Adherence to guideline excision margins in head and neck melanoma: the influence on 5-year survival and loco-regional recurrence

Guidelines for the management of cutaneous melanoma suggest wide local excision of increasing margins for increasing Breslow thickness of the primary neoplasm. These guidelines are based on randomized controlled trial data from limb and trunk melanoma studies. We performed retrospective analysis of our institution's head and neck melanoma database to investigate the effect of narrow excision margins on survival and loco-regional recurrence. We identified 101 patients with node-negative head and neck melanoma from 1993 to 2001 who had prospectively gathered data. The overall 5-year loco-regional recurrence rate (LR) was 37%. The overall 5-year melanoma-specific survival rate (5y.s.) was 70%. When guidelines were followed (n = 36), LR was 19% and 5y.s. was 89%. When guidelines were not followed (n = 65), LR was 46% and 5y.s. was 60%. On univariate analysis, we found scalp location (p < 0.001), male gender (p < 0.025), advanced tumour T stage (p < 0.005) and non-adherence to guidelines (p < 0.003) were significantly associated with poorer 5y.s., whilst scalp location (p < 0.004), advanced tumour T stage (p < 0.030) and non-adherence to guidelines (p < 0.010) were significantly associated with greater LR. On multivariate analysis, only scalp location (p < 0.001; p < 0.001) and advanced tumour T stage (p < 0.020; p < 0.014) remained significant predictors of 5y.s. and LR. We conclude it is often impossible to perform excision margins as recommended in published guidelines for cutaneous melanoma in the head and neck, given functional and aesthetic constraints. While such margins should be adhered to where possible, adherence is not the major factor in long-term recurrence and survival (level of evidence: IV).