Zitelli J A, Brown C D, Hanusa B H
Shadyside Medical Center, Pittsburgh, PA, USA.
J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9. doi: 10.1016/s0190-9622(97)70144-0.
A major controversy in the treatment of melanoma is the width of the surgical margin necessary for complete excision. Although surgical margins have decreased in recent years, the current recommendations are mainly based on arbitrary choices, only two of which have been tested in clinical trials.
Our purpose was to use prospective data, measuring the extent of subclinical melanoma extensions, to develop guidelines for predetermined surgical margins for the excision of cutaneous melanoma.
A prospectively collected series of 535 patients with 553 primary cutaneous melanomas was studied. All melanomas were excised by means of the fresh tissue technique of Mohs micrographic surgery with frozen section examination of the margin. The surgical margin needed for excision of melanoma was determined by measuring the invisible extensions of tumor around the melanoma. The minimum surgical margin was 6 mm and the total margin was calculated by adding an additional 3 mm for any melanoma requiring a subsequent stage to remove the tumor completely.
Eighty-three percent of melanomas were successfully excised with a 6 mm margin; 9 mm removed 95% of the melanomas; and a 1.2 cm margin was necessary to remove 97% of all melanomas. Margins to remove melanomas on the head, neck, hands, and feet were wider than those on the trunk and extremities. Margins to remove melanomas that were more than 2 to 3 cm in diameter were wider than for smaller melanomas.
Predetermined surgical margins for excision of melanoma or melanoma in situ by standard surgical techniques should include 1 cm of normal-appearing skin for melanomas on the trunk and proximal extremities that are smaller than 2 cm in diameter, or a 1.5 cm margin for tumors larger than 2 cm in diameter. For melanomas on the head, neck, hands, and feet, a minimum surgical margin of 1.5 cm is recommended or a margin of 2.5 cm for melanomas larger than 3 cm in diameter. Mohs micrographic surgery is a useful alternative to standard surgery when more narrow margins are desired, particularly for melanomas on the head, neck, hands, and feet, or melanomas larger than 2.5 cm in diameter, or for melanomas without distinct clinical margins.
黑色素瘤治疗中的一个主要争议是完全切除所需的手术切缘宽度。尽管近年来手术切缘有所减小，但目前的建议主要基于主观选择，其中只有两项在临床试验中得到验证。
我们的目的是利用前瞻性数据测量亚临床黑色素瘤扩展范围，制定皮肤黑色素瘤切除的预定手术切缘指南。
对前瞻性收集的535例患者的553例原发性皮肤黑色素瘤进行研究。所有黑色素瘤均采用莫氏显微外科新鲜组织技术切除，并对切缘进行冰冻切片检查。通过测量黑色素瘤周围肿瘤的不可见扩展范围来确定黑色素瘤切除所需的手术切缘。最小手术切缘为6毫米，对于任何需要后续阶段才能完全切除肿瘤的黑色素瘤，总切缘通过额外增加3毫米来计算。
83%的黑色素瘤通过6毫米切缘成功切除；9毫米切缘可切除95%的黑色素瘤；1.2厘米切缘对于切除所有黑色素瘤的97%是必要的。头、颈、手和足部黑色素瘤的切除切缘比躯干和四肢的更宽。直径超过2至3厘米的黑色素瘤的切除切缘比小黑色素瘤的更宽。
采用标准手术技术切除黑色素瘤或原位黑色素瘤时，对于直径小于2厘米的躯干和近端肢体黑色素瘤，预定手术切缘应包括1厘米外观正常的皮肤，对于直径大于2厘米的肿瘤，切缘应为1.5厘米。对于头、颈、手和足部的黑色素瘤，建议最小手术切缘为1.5厘米，对于直径大于3厘米的黑色素瘤，切缘为2.5厘米。当需要更窄切缘时，莫氏显微外科手术是标准手术的一种有用替代方法，特别是对于头、颈、手和足部的黑色素瘤，或直径大于2.5厘米的黑色素瘤，或没有明显临床切缘的黑色素瘤。
