Melanoma and Margins

[poppynic]

Hi. I recently had a melanoma removed from my face. I complained to the surgeon that I wanted a wider margin for safety but he had chosen a narrower one for looks.

Yesterday he explained to me about the studies that have been done and why he believes 1 cm is enough. He is the head of dept of a large teaching hospital and I'm sure I should trust him. Butt...... yesterday he said if I was really really worried every day then he would operate again to reduce my worry!!!! He said about three times he wouldn't recommend it and I think he was just trying to make me feel safe and I'm pretty sure it's not worth another op for - I would probably just find something else to worry about. Can you reassure me to leave things be!

The tissue you had removed will have been examined by a Pathologist. They will check that the margins are clear, and if not will recall you.
I work in a lab that prepares these type of tests.

hth

I'm sorry that I can't remember what margin the surgeons use at work (I'm an HCA in a local dermatology unit) but I've had a quick scout over some clinical trials and the general consensus seems to be that a 1cm margin is enough for a melanoma that isn't very deep. However, a wider margin is generally thought of as being safer in some circumstances. A 3cm margin would be quite a lot of skin to remove from your face and it would probably require far more complex surgery than your previous 1cm margin. Having said that, it seems to be common practice on our unit to remove the melanoma with a reasonable margin then do a re-excision to remove more skin for safety. I presume that they decide how much extra skin to remove depending on the histopathology report. If I were you, I would maybe ask for a second opinion and ask about what some more surery would be like including the cosmetic result. I know that it may not seem to matter very much now but it could bother you in the future. The consultant should be able to tell you what can be done to help cosmetically if needed.

Thanks for your input. Yes I think 3 cm would be too much. I was originally told by the dermatologist it would be 2 cm and a skin graft. They didn't do an initial excision in the dematology dept as they said it was too big and on my face and so the plastic surgeon did the initial (and only excision).

The depth was 1.9 mm. I have had a CT scan and sentinal lymph node biopsy - both clear. I would feel uncomfortable about asking for a second opinion (though of course a lot more uncomfortable if I had a return). Who would I ask for one from? The guy who did the surgery is the head of plastic surgery dept. He said the second operation, if it was done while present scar still new, would not be a a lot worse cosmetically.

I am being referred to an oncologist just for one meeting (mainly because I have asked lots of questions and been very anxious, and young for this kind of thing (i.e. not 70) - as usually would need a depth of more than 2 mm. Do you think he would suffice for a second opinion? I'm pretty sure he would agree with the first guy as they have been talking about my case already.

Yes he would suffice or you could ask to see a dermatologist. It couldbe quite interesting to see what the oncologist says as he is primarily concerned with your cancer whereas the plastic surgeon specialises in the cosmetic outcome (though obviously still cares about your cancer). I've not heard of 2cm as a standard margin and wonder why he picked that figure when it seems that 1 or 3cm are the norm. But hey, I'm an HCA not a doctor. Have you had a full thickness skin graft explained to you? From what I can work out from reading the results of some clinical trials, because your melanoma was reasonably superficial and your CT and sentinal node biopsy were clear then it would be normal to have a 1cm margin. It is a little unclear as to how much your prognosis improves by a wider margin. I can see both points of view and wouldn't like to be in your position. I think you could also do with speaking to a macmillan skin cancer nurse specialist. We have a fab one here in Southampton who is very good at talking through options, fears, skin checks, sun protection etc etc.

If you'd like, I can add a prayer request for you on the Christian prayer thread for wisdom in your decision making and for your health and healthcare.

Thanks again. Yes, the plastic surgeon explained that the results are unclear as to how much prognosis improves by a wider margin. I think I will wait to talk to the oncologist. In any case, practically, I can't see my partner taking another 3 days off work to look after me and the children unless the operation is recommended by the oncologist or someone close to as senior as the plastic surgeon. I will book another appointment with the Macmillan cancer counsellor at the hospital to have a chat with her. (However my surgeon seems to a be a bit of a god at that hospital as everyone has raved about him.) Hmmm, maybe that is telling me something in itself.

Although I'm not currently a practising Christian (I have been very keen in the past), I have been on various prayer chains through friends and relations. I think I'm pretty covered in that area, although thank you for your offer.

Thanks again, it's very nice to have people interested in helping.