The main aim of wide excision of melanoma after a diagnostic excision is to prevent the cancer recurring at the site of origin, and to maximize long-term survival. The functional and cosmetic impact of surgery on an individual patient, are major secondary considerations when planning a further excision.
Our current theory of how further surgery helps control melanoma is that a wider excision will likely remove any residual tumour cells at the site of origin of the tumour and any microsatellites of disease that may exist in the skin near the tumour, or in the local lymphatic system.
Although there is consensus that after a diagnostic (usually 2mm wide margin) excision, a further excision is beneficial in reducing the risk of local recurrence, the optimal width of a further excision has long been debated. The Scottish Physician, William Handley studied the lymphatic drainage of breast cancer and melanoma, and in the early 1900s suggested performing an approximately 5cm wide excision of melanoma with removal of the draining lymph nodes.
The contemporary approach to wide excision is based on good quality randomised trials of different margin widths, which tested the benefit of different margins of excision of the primary melanoma guided by the Breslow thickness of the primary tumour (i.e. testing with many patients randomly assigned to different excision margins to see if the recurrence rate of a melanoma is the same for a given Breslow thickness melanoma).
For example, the MSG/BAPS randomized trial, recently presented and subsequently published in the Lancet Oncology by my colleague Mr Andrew Hayes of the Royal Marsden, on behalf of his trial colleagues asked the question of whether a 1cm or 3cm excision margin is best for a 2mm Breslow (Stage II) melanoma. Long-term follow up of the 900 patients with Stage II melanoma recruited throughout the UK and randomly assigned either a 1cm or 3cm excision demonstrated no difference in overall survival with a wider excision of 3cm.
The current NICE guidelines recommend a margin of at least 1cm to people with a diagnosis of stage I melanoma (Breslow depth 1-2mm), and margin of at least 2cm to people with stage II melanoma (Breslow depth 1-2mm). For melanoma in situ, a 0.5cm margin is sufficient. Occasionally, in a cosmetically sensitive area, close clinical surveillance after a narrow excision may be considered.
The procedure may be performed by a Dermatologist, General Surgeon, GP or Plastic Surgeon, often as a day case under local anaesthetic. Usually, the wound can be closed primarily with sutures (beneath the skin sometimes) or skin clips; however, if the area is difficult to close, a skin graft or other Plastic surgical procedure may be required to close the excision site. If reconstruction, a 2cm excision, or a sentinel node biopsy is being performed at the same time, a general anaesthetic is generally required. It is important to realise that the excisions may be quite long, as one needs to make the length of the incision longer than the width to close the wound neatly and ensure it is apposed.
Usually, the wound is covered for 24-48 hours, and sutures or clips removed between 5-14 days later depending on the location of the wound, and you will be scheduled a follow-up appointment to ensure good wound healing, removal of sutures and discussion of the pathology examination of the specimen.
References/further reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303163/
https://www.skincancer.org/skin-cancer-information/melanoma/the-stages-of-melanoma/guide-to-staging-melanoma
http://www.nejm.org/doi/full/10.1056/NEJMoa030681
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(15)00482-9/abstract
https://www.royalmarsden.nhs.uk/our-consultants-units-and-wards/clinical-units/skin-unit
https://www.royalmarsden.nhs.uk/private-care-magazine/skin-cancer-below-surface
Sunscreen may prevent melanoma in adults
A recent interesting study from Australia looked at the potential benefit from sunscreen, by asking whether use in childhood or early adulthood reduces the future risk of melanoma. This was a case-control study looking at over 600 patients who regularly used sunscreen in the Australian Melanoma Family Study comparison to a larger control group outside the study.
The main finding of this research is that regular sunscreen use is associated with a reduced risk of melanoma in young adults who regularly use sunscreen.
A previous randomised trial from Australia demonstrated a major reduction in melanoma in people using daily sunscreen compared to discretionary use (11 melanomas in those using daily sunscreen compared to 22 in those using is at their discretion) aged 22-75 years old.
Taken together with other population-based studies – which examine what happens in real-world conditions – there is quality evidence that appropriate use of sunscreen may prevent the development of melanoma.
There are many good sources of melanoma advice regarding sunscreen including the British Association of Dermatology and Melanoma UK
Myles Smith joins Editorial Board of European Journal of Surgical Oncology
Mr Myles Smith is excited to join the European Journal of Surgical Oncology Editorial Board and looks forward to contributing to the development of the journal, and promotion of Surgical Oncology research in Europe and beyond.
Dedicated to publishing cutting edge cancer surgery research, the European Journal of Surgical Oncology (EJSO) is the official publication of the European Society of Surgical Oncology (ESSO) and BASO ~ The Association for Cancer Surgery. It aims to advance surgical oncology research and practice through the publication of original research articles, review articles, editorials, debates and correspondence.
The publication welcomes submissions on clinical research and all other aspects of surgical oncology which advance the care of patients with cancer, including surgical quality control, epidemiology, preventative aspects of surgical oncology, as well as translational research relevant to surgical oncology practice.
Follow the EJSO: @ejsotweets
Lymphoedema after surgery for melanoma
Lymphoedema, in the context of surgery for melanoma, is swelling in a limb due to the excision of lymph glands and disruption of lymphatic vessels. It can occur when someone has either a dissection (removal) of all lymph nodes in a basin (as in the axilla or armpit) or the groin (inguinal nodes); or a sentinel lymph node biopsy (SLNB).
Although lymphoedema can occur with either a sentinel node biopsy or node dissection, it is more frequent in those having a node dissection.
For example, in trials of SLNB, the rate of lymphoedema range from 4.6-7.2% in the Sunbelt Trial (1) and the MSLT-I (2) trials respectively, with a rate of 12.5% for those having a node dissection in MSLT-I. However, in case series and other studies, higher rates have been described, with a higher risk of lymphoedema associated with higher body mass index, co-morbidities such as diabetes, and in the groin, whether the deep (iliac nodes) are also dissected as part of the operation.
After lymph node surgery, you should be assessed for lymphoedema, and if it occurs, referred on for appropriate management. Although there is no definitive cure if it occurs, it can be successfully controlled with methods to reduce the accumulation of fluid and improve drainage.
Treatment for Lymphoedema after surgery for melanoma
Approaches include compression dressings and garments, massage and exercise as part of a supervised regime. There are many people living well with lymphoedema, and if you have been affected, it may be helpful to contact the Lymphoedema Support Network, to access more information and gain support.
References:
Men are generally at a higher risk of developing melanoma
Men are generally at a higher risk of developing melanoma, and often have a worse outcome when then develop melanoma. Why is this?
A study from Rutherford and colleagues published in the British Journal of Cancer in 2015 suggested that addressing the differences in stage of melanoma in men may reduce melanoma deaths. In other words, if more men in the UK presented early with melanoma, less would die from the disease.
There appeared to be a difference in the type of melanoma that men developed when compared with women, with more women having a superficial spreading type of melanoma (which are generally earlier stage) than men. However, the authors believed that much of the differences may have come from men delaying seeking help for their melanoma.
This might be due to a lack of understanding of the warning signs of melanoma, or for other patient-related reasons. For example, Forbes and colleagues, again in the British Journal of Cancer, asked why people delay presenting to a doctor with a symptom of cancer (including patients with melanoma).
The most common reason was not realising the symptom was serious, with the other common reasons: being worried about wasting doctor’s time, worry about what the doctor might find, being too busy to make time to see a doctor, difficulty in making a doctor’s appointment and being embarrassed to see a doctor.
So if you or any of the men in your life have a mole that is getting bigger, changing shape or colour, bleeding or becoming crusty, or is itchy or sore – you should see your GP or Dermatologist. To book an appointment with Mr Myles Smith at the Royal Marsden Hospital on 020 7808 2785 or at the Lister Hospital on 020 3770 5864.
Wide margin excision in melanoma
The main aim of wide excision of melanoma after a diagnostic excision is to prevent the cancer recurring at the site of origin, and to maximize long-term survival. The functional and cosmetic impact of surgery on an individual patient, are major secondary considerations when planning a further excision.
Our current theory of how further surgery helps control melanoma is that a wider excision will likely remove any residual tumour cells at the site of origin of the tumour and any microsatellites of disease that may exist in the skin near the tumour, or in the local lymphatic system.
Although there is consensus that after a diagnostic (usually 2mm wide margin) excision, a further excision is beneficial in reducing the risk of local recurrence, the optimal width of a further excision has long been debated. The Scottish Physician, William Handley studied the lymphatic drainage of breast cancer and melanoma, and in the early 1900s suggested performing an approximately 5cm wide excision of melanoma with removal of the draining lymph nodes.
The contemporary approach to wide excision is based on good quality randomised trials of different margin widths, which tested the benefit of different margins of excision of the primary melanoma guided by the Breslow thickness of the primary tumour (i.e. testing with many patients randomly assigned to different excision margins to see if the recurrence rate of a melanoma is the same for a given Breslow thickness melanoma).
For example, the MSG/BAPS randomized trial, recently presented and subsequently published in the Lancet Oncology by my colleague Mr Andrew Hayes of the Royal Marsden, on behalf of his trial colleagues asked the question of whether a 1cm or 3cm excision margin is best for a 2mm Breslow (Stage II) melanoma. Long-term follow up of the 900 patients with Stage II melanoma recruited throughout the UK and randomly assigned either a 1cm or 3cm excision demonstrated no difference in overall survival with a wider excision of 3cm.
The current NICE guidelines recommend a margin of at least 1cm to people with a diagnosis of stage I melanoma (Breslow depth 1-2mm), and margin of at least 2cm to people with stage II melanoma (Breslow depth 1-2mm). For melanoma in situ, a 0.5cm margin is sufficient. Occasionally, in a cosmetically sensitive area, close clinical surveillance after a narrow excision may be considered.
The procedure may be performed by a Dermatologist, General Surgeon, GP or Plastic Surgeon, often as a day case under local anaesthetic. Usually, the wound can be closed primarily with sutures (beneath the skin sometimes) or skin clips; however, if the area is difficult to close, a skin graft or other Plastic surgical procedure may be required to close the excision site. If reconstruction, a 2cm excision, or a sentinel node biopsy is being performed at the same time, a general anaesthetic is generally required. It is important to realise that the excisions may be quite long, as one needs to make the length of the incision longer than the width to close the wound neatly and ensure it is apposed.
Usually, the wound is covered for 24-48 hours, and sutures or clips removed between 5-14 days later depending on the location of the wound, and you will be scheduled a follow-up appointment to ensure good wound healing, removal of sutures and discussion of the pathology examination of the specimen.
References/further reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303163/
https://www.skincancer.org/skin-cancer-information/melanoma/the-stages-of-melanoma/guide-to-staging-melanoma
http://www.nejm.org/doi/full/10.1056/NEJMoa030681
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(15)00482-9/abstract
https://www.royalmarsden.nhs.uk/our-consultants-units-and-wards/clinical-units/skin-unit
https://www.royalmarsden.nhs.uk/private-care-magazine/skin-cancer-below-surface
Mr Myles Smith supports the Loneliest Cancer Campaign
As a consultant surgical oncologist and specialist in Sarcoma surgery at the Royal Marsden Hospital, Mr Myles Smith supports The Loneliest Cancer Campaign (#TheLoneliestCancer) launched by Sarcoma UK.
Sarcoma is a cancer that few have heard of and, although rare, can have a profound impact on sufferers and their families and friends. Because little is known about it, there are a number of issues which seem unique to sarcoma.
Sarcoma UK has launched its largest sarcoma awareness campaign, illustrating the general lack of knowledge around this cancer and the impact that has on patients. Richard Davidson, Chief Executive of Sarcoma UK, believes sarcoma awareness needs to grow. He says: ‘We know the patient journey can be isolating, frightening and traumatic for many. The unfortunate truth is that people only really become aware of what sarcoma is when it touches their life or those in their family.
Sarcoma UK (@SarcomaUK) invests in research, support and increasing sarcoma awareness in the UK and internationally.
The report issued by Sarcoma UK also finds:
Mr Myles Smith’s Guidance on COVID-19
If you are referred to as a new patient with cancer or suspected cancer, but develop symptoms of a high temperature or a new continuous cough, you should stay at home and use the 111 coronavirus service.
If you are a patient who attends Mr Smith for post-operative follow-up or surveillance, you may be offered a telephone or virtual consultation. If you would prefer to defer your clinic appointment, surgery, or imaging test, Mr Smith would be happy to facilitate you.
The HCA Chiswick Medical Centre is temporarily closed, please contact us for further advice if you were booked to see Mr Smith, or planning to see him. We apologise for any inconvenience this may cause.
Please refer to the HCA Healthcare Website for the latest information regarding COVID-19 if you were booked to see Mr Smith at the Chelsea Outpatient Centre, or planning to do so, please contact us prior to your appointment, check the HCA Healthcare website for the latest updates on services.
Please go to our Contact Page for all contact details.
The quality of Retroperitoneal Sarcoma surgery is superior in a reference centre
The French Netsarc group compared the outcomes of retroperitoneal sarcoma surgery, in reference in France, compared to those outside of a specialist centre, publishing their results in the Annals of Surgical Oncology.
They found that much higher volumes of cases were being performed in the specialist centre, with better adherence to the standard of care, and a much higher rate of clear margins. Moreover, the overall survival at 2 years was 87% vs. 70% (p < 0.001), in this rare and challenging group of patients.
Performing an analysis of all of the factors associated with improved survival, surgery at a specialist centre was identified as an independent factor associated with survival and reduced risk of death.
This paper adds to the evidence supporting sarcoma surgery in specialist centres and performed by experts in the field.
Men’s Health Week 2019: skin cancer symptoms you should never ignore
Men are known for presenting late with symptoms that may represent skin cancer. It is important this Men’s Health Week to remember that any mole that is getting bigger, changing shape or colour, becomes itching, painful or inflamed, or starts bleeding or becoming crusty should be seen by a medical professional.
Call 020 7808 2785 to book a consultation with Mr Myles Smith if you’re concerned regarding any skin concerns.
Presentation at the British Sarcoma Group Conference
Mr Myles Smith recently presented the initial experience, and indications for Robotic Surgery in GIST treatment, at the British Sarcoma Group Conference in London (February 2019). Surgery for GIST has evolved from open surgery, to laparoscopic, and now through several iterations of robotic platforms.
Although the operative time is higher than open or laparoscopic surgery, it may expand the benefits of a minimally invasive approach, to large tumours in unfavourable sites, offsetting the costs of the procedure with a reduced length of stay for most patients.
To arrange a consultation with Mr Myles Smith, please contact his secretary; either email Myles.smithPA@rmh.nhs.uk or telephone us at the Royal Marsden at 020 7808 2785.