Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas

Background: The Intergroup Melanoma Surgical Trial began in 1983 to examine the optimal surgical margins of excision for primary melanomas of intermed iate thickness (i.e., 1-4 mm). There is now a median 10-year follow-up. Methods: There were two cohorts entered into a prospective multi-institutio nal trial: (1) 468 patients with melanomas on the trunk or proximal extremi ty who randomly received a 2 cm or 4 cm radial excision margin and (2) 272 patients with melanomas on the head, neck, or distal extremities who receiv ed a 2 cm radial excision margin. Results: A local recurrence (LR) was associated with a high mortality rate, with a 5-year survival rate of only 9% (as a first relapse) or 11% (anytim e) compared with an 86% survival for those patients who did trot have a LR (P < .0001). The 10-year survival for all patients with a LR was 5%. The 10 -year survival rates were not significantly different when comparing 2 cm v s. 4 cm margins of excision (70% vs. 77%) or comparing the management of th e regional lymph nodes (observation vs, elective node dissection). The inci dences of LR were the same for patients having a 2 cm vs. 4 cm excision mar gin regardless of whether the comparisons were made as first relapse (0.4% vs. 0.9%) or at anytime (2.1% vs. 2.6%). When analyzed by anatomic site, th e LR rates were 1.1% for melanomas arising on the proximal extremity, 3.1% for the trunk, 5.3% fur the distal extremities, and 9.4%, for the head and neck. The most profound influence on LR rates was the presence or absence o f ulceration; it was 6.6% vs. 1.1% in the randomized group involving the tr unk and proximal extremity and was 16.2% vs. 2.1% in the nun-randomized gro up involving the distal extremity and head and neck (P < .001). A multivari ate (Cox) regression analysis showed that ulceration was an adverse and ind ependent factor (P = .0001) as was head and neck melanoma site (P = .01), w hile the remaining factors were not significant (all with P > .12). Conclusion: For this group of melanoma patients, a local recurrence is asso ciated with a high mortality rate, a 2-cm margin of excision is safe and ul ceration of the primary melanoma is the most significant prognostic factor heralding an increased risk for a local recurrence.