Surgical Management of Primary Cutaneous Melanoma: Excision Margins and the Role of Sentinel Lymph Node Examination

Thirty years ago, most melanomas were widely excised with 3-cm to 5-cm margins, and many centers treated regional lymph nodes with routine elective lymph node dissection (ELND). These management policies were not evidence-based, they simply represented a continuation of surgical practices that had been accepted for many decades. These policies were perhaps rein-forced by the observation that patients whose melanomas had been managed by excision with narrow rather than wide margins sometimes developed local recurrence of their disease, whereas others who did not undergo an ELND sometimes presented later with metastatic disease in regional lymph nodes that was difficult or impossible to treat surgically. Retrospective studies also suggested that ELND conferred a survival advantage. In some centers, wide excision of the primary melanoma and ELND were performed in continuity, with excision of a broad strip of skin, subcutaneous tissue, and sometimes deep fascia between the primary melanoma site and the nearest anatomic group of lymph nodes. This policy was originally based on Hogarth Pringle’s [1] advice in 1908; extrapolating from his experience with three cases, he stated, ‘‘All tha