Excisional biopsy of a pigmented lesion reveals melanoma with a thickness of 1.5 mm. No ulceration or mitoses are present per the pathology report. What should be the margins or re-excision be?
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A 2 cm margin excision is considered appropriate for melanomas greater than 1 mm in thickness. A margin of 1 cm is also acceptable for melanomas of less than 2 mm in Breslow depth. In the 1-2 mm thickness range a 2 cm margin showed a lower local recurrence rate than a 1 cm margin, but there was no difference in overall survival.
Five cm margins were used in the past, but recent study indicates wider resection does not decrease the risk of melanoma recurrence.
The Breslow depth is a key determinate of prognosis. The Breslow depth for melanomas along with mitosis and ulceration determines the T-score, which in turn is used to determine the TNM staging of the tumor. For tumors without ulceration or mitosis tumor less than 1 mm thick are T1, tumors 1-2 mm thick are T2, tumors 2-4 mm thick are T3, and tumors >4mm in thickness are T4.
Clark classification defines level I - Involves only epidermis (in situ melanoma) no invasion; level II - Invades papillary dermis but not papillary-reticular dermal interface; level III - Invades and expands papillary dermis up to the interface with, but not into, reticular dermis; level IV - Invades reticular dermis but not into subcutaneous tissue; and level V - Invades into subcutaneous tissue.
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