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The surgical standard for the local treatment of a primary melanoma is a wide excision of the diagnostic biopsy site and/ or residual intact primary lesion, inclusive of a surrounding margin of normal skin, en bloc with the underlying subcutaneous tissue including the superficial fascia. The rationale for such a surgical approach is to excise both the primary melanoma and any surrounding microsatellites in the lymphatics. Failure to excise both the primary and subclinical locally metastatic disease could result in a local recurrence (LR), which in reality is better termed ‘‘local metastasis.’’ Such events have been associated with melanoma mortality; therefore, the concern of inadequate surgery leading to LR and a risk of dying has been the underpinnings of the widely adopted paradigm that LR is both a function of primary tumor biology (tumor thickness and ulceration in particular) and extent of excision margin and that wider margins would be required for high-risk tumors. If such a paradigm were true, then various outcome measures, including the frequency of local and regional recurrences, and possibly overall survival, would be impacted by the extent of excision margin, and in turn, the following assumptions or even conclusions could be made: (1) microscopic satellite disease is present more frequently with thicker (higher risk) melanomas and may have spread further from the periphery of the primary melanoma; (2) these microsatellites are a source of subsequent locoregional and distant relapse; and (3) wider margins more completely remove microscopic disease that would otherwise remain if narrower margins were used. This paradigm was tested formally in multiple, prospective, randomized, surgical trials across the entire spectrum of stage I and II thickness groups, comparing conservative margins (1 or 2 cm) to wider margins (3, 4, or 5 cm). Long-term results of these trials failed to demonstrate that a wider excision independently predicted melanoma-specific survival. One could conclude, and many have, that there is little evidence to support the paradigm and believe that any width of histologically clear excision margin is acceptable. However, the prospectively randomized trial from the United Kingdom Melanoma Study Group (UKMSG) did demonstrate that the combined frequency of local, in transit, and nodal relapses were significantly higher when 1-cm margins compared with when 3-cm margins were used to treat 900 patents with melanomas thicker than 2 mm (T3 and T4). In the World Health Organization trial for T1 and T2 melanomas, a trend was observed for an increased incidence of LR in the subset of patients with T2 melanomas when randomized to receive the narrower 1-cm margin compared with a 3-cm margin. It is important to note that no study has prospectively examined margins narrower than 1 cm for invasive melanoma of any thickness. Furthermore, none of these trials included extensive analyses of the wide excision specimens looking for the presence of microsatellite disease. Recent reports have suggested, for the first time, that there is some risk for using too conservative margins when excising primary melanomas, not only in terms of LR rates but also in terms of melanoma-specific mortality. This includes two reports in this issue of the Annals of Surgical Oncology for thin (T1) and intermediate thickness (T2) melanomas as part of a series of reports for various T-stage patients from the Melanoma Institute of Australia (MIA) as well as a recent update from the aforementioned UKMSG trial presented at the 2015 annual meeting of the American Society of Clinical Oncology. In a recent update of the UKMSG Trial, with a mean follow-up of 8.8 years, patients with a narrower 1-cm margin had a higher melanoma-specific Society of Surgical Oncology 2015

Excision Margins of Melanoma Make a Difference: New Data Support an Old Paradigm