1 2 3 4 5 6 7 15 16 17 This study investigated both the influence of diagnostic biopsy type and the presence of residual tumor cells in the re-excision specimen on melanoma patient disease free survival (DFS) and overall survival (OS), in 471 patients with a mean FU of more than 5 years. Survival analysis was done using Cox’s proportional hazard model adjusted for; gender, age, site of primary melanoma, Breslow thickness, type of melanoma, ulceration, lymphatic invasion and sentinel node (SN) status. Both the diagnostic biopsy type and the presence of tumor cells in the re-excision specimen were found not to influence melanoma patient survival. METHODS Patients 18 20 To investigate the influence on survival, patients were divided both according to their diagnostic biopsy type; wide excisional biopsy (lateral clearance ≥ 2 mm), narrow excisional biopsy (lateral clearance < 2 mm), excisional biopsy with positive margins and incisional biopsy (includes punch) and the presence of residual tumor cells in their re-excision specimen. Statistical Analysis P RESULTS Patient Population Between August 1993 and September 2004, 551 patients were diagnosed with clinical stage I/II cutaneous melanoma, 257 male (46.6%) and 294 female (53.4%) with a mean age of 49.9 years (Table 1). Most primary melanomas were located on the trunk (43.7%) or on the lower extremities (36.7%). Breslow thickness was categorized into four groups ( ≤ 1.00 mm; 1.01–2.00 mm; 2.01–4.00 mm; >4.01 mm), but due to spontaneous regression of the primary lesion remained unknown in 38 patients. The majority of patients had a superficial spreading melanoma (65.0%) or a nodular melanoma (26.7%). In 46 patients the type of melanoma was different or remained unknown (8.3%). Ulceration, defined as the absence of intact epidermis overlying the major portion of primary melanoma, was diagnosed in 80 patients (14.5%), unknown in 1 patient (0.2%) and absent in 470 patients (85.3%). Lymphatic invasion was present in 25 patients (4.5%), absent in 521 patients (94.6%) and remained unknown in 5 patients (0.9%). The SN was negative in 446 patients (80.9%) and positive in 94 patients (17.1%). In 11 patients the SN was not removed and the SN status remained unknown (2.0%). In total, there were 101 missing variables in 80 patients; all were excluded from the study. SN Identification In 11 of the 551 patients the SN status remained unknown (2.0%), in 5 of these patients the SN was located in the deep lobe of the parotid gland and in one patient the SN was located high in the left axilla, in all cases the decision was made not to remove the SN to avoid potential morbidity associated with the intervention. The SN was not identified in 3 cases due to non-visualization by preoperative lymphoscintigraphy. In one patient the SN was located in the right axilla and could not be removed because the patient was suffering from frozen shoulder syndrome, the physical condition of another patient did not allow further treatment. Therefore, the success rate of SN identification was 98% (540 of 551 patients). Two of the patients with the SN located in the deep lobe of the parotid gland experienced metastasis of the parotid gland, one patient is still alive with disease and one patient is dead of disease. The patient whose physical condition did not allow further treatment, passed away soon after re-excision of the primary melanoma site, from massive hematogenic and lymphogenic metastasis. The 8 remaining patients have shown no evidence of disease. Diagnostic Biopsy Type and Survival 2 TABLE 1. Patient characteristics Characteristics Patients (n = 551) Follow up (years)   Mean (SD) 5.1 (2.8) Gender   Male 257 (46.6%)   Female 294 (53.4%) Age (years)   Mean (SD) 49.9 (15.3) Site of primary melanoma    Lower extremity 202 (36.7%)   Upper extremity  63 (11.4%)   Head/Neck 45 (8.2%)   Trunk 241 (43.7%) Breslow thickness (mm)   0 < x ≤ 1 153 (27.8%)   1 < x ≤ 2 207 (37.6%)   2 < x ≤ 4 114 (20.7%)   > 4 39 (7.1%)   Unknown (regression) 38 (6.9%) Type of melanoma   Superficial spreading 358 (65.0%)   Nodular 147 (26.7%)   Other/Unknown 46 (8.3%) Ulceration   No 470 (85.3%)   Yes 80 (14.5%)   Unknown 1 (0.2%) Lymphatic invasion   No 521 (94.6%)   Yes 25 (4.5%)   Unknown 5 (0.9%) Sentinel node status   Negative 446 (80.9%)   Positive 94 (17.1%)   Unknown 11 (2.0%) TABLE 2. Patient distribution according to (A) diagnostic biopsy type and (B) the presence of residual tumor cells in the re-excision specimen A Patients (n = 471) Follow up (years; mean ± SD) Diagnostic biopsy type   Wide excision biopsy ( ≥ 2 mm) 279 (59.3%) 5.0 ± 3.0   Narrow excision biopsy (0<x<2 mm) 109 (23.1%) 6.0 ± 2.7   Excision biopsy with positive margins 52 (11.0%) 5.8 ± 2.9   Incision biopsy 31 (6.6%) 5.4 ± 2.4 B Patients (n = 441) Follow up (years; mean ± SD) Re excision specimen   No residual tumor cells 400 (90.7%) 5.1 ± 2.9   Residual tumor cells 41 (9.3%) 5.8 ± 2.6 In 91/471 patients (19.3%) the SN was positive, 58/279 patients (20.8%) after a wide excision biopsy, 14/109 patients (12.8%) after a narrow excision biopsy, 15/52 patients (28.8%) after an excision biopsy with positive margins and 4/31 patients (12.9%) after an incisional biopsy. In 79/471 patients (16.8%) a recurrence was found during FU, 45/279 patients (16.1%) after a wide excision biopsy (21 locoregional skin, 8 SN basin and 16 systemic), 17/109 patients (15.5%) after a narrow excision biopsy (7 locoregional skin, 2 SN basin and 8 systemic), 10/52 patients (19.2%) after an excision biopsy with positive margins (5 locoregional skin, 2 SN basin and 3 systemic) and 7/31 patients (22.6%) after an incision biopsy (5 locoregional skin, and 2 systemic). But confounding factors were not equally distributed between the diagnostic biopsy groups. Therefore, survival analysis was done using Cox’s proportional hazard model adjusted for; gender, age, site of primary melanoma, Breslow thickness, type of melanoma, ulceration, lymphatic invasion and sentinel node (SN) status. 3 3 3 TABLE 3. Univariate and multivariate Cox regression analysis of disease-free survival and overall survival according to diagnostic biopsy type  Disease Free Survival Overall Survival Univariate Multivariate Univariate Multivariate Tested variables P HR 95% CI P P HR 95% CI P Diagnostic biopsy type   Wide excision biopsy 0.691 1.00 – 0.204 0.500 1.00 – 0.765   Narrow excision biopsy 0.360 0.71 0.39–1.28 0.255 0.315 0.74 0.37–1.51 0.411   Excision biopsy with positive margins 0.870 0.59 0.29–1.18 0.132 0.748 0.75 0.34–1.65 0.476   Incision biopsy 0.581 0.47 0.19–1.16 0.101 0.387 0.74 0.29–1.89 0.530 Gender 0.018 1.15 0.70–1.89 0.573 0.004 1.44 0.81–2.57 0.215 Age (years) 0.004 1.02 1.00–1.04 0.018 0.002 1.03 1.01–1.05 0.007 Site of primary melanoma   Lower extremity 0.091 1.00 – 0.023 0.153      Upper extremity 0.825 0.91 0.41–2.01 0.809 0.071      Head/Neck 0.014 3.40 1.45–7.97 0.005 0.095      Trunk 0.731 0.93 0.54–1.61 0.790 0.063    Breslow thickness (mm)   0 < x ≤ 1 <0.001 1.00 – <0.001 <0.001 1.00 – 0.001   1 < x ≤ 2 0.003 13.19 1.77–98.41 0.012 0.016 8.15 1.07–62.19 0.043   2 < x ≤ 4 <0.001 34.11 4.50–258.60 0.001 <0.001 21.43 2.79–164.84 0.003   > 4 <0.001 15.73 1.86–132.81 0.011 <0.001 11.85 1.35–103.70 0.025   Type of melanoma <0.001 1.58 0.95–2.62 0.078 <0.001 1.57 0.88–2.79 0.128   Ulceration <0.001 1.83 1.09–3.07 0.023 <0.001 1.64 0.89–3.04 0.116   Lymphatic invasion <0.001 3.98 2.05–7.72 <0.001 <0.001 2.19 1.07–4.48 0.032   Sentinel node status <0.001 3.87 2.23–6.70 <0.001 <0.001 3.19 1.75–5.81 <0.001 3 3 1 FIG. 1. A B  The same analysis was done after combining the groups; the wide excision biopsy group was joined with the narrow excision biopsy group and compared to the excision biopsy group with positive margins joined with the incision biopsy group. Still, diagnostic biopsy type did not have a significant influence on either DFS or OS (data not shown). Residual Tumor Cells in the Re-Excision Specimen and Survival 2 4 4 4 TABLE 4. Univariate and multivariate Cox regression analysis of disease-free survival and overall survival according to the presence of residual tumor cells in the re-excision specimen  Disease Free Survival Overall Survival Univariate Multivariate Univariate Multivariate Tested variables P HR 95% CI P P HR 95% CI P Residual tumor cells 0.094 0.79 0.38–1.64 0.532 0.230 0.83 0.36–1.92 0.668 Gender 0.025 1.14 0.68–1.92 0.611 0.009 1.22 0.65–2.28 0.531 Age (years) 0.007 1.02 1.00–1.04 0.038 0.007 1.02 1.00–1.04 0.040 Site of primary melanoma   Lower extremity 0.032 1.00 – 0.033 0.105 1.00 – 0.123   Upper extremity 0.830 0.95 0.41–2.20 0.910 0.069 2.21 0.85–5.71 0.102   Head/Neck 0.004 3.22 1.35–7.66 0.008 0.040 3.22 1.03–10.09 0.045   Trunk 0.647 0.96 0.54–1.74 0.903 0.049 2.02 0.98–4.20 0.059 Breslow thickness (mm)   0 < x ≤ 1 <0.001 1.00 – <0.001 <0.001 1.00 – 0.004   1 < x ≤ 2 0.005 12.82 1.71–96.07 0.013 0.020 7.99 1.04–61.49 0.046   2 < x ≤ 4 <0.001 30.16 3.97–229.22 0.001 <0.001 20.13 2.59–156.25 0.004   > 4 <0.001 15.91 1.86–136.25 0.012 <0.001 11.84 1.32–106.54 0.028   Type of melanoma <0.001 1.61 0.95–2.73 0.076 <0.001 1.63 0.87–3.04 0.128   Ulceration <0.001 1.55 0.90–2.67 0.119 <0.001 1.61 0.85–3.05 0.141   Lymphatic invasion <0.001 4.16 2.13–8.14 <0.001 <0.001 2.24 1.04–4.80 0.038   Sentinel node status <0.001 3.30 1.87–5.83 <0.001 <0.001 3.05 1.56–5.96 0.001 4 2 FIG. 2. A B  Consistent Confounders of Melanoma Patient Survival 3 4 3 4 3 4 DISCUSSION 8 9 10 11 12 13 14 15 16 17 1 2 21 23 24 25 26 27 1 4