Elsevier

Surgery

Volume 153, Issue 4, April 2013, Pages 535-541
Surgery

Original Communication
Preservation of the deep muscular fascia and locoregional control in melanoma

https://doi.org/10.1016/j.surg.2012.09.009Get rights and content

Background

Locoregional recurrence occurs in approximately 20% of patients with melanoma and is associated with a significantly worse prognosis. Standards are well established for peripheral margins; however, there is insufficient evidence regarding depth of resection.

Methods

Retrospective review of 964 patients undergoing excision of trunk or extremity melanoma ≥1 mm thick during a 29-year period at a tertiary academic center. Multivariate analysis and hazard ratios were used to determine the effect of excision of the deep muscular fascia on locoregional recurrence.

Results

A total of 278 (29%) patients underwent resection of the muscular fascia. Of these patients, 18 (6%) developed local, 33 (12%) developed in-transit, and 68 (24%) developed nodal recurrence within 5 years. A total of 686 (71%) patients underwent excision of their primary melanoma with preservation of the muscular fascia. Of these patients, 40 (6%) developed local, 30 (4%) developed in-transit, and 84 (12%) developed nodal recurrence at 5 years. In multivariate analysis excision of the deep muscular fascia was an independent predictor of locoregional recurrence in patients treated with sentinel lymph node biopsy. Specifically, fascia resection was associated with a 2.5-fold increased risk of nodal recurrence but not associated with local recurrence or overall survival.

Conclusion

On the basis of no demonstrated advantage for resection of the deep muscular fascia, but potential for increased risk of intralymphatic recurrences, we recommend preservation of the deep muscular fascia during resection of primary cutaneous melanoma.

Section snippets

Methods

We performed an institutional research board–approved retrospective review of all patients age 18 or older with a primary cutaneous melanoma ≥1 mm in Breslow depth, located on the trunk or extremities, who underwent wide local excision at Mayo Clinic, Rochester, MN, from 1980 to 2008 and Mayo Clinic, Scottsdale, AZ, from 1997 to 2008. Patients in whom resection or preservation of the deep muscular fascia was not clearly defined as well as those who underwent amputation were excluded. Primary

Results

A total of 964 patients (661 undergoing resection at Mayo Clinic Rochester and 303 from Mayo Clinic Scottsdale) who met all inclusion and exclusion criteria were included in this analysis. The median follow-up was 61 months for the entire cohort and 77 months for the 592 survivors. The median age was 57 years (range, 18–93). The median Breslow depth was 2.0 mm (range, 1–40 mm), and 140 (15%) patients had nodal metastasis at presentation. Peripheral margins were negative in all cases, and the

Discussion

Our data demonstrate that removing the muscular fascia at the time of primary excision for melanoma of the trunk and extremity does not improve overall survival or local recurrence. This finding is also consistent with a recent trial in which the authors addressed fascia resection and local recurrences in patients with breast cancer; patients were randomized to preservation or resection of the pectoralis fascia, and the authors demonstrated that local chest wall recurrence was not substantially

References (18)

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