melanoma. Cum Rob1 Surg, December. Kopf, A. W.,Mintzis, M. & Bart, R. S. 1975. Diagnostic accuracy in malignant melanoma. Arch Dermatol 111, 1291. Mattsson, W., Gynning, J., Hogeman, K.-E., Jacobsson, S. & Linell, F. 1976. A retrospective study of 304 cases of malignant melanoma in Malmo 1952-71. Scand J PIast Reconstr Surg 10, 189. McGovern, V. J., Mihm, M. C., Jr, Bailly, C., Booth, J. C., Clark, W. H. Jr. Cochran, A. J., Hardy, E. G., Hicks, J. D., Levene, A., Lewis, M. G., Little, J. H. & Milton, G. W. 1973. The classification of malignant melanoma and its histologic reporting. Cancer 32, 1446. Olsen, G. 1966. The malignant melanoma of the skin. Acta Chir Scand, Suppl. 365.

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Excisional biopsy and delayed wide excision versus primary wide excision of malignant melanoma.

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