Surgery (Wide Local Excision)

If melanoma is caught early, it is highly treatable. Surgery with a wide local excision is the main treatment for early melanomas and may be used as part of the treatment approach for advanced melanomas.

At Saint John’s Health Center, we employ decades of research experience via the Saint John’s Cancer Institute, a pioneer in melanoma research since the 1990s.

What is the Wide Local Excision Procedure?

Wide local excision is a procedure that removes a rim of normal tissues around the lesion, called the margin. The size of the margin depends on the Breslow thickness of the melanoma and sometimes the location on the body. This procedure is well-tolerated and typically only requires over-the-counter pain medications like Tylenol or ibuprofen. The procedure is usually an outpatient procedure.

Current NCCN Recommendations for Wide Local Excision

After the primary tumor is removed, the skin area excision is closed with stitches or sometimes a skin graft is needed to cover the site. This can be done either in the clinic or in the operating room. The tissue removed is sent to pathology for examination, and a report is usually complete in 5-7 days.

The Breslow Thickness measurement is a crucial prognostic tool in melanoma surgery. It quantifies the depth of the melanoma from the top of the granular layer of the epidermis (or from the base of an ulcer if the surface is ulcerated) to the deepest point of tumor invasion. This measurement, recorded in millimeters, is the single most important factor in determining the prognosis for localized primary melanoma and guides surgical decisions, such as the extent of tissue removal during wide local excision.

Preparing for Surgery

While preparations for skin surgery, such as wide local excision for melanoma, are generally minimal, patients should consider several factors to ensure a smooth experience. It’s important to follow any preoperative instructions provided by the surgeon, which may include guidelines on fasting or medication adjustments. Patients should also arrange for transportation to and from the surgical facility, as they may not be able to drive post-procedure due to anesthesia effects. Additionally, wearing loose, comfortable clothing can help avoid irritation around the surgical site. Lastly, planning for post-surgery care, such as having over-the-counter pain medications and arranging for help with daily activities, can facilitate a quicker and more comfortable recovery. You may also receive specific instructions regarding your surgical case.

Recovery from Wide Local Excision

Recovery is usually fairly quick. Depending on the location and size of the incision, most patients feel well a few days after the surgery. Each surgery has different activity restrictions based on where the incision is. Your surgeon will give you specific postoperative instructions.

How does Wide Local Excision differ from Moh’s Surgery?

Wide local excision involves removing the tumor along with a margin of surrounding healthy tissue. The size of the margin depends on the Breslow thickness of the melanoma. This procedure is typically quicker and performed on an outpatient basis. The excised tissue is sent to pathology for examination, and results are usually available within a few days.

Mohs surgery, also known as Mohs micrographic surgery, is a specialized technique primarily used for basal cell carcinoma and squamous cell carcinoma, though it can be used for melanoma in certain cases. During Mohs surgery, the tumor is removed layer by layer, and each layer is examined under a microscope immediately. This process continues until no cancer cells are detected in the tissue. Mohs surgery is highly precise and conserves as much healthy tissue as possible, making it ideal for tumors in cosmetically or functionally critical areas, such as the face.

Key Differences:

• Technique: Wide local excision removes a predetermined margin of tissue, while Mohs surgery removes tissue layer by layer with immediate microscopic examination.
• Precision: Mohs surgery offers higher precision and tissue conservation, which is particularly beneficial for tumors in sensitive areas.
• Time: Wide local excision is generally quicker, whereas Mohs surgery can take several hours due to the iterative process of tissue examination.
• Applications: Wide local excision is commonly used for melanoma, while Mohs surgery is preferred for basal cell carcinoma and squamous cell carcinoma, and occasionally for melanoma in specific cases.
  Both procedures aim to achieve clear margins and prevent recurrence, but the choice between them depends on the type of skin cancer, its location, and the patient’s overall health.

Multidisciplinary Approach to Melanoma Treatment

Wide local excision is often part of a comprehensive treatment plan for melanoma, especially in advanced cases. This multidisciplinary approach may include:

• Chemotherapy: Used to kill cancer cells or stop them from growing. It can be administered before surgery (neoadjuvant therapy) to shrink tumors or after surgery (adjuvant therapy) to eliminate remaining cancer cells.
• Targeted Immunotherapy: Drugs like PD-1 inhibitors and BRAF/MEK inhibitors target specific molecules on cancer cells, enhancing the immune system’s ability to fight melanoma. These therapies can be used alongside surgery to improve outcomes.
• Radiation Therapy: High-energy rays or particles are used to destroy cancer cells. Radiation therapy can be used before surgery to reduce tumor size or after surgery to target residual cancer cells.

Recent Advancements

Recent advancements in melanoma treatment have refined surgical techniques and integrated new therapies. For instance, the MelMarT-II trial is investigating optimal excision margins to balance effective treatment with minimal complications. Additionally, new guidelines emphasize the importance of a multidisciplinary approach to optimize patient outcomes.

Patient Experience

Patients undergoing wide local excision can expect a relatively straightforward procedure with minimal discomfort. The integration of other therapies, such as immunotherapy or radiation, may enhance the effectiveness of the treatment and improve long-term survival rates.

The experts at Saint John’s Health Center and researchers of the Saint John’s Cancer Institute are ready to support you and help you navigate through this challenging time. Whether you are looking for an expert second opinion, a better understanding of your health situation, or access to personalized clinical trials, please reach out to us today. We are committed to providing you with the best possible care and outcomes.