How Much We Follow Guidelines in Surgery of Melanoma: It's Time to Reflect!

This article is referred to by:

Are We Cutting Enough? A Five-Year Audit of Melanoma Excision Margins in the South East of Ireland

A guideline is a statement by which to determine a course of action. Guidelines aim to streamline particular processes according to a set routine or sound practice.¹ For definition, guidelines are recommended and not mandatory, accordingly they can be followed or not.¹ Indeed, during the daily clinical practice, it is not always easy follow a specific guideline for a specific disease. This can be due to several factors: patient choice and/or choice of patient relatives, comorbidities, low medical update, absence of interdisciplinary discussion of clinical cases, medical negligence or, simply, because of the highlighted possibility of variability in interpretation of the guidelines, generating important critical issues.

Consequently the question: “Why follow the guidelines, since they are recommendation and not obligation?” We could briefly list below some positive and negative reasons.

Regarding the positives, guidelines are recommendations of clinical behavior, elaborated through a systematic review of literature and scientific opinions; guidelines require more responsibility for the clinician;¹ guidelines obligate clinician for strictly following the recommendations for a certain periods of time (at least until the next update of the guidelines) and offer greater medical-legal protection. Regarding the negatives, the drawing up of the guidelines sometimes takes into account the needs of expenditure restraint that is economic, but extraneous to the health of the patient. A further negative reason could be the impact of the “defensive medicine” that might induce clinicians to follow always and in any case the guidelines, even when the case is peculiar and requires a different therapeutic approach, compared to the expected one.²

As for the other malignancies, clinical practice guidelines have been developed to improve melanoma patient care. However, remains unclear whether failure to comply with these standards (either excessive or inadequate treatment) increases morbidity or relapse rates.³

Although it was once considered uncommon, the annual incidence of melanoma has increased dramatically over the past few decades. Surgery is the definitive treatment for early-stage melanoma, with oncological management reserved for advanced stages. It is well known that melanoma is a malignancy with an intrinsic high risk of local recurrence and metastatic spread, for this reason it is important to have an accurate, periodic and standardized clinical and instrumental follow-up, as well as an adequate surgical excision of primitive tumor and of the subsequent wide local excision (WLE). Indeed, WLE is necessary to achieve adequate guideline margins. Guidelines recommend that melanomas ≤1.00 mm require 1cm margins, 1.01–2 mm require 1–2 cm margins, 2.1–4.00 mm require 2–3 cm margins and melanomas ≥4.01 mm require 3 cm margins during WLE.⁴ The incorrect execution of these guidelines might cause important inconveniences.

Melanomas have a 5-fold increased risk for positive margins if they are excised with narrower than recommended surgical margins or if they are located on the head, neck, hands, feet, genitals, or pretibial leg.⁵ In fact, in a recent study of 1.345 lesions, noncompliance with recommended margins (as well as anatomic location in functionally or cosmetically sensitive areas) were the most powerful risk factors for positive or equivocal margins after WLE.⁵ Besides, postoperative complications are 3.4-fold higher for patients treated in a margin-noncompliant fashion and 2.4-fold higher for patients treated in a lymph-node-noncompliant manner.³ In their report, Erickson et al. found that locoregional disease alone as the first site of relapse was 24% of margin-noncompliant versus 6% of margin-compliant cases and 33% of lymph-node-noncompliant versus 6% of lymph-node-compliant cases.³ In another study, Mangold et al. found that, interestingly, patients with positive margins at WLE had positive margins on initial biopsy and a higher rate of melanoma in situ component on initial biopsy.⁶ In a wider study of 11.290 thin melanomas (≤1.00 mm), MacKenzie Ross et al. confirmed that a ≥1 cm clinical excision margin for thin (T1) primary melanomas reduces significantly the risk of local recurrences.⁷ All these findings, stress the importance to follow surgical guidelines for melanomas, starting also from early stages.

In the article entitled “Are we cutting enough? A 5-year audit of Melanoma Excision Margins in the South East of Ireland”, the Authors wanted to highlight that the adherence to guidelines is important, although requires additional and important improvements.⁸ In fact, in a retrospective analysis of 459 patients, they found that 74.5% of cases fulfilled adequate guidelines and that the main factors associated with a margin less than recommended by the guidelines were: high tumor thickness (2.01–4.00 mm and ≥4.01 mm), melanomas on the head and neck and the feasibility of further surgery due to tissue site availability.⁸

Besides, the authors found that sentinel lymph-node biopsy (SNLB) reporting was just 37% of the total sample eligible for screening, showing an important gap in the routine analysis of SNLB. Indeed, although it has been showed that an immediate complete lymph-node dissection does not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases⁹, SLNB should be performed in order to provide prognostic information, optimizing clinical and instrumental follow-ups and improving regional disease control.

Finally, as in previous reports^3,6, also in this study it is confirmed an important percentage of recurrences in thin melanomas ≤1.00 mm (21.6% among melanomas with a recurrence) and that 8.6% of patients with thin melanoma did not regularly follow the guidelines. As reported above, all these findings stress the importance of follow guidelines, also in thin lesions⁹.

In conclusion, in melanoma, sub-optimal compliance with appropriate guidelines result in poorer outcomes and increased morbidity and mortality. Adhering to guidelines is also important for thin lesions. Particular attention must be paid to melanomas of specific anatomical sites (as head and neck), melanomas with high tumor tickness and to melanomas arose in particular classes of patients (e.g., aged patients with important comorbidities). In all these cases, an interdisciplinary discussion might help to take the most important decisions.

Guidelines were made to be discussed and not just to be executed. In case of indecisions: talk, talk and still talk with your colleagues, having guidelines always in your hands!

DECLARATION OF INTEREST

The author reports no conflict of interest. The author alone is responsible for the content and writing of the article.