Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia.
Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia.
Pathology. 2022 Feb;54(1):71-78. doi: 10.1016/j.pathol.2021.05.094. Epub 2021 Aug 13.
Wide local excision (WLE) to achieve adequate clearance margins is the standard initial definitive treatment for patients with biopsy-proven primary cutaneous melanoma. Residual melanoma in WLE specimens after prior complete excision-biopsy (CEB) is reported in 0-6.3% of cases. However, studies evaluating the prevalence, clinicopathological features and relevance of persistent disease in WLE specimens are limited. This study sought to determine the frequency of and clinicopathological characteristics associated with residual melanoma in WLE specimens performed after a CEB of primary cutaneous or acral melanoma (in situ or invasive) with clinically and histologically tumour-free margins, and assess its relevance. A review of the research database and pathology archives of a large Australian tertiary referral melanoma treatment centre was performed. Eligible patients were those for whom a definitive WLE was performed after CEB of a primary melanoma (in situ or invasive) with negative clinical and histological margins, between May 2013 and May 2015. All partial biopsies were excluded. Of 640 eligible patients, 510 (79.7%) had invasive melanoma and 130 (20.3%) had melanoma in situ. Residual disease was identified in 20 cases (20/640, 3.1%), of which three (15%) were melanoma in situ on CEB and 17 (85%) were invasive melanoma. On univariate analysis, the presence of residual disease in WLE specimens was associated with lentigo maligna (LM)/LM melanoma (LMM) subtype [odds ratio (OR) 10.33; 95% confidence interval (CI) 2.84-37.54; p=0.004], nodular melanoma (NM) subtype (OR 4.92; 95% CI 1.53-15.85; p=0.0076) and, for invasive tumours, higher tumour mitotic rate (mean 7.7, SD 7.51 vs 3.4, SD 4.83; OR 1.11; 95% CI 1.04-1.18; p=0.0014). Breslow thickness >4 mm was associated with a higher risk of residual disease (OR 7.30; 95% CI 1.88, 28.26; p=0.004). Cases with residual disease had primary tumours with a significantly larger diameter (median 14 mm, range 4-25) than those without residual disease (median 9 mm, range 2-60), (OR 1.07; 95% CI 1.03-1.11; p≤0.001) and were also more likely to be amelanotic (38% vs 14%), (OR 3.69; 95% CI 1.17, 11.60; p=0.026). Residual disease was associated with assessment of >3 slides of tissue (OR 6.98; 95% CI 1.54-31.62; p=0.0118) and complete blocking of the scar (OR 31.69; 95% CI 3.98-252.21; p=0.0011). Residual melanoma in WLE specimens is an infrequent occurrence. Risk factors for residual disease are LM/LMM and NM melanoma subtypes, higher mitotic rate, larger lesion diameter and amelanosis. Tumours with these features warrant more extensive pathological sampling. WLE after CEB for melanoma remains an important procedure to reduce local recurrence; however, limited pathological sampling of the WLE scar is probably appropriate for cases lacking high risk features.
广泛局部切除术（WLE）以达到足够的清除边缘是经活检证实的原发性皮肤黑色素瘤的标准初始确定性治疗。先前完全切除活检（CEB）后 WLE 标本中残留黑色素瘤的报道为 0-6.3%。然而，评估残留疾病的普遍性、临床病理特征和相关性的研究是有限的。本研究旨在确定在临床和组织学肿瘤边缘无肿瘤的原发性皮肤或肢端黑色素瘤（原位或浸润性）的 CEB 后进行 WLE 标本中残留黑色素瘤的频率和相关的临床病理特征，并评估其相关性。对澳大利亚一家大型三级转诊黑色素瘤治疗中心的研究数据库和病理档案进行了回顾。符合条件的患者是在 CEB 后进行 WLE 的患者，包括原发性黑色素瘤（原位或浸润性），临床和组织学边缘阴性，时间为 2013 年 5 月至 2015 年 5 月。所有部分活检均被排除。在 640 名符合条件的患者中，510 名（79.7%）患有浸润性黑色素瘤，130 名（20.3%）患有黑色素瘤原位。在 20 例（20/640，3.1%）患者中发现了残留疾病，其中 3 例（15%）为 CEB 中的黑色素瘤原位，17 例（85%）为浸润性黑色素瘤。单因素分析显示，WLE 标本中存在残留疾病与交界性痣/交界性痣黑色素瘤（LMM）亚型相关（优势比[OR]10.33；95%置信区间[CI]2.84-37.54；p=0.004），结节性黑色素瘤（NM）亚型（OR 4.92；95%CI 1.53-15.85；p=0.0076），对于浸润性肿瘤，较高的肿瘤有丝分裂率（平均 7.7，SD 7.51 与 3.4，SD 4.83；OR 1.11；95%CI 1.04-1.18；p=0.0014）。Breslow 厚度>4mm 与残留疾病的风险增加相关（OR 7.30；95%CI 1.88,28.26；p=0.004）。有残留疾病的病例原发肿瘤直径明显较大（中位数 14mm，范围 4-25），无残留疾病的病例（中位数 9mm，范围 2-60）（OR 1.07；95%CI 1.03-1.11；p≤0.001），并且更可能是无色素的（38%比 14%）（OR 3.69；95%CI 1.17,11.60；p=0.026）。残留疾病与评估超过 3 张组织切片（OR 6.98；95%CI 1.54-31.62；p=0.0118）和完全阻塞疤痕（OR 31.69；95%CI 3.98-252.21；p=0.0011）相关。WLE 标本中残留黑色素瘤的发生率较低。残留疾病的危险因素包括 LM/LMM 和 NM 黑色素瘤亚型、较高的有丝分裂率、较大的病变直径和无色素沉着。具有这些特征的肿瘤需要更广泛的病理取样。CEB 后 WLE 仍然是减少局部复发的重要程序；然而，对于缺乏高危特征的病例，可能适当进行 WLE 疤痕的有限病理取样。
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