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Wide local excision

Wide local excision is a surgical procedure in which a tumor or abnormal lesion is removed along with a margin of surrounding normal tissue using a scalpel to ensure complete excision and reduce the risk of cancer recurrence.^[1] This technique, also known as breast-conserving surgery or lumpectomy when applied to breast cancer, is commonly used for early-stage solid tumors where preservation of surrounding structures is desirable, such as in melanoma, breast cancer, soft tissue sarcomas, and certain gynecologic cancers like vulvar or vaginal malignancies.^[2]^[3]^[4] In breast cancer, it targets tumors confined to the breast or nearby lymph nodes, removing the cancerous lump and a rim of healthy tissue while leaving most of the breast intact.^[2] For melanoma, it serves as the primary treatment for localized disease, with excision margins tailored to tumor thickness—typically 0.5–1 cm for in situ lesions, 1 cm for tumors less than 1 mm thick, 1–2 cm for 1–2 mm thick tumors, and 2 cm for thicker lesions—to achieve negative margins without compromising survival outcomes.^[3] Evidence from clinical trials, including the Intergroup Melanoma Surgical Trial, indicates that margins wider than 2 cm do not improve survival but may increase complications like the need for skin grafts.^[3] The procedure is typically performed under general or local anesthesia on an outpatient basis, beginning with an incision over the lesion, followed by excision down to the fascial layer (for skin cancers) or through the tumor bed, and closure of the wound, which may involve sutures, skin flaps, or grafting if the defect is large.^[5]^[2] Sentinel lymph node biopsy is often integrated to assess for metastasis, particularly in melanoma or breast cases, guiding whether further nodal surgery is needed.^[3]^[2] Postoperative care includes monitoring for clear margins via pathology, with adjuvant therapies like radiation (standard after breast WLE) or immunotherapy enhancing local control and overall survival.^[2]^[3] While effective for local disease control, WLE carries risks such as bleeding, infection, scarring, changes in body contour (e.g., breast asymmetry), and rare complications like lymphedema from associated lymph node procedures.^[2] It is contraindicated in cases of multifocal disease, inflammatory cancers, or when radiation is not feasible, where more extensive surgery like mastectomy may be preferred.^[2] Ongoing research supports WLE's role in personalized treatment, emphasizing narrower margins in select low-risk melanomas to improve cosmesis without sacrificing efficacy.^[3]

Overview

Definition

Wide local excision is a surgical procedure involving the removal of a localized tumor or lesion along with a surrounding margin of healthy tissue to achieve complete excision and reduce the risk of local recurrence.^[1]^[6] The core principles of wide local excision emphasize achieving negative margins, where no cancer cells are present at the inked edge of the removed tissue, while preserving adjacent anatomical structures to the greatest extent possible and pursuing curative intent for early-stage malignancies.^[7]^[8]^[9] The primary objectives are to secure local control of the disease and to limit cosmetic and functional impairments relative to more radical surgeries, such as mastectomy.^[8]^[10] A key anatomical consideration is that margin width varies by cancer type; for example, 1–2 cm for melanoma based on tumor thickness and no ink on tumor for invasive breast cancer lesions.^[11]^[12]

Historical Development

The concept of wide local excision (WLE) traces its roots to the late 19th century, when William Halsted developed the radical mastectomy as the standard treatment for breast cancer, emphasizing aggressive removal of the tumor and surrounding tissues to control local-regional disease.^[13] This approach dominated surgical oncology for nearly a century, but by the mid-20th century, accumulating evidence suggested that less radical procedures could achieve similar outcomes while preserving quality of life. In the 1970s, WLE emerged as a breast-conserving alternative, particularly following the initiation of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial in 1976, which compared lumpectomy (a form of WLE) plus radiation to radical mastectomy.^[14] The 1985 publication of NSABP B-06 results marked a pivotal shift, demonstrating that WLE combined with radiation therapy yielded equivalent disease-free and overall survival rates to mastectomy at seven years, with ipsilateral breast tumor recurrence rates of 14.3% versus 39.2% without radiation.^[15] This evidence drove the transition from empirical wide resections to breast-conserving surgery as a viable option for early-stage breast cancer. Concurrently, in the 1980s, WLE gained adoption for cutaneous melanoma, influenced by Alexander Breslow's 1970 work establishing tumor thickness as a key prognostic factor, which informed margin recommendations tailored to depth (e.g., 1 cm for lesions ≤1 mm thick).^[16] Standardized guidelines from the American College of Surgeons formalized these practices, recommending margins of 1-2 cm based on Breslow depth to balance oncologic safety and cosmesis.^[9] The 1990s saw further evolution through integration with sentinel lymph node biopsy (SLNB), introduced for melanoma around 1992 to stage regional nodes without full lymphadenectomy, reducing morbidity while maintaining prognostic accuracy.^[17] Randomized trials, such as the Multicenter Selective Lymphadenectomy Trial, validated SLNB's role alongside WLE, shifting protocols from routine elective node dissection to targeted approaches. For breast cancer, SLNB adoption followed similar trajectories, enhancing WLE's precision in axillary staging. This period marked a broader move toward evidence-based margins, informed by trials like the World Health Organization's 1980s study on melanoma excision widths.^[17] As of 2025, WLE protocols continue to refine toward minimally invasive techniques, incorporating advanced imaging guidance for precise margin assessment and tumor localization, as outlined in the National Comprehensive Cancer Network (NCCN) guidelines for both breast cancer and melanoma. These updates emphasize multidisciplinary integration, with radiation and adjuvant therapies optimizing outcomes for tumors amenable to conservation, while maintaining historical emphasis on negative margins for local control.^[18]^[19]

Indications and Patient Selection

Primary Indications

Wide local excision (WLE) is primarily indicated for early-stage, localized solid tumors where complete surgical removal with adequate margins is feasible, minimizing the need for more extensive procedures while preserving function and cosmesis. In breast cancer, it serves as the standard initial treatment for stage I and II invasive disease, as well as ductal carcinoma in situ (DCIS), particularly when the tumor is small relative to breast size and imaging confirms no multifocal involvement.^[20]^[21] For cutaneous melanoma, WLE is recommended for localized disease, including melanoma in situ and invasive lesions of any Breslow thickness (T1a–T4a), with margins tailored to tumor thickness: 0.5 cm for in situ; 1 cm for tumors ≤1 mm; 1–2 cm for tumors 1–2 mm; and 2 cm for tumors >2 mm, offering a high likelihood of cure exceeding 95% five-year survival for thin lesions (≤1 mm) when margins are clear and adjuvant therapies are applied as needed.^[22]^[3]^[5] In non-melanoma skin cancers, such as basal cell carcinoma (BCC) and squamous cell carcinoma (cSCC) on low-risk sites (e.g., trunk or extremities, tumors <2 cm), WLE with 4-6 mm margins is preferred for low-risk, localized disease to achieve complete excision while avoiding Mohs micrographic surgery unless high-risk features are present.^[23]^[24] For gynecologic cancers, WLE is indicated for early-stage vulvar intraepithelial neoplasia or microinvasive squamous cell carcinoma (stage IA), and select localized vaginal cancers, with margins of 1–2 cm to preserve anatomy and function, often combined with sentinel lymph node evaluation.^[25]^[26] WLE is also indicated for select soft tissue sarcomas in extremity locations, particularly low-grade, superficial tumors smaller than 5 cm where wide margins (1-2 cm of normal tissue) can be obtained without compromising limb function, often combined with radiation for intermediate-risk cases.^[27]^[28] Patient selection emphasizes favorable tumor location, size under 5 cm, and absence of lymphovascular invasion to optimize oncologic outcomes and cosmetic results, as endorsed by updated NCCN guidelines (version 5.2025 for breast cancer, version 2.2025 for melanoma) and ASCO consensus statements prioritizing breast-conserving approaches over radical mastectomy.^[20]^[22]^[21]

Contraindications and Considerations

Wide local excision (WLE) is contraindicated in cases of multicentric disease, where multiple tumor foci are present in different quadrants of the breast, as complete removal with adequate margins while preserving cosmesis is often infeasible.^[29] Inflammatory breast cancer represents another absolute contraindication due to its diffuse involvement of the skin and lymphatics, precluding localized excision.^[29] Similarly, tumors larger than 5 cm that invade the chest wall cannot be adequately addressed with WLE, as they typically require more extensive surgery such as mastectomy.^[29] In melanoma, absolute contraindications are less rigidly defined but include unresectable advanced disease (stage III or IV), where WLE cannot achieve curative intent.^[3] Relative contraindications for WLE encompass prior radiation therapy to the affected area, which complicates adjuvant radiotherapy and increases risks of poor wound healing.^[19] Comorbidities that elevate surgical risk, such as uncontrolled diabetes or active connective tissue diseases like scleroderma, may render WLE inadvisable due to heightened chances of infection or delayed healing.^[29]^[19] For skin cancers in cosmetically or functionally critical areas, such as the face or hands, alternative techniques like Mohs micrographic surgery are preferred over standard WLE to minimize tissue loss and preserve aesthetics.^[29] Patient selection for WLE requires careful evaluation of factors including age, overall performance status via ECOG score, and genetic predispositions; for instance, BRCA1 or BRCA2 mutations often favor mastectomy over WLE to reduce future cancer risk in the preserved breast tissue.^[29] Multidisciplinary assessment involving surgeons, oncologists, and radiation specialists is essential to determine feasibility, particularly when tumor size relative to breast volume or lesion location impacts cosmetic outcomes.^[19] In melanoma, patient preferences and tumor characteristics, such as thickness and anatomic site, guide margin decisions to balance oncologic efficacy with functional preservation.^[3] Special considerations apply in pregnancy, where WLE is absolutely contraindicated in the first trimester due to radiation risks following breast conservation, though it may be deferred or adapted in later trimesters.^[29] For immunosuppressed patients, such as those on chronic steroids or with HIV, prophylactic antibiotics are recommended perioperatively to mitigate infection risks during WLE.^[19]

Surgical Procedure

Preoperative Preparation

Preoperative preparation for wide local excision (WLE) involves a series of diagnostic, evaluative, and optimization steps tailored to the underlying malignancy, typically breast cancer or cutaneous melanoma, to ensure accurate staging, minimize risks, and facilitate successful surgical outcomes. This process begins with confirmatory diagnostics and extends to patient-specific planning, emphasizing multidisciplinary input to align treatment with disease extent and individual health status.^[19]^[18] Diagnostic imaging and biopsy confirmation are foundational to delineate the tumor's characteristics and confirm the need for WLE. For breast cancer, mammography and ultrasound are routinely employed to localize the lesion and assess its size, often supplemented by MRI for multifocal disease evaluation. Core needle biopsy or fine-needle aspiration is performed to verify invasive carcinoma, with metallic clips inserted at the biopsy site to mark the tumor bed for subsequent excision. In cutaneous melanoma, dermoscopy enhances preoperative visualization of atypical features such as asymmetry or irregular borders, aiding in the selection of lesions warranting biopsy; an excisional or incisional biopsy follows to determine Breslow depth and ulceration status. Staging incorporates sentinel lymph node biopsy (SLNB) if indicated, particularly for tumors exceeding 0.8 mm in melanoma or node-negative breast cancer, performed concurrently or prior to WLE to guide margins and adjuvant therapy.^[19]^[2]^[30]^[18] Patient optimization requires multidisciplinary consultation involving oncologists, surgeons, and pathologists to review pathology results and formulate a cohesive plan, ensuring WLE aligns with overall oncologic strategy. Informed consent is obtained, detailing procedural risks, expected margins (e.g., 1-2 cm for invasive breast tumors or based on melanoma thickness), and reconstruction options if applicable. Laboratory assessments include a complete blood count (CBC) to detect anemia or infection risk, and coagulation profile (prothrombin time, partial thromboplastin time, platelet count) to identify bleeding tendencies, particularly in patients on anticoagulants or with comorbidities. These steps mitigate perioperative complications and confirm surgical candidacy.^[19]^[18]^[2]^[31] Surgical marking and planning occur preoperatively, with the surgeon delineating excision margins based on tumor dimensions from pathology reports—typically 0.5–1 cm for melanoma in situ, 1 cm for tumors less than 1 mm thick, 1–2 cm for tumors 1–2 mm thick, and 2 cm for tumors thicker than 2 mm—to achieve clear histological margins while preserving cosmesis. Discussion of anesthesia type is essential: local anesthesia suffices for superficial skin excisions, whereas general anesthesia is preferred for breast WLE or combined SLNB procedures to ensure patient comfort and procedural precision.^[18]^[32]^[19] Lifestyle adjustments focus on modifiable risk factors to enhance healing and reduce infection rates. Smoking cessation is strongly advised at least 4-6 weeks prior to surgery, as nicotine impairs wound healing and increases complication risks in both breast and skin procedures; counseling and pharmacotherapy support compliance. Prophylactic antibiotics, such as cefazolin, are administered perioperatively for high-risk patients, including those undergoing breast WLE with SLNB or axillary dissection, to prevent surgical site infections, though routine use in isolated skin excisions is selective based on contamination potential.^[19]^[33]^[34]

Intraoperative Technique

Wide local excision is typically performed under local anesthesia for superficial lesions such as those in skin cancers, where lidocaine with epinephrine is injected to numb the area and provide vasoconstriction for reduced bleeding.^[35] For larger excisions or those involving deeper tissues, such as in breast cancer, general anesthesia is commonly used to ensure patient comfort and immobility during the procedure.^[2] The excision begins with marking the elliptical incision based on preoperative planning, encompassing the visible or palpable tumor and a predetermined margin of healthy tissue to achieve oncologic clearance.^[9] A scalpel is used to incise through the skin and subcutaneous layers, with electrocautery employed for precise dissection and hemostasis to minimize blood loss.^[35] Margins vary by tumor type and characteristics; for basal cell carcinoma, a 4 mm margin of clinically normal skin is standard, while for melanoma, margins are guided by Breslow thickness, such as 1 cm for tumors ≤1 mm thick, 1–2 cm for tumors 1–2 mm thick, and 2 cm for those >2 mm thick.^[36]^[37] Intraoperative margin assessment may involve frozen section pathology to evaluate tissue edges for residual tumor cells, particularly in cases of non-melanoma skin cancers or when close margins are suspected, allowing for immediate re-excision if necessary.^[38] The excised specimen is oriented with sutures or clips to facilitate accurate pathological mapping during permanent sectioning. Closure depends on the defect size and location; small wounds (<2 cm) are amenable to primary layered closure with absorbable subcutaneous sutures and skin approximation using non-absorbable sutures or adhesive.^[40] Larger defects may require skin grafts or local flaps to restore contour and function while minimizing cosmetic deformity.^[35] If indicated by tumor staging protocols, such as in intermediate-thickness melanoma, sentinel lymph node biopsy is performed concurrently through separate incisions to assess regional nodal involvement.^[37]

Clinical Applications

Breast Cancer

Wide local excision serves as a primary form of breast-conserving surgery (BCS) for early-stage breast cancer, involving the removal of the tumor along with a surrounding margin of 1-2 cm of normal breast tissue to achieve clear margins while preserving the natural contour and appearance of the breast.^[41]^[42] This approach, also known as lumpectomy or partial mastectomy, typically spares the nipple-areola complex unless it is directly involved by the malignancy, allowing for breast preservation in suitable candidates.^[43] Following the procedure, whole-breast irradiation is standard to reduce the risk of local recurrence, with studies demonstrating equivalent survival outcomes to mastectomy when combined appropriately.^[10] Patient eligibility for wide local excision in breast cancer is generally limited to those with unifocal invasive ductal carcinoma measuring less than 5 cm, where the tumor size is proportionate to the breast volume, and without extensive ductal carcinoma in situ (DCIS) that would preclude adequate margins. Contraindications include multifocal or multicentric disease, inflammatory breast cancer, or prior therapeutic chest wall irradiation. Surgical margins are defined as adequate when there is no ink on tumor for invasive cancer, per the Society of Surgical Oncology (SSO)-American Society for Radiation Oncology (ASTRO) consensus guidelines, which aim to minimize re-excision rates without compromising oncologic safety.^[44] Technique-specific adaptations in breast cancer include wire localization for non-palpable lesions, where a thin wire is inserted under imaging guidance preoperatively to guide precise tumor excision and ensure complete removal.^[2] For cases with positive margins identified intraoperatively or on final pathology, cavity shavings—additional excision of tissue from the lumpectomy cavity walls—can reduce the positive margin rate by nearly 50% and halve reoperation needs, as shown in randomized trials.^[45] Wide local excision is integrated with axillary staging, often via sentinel lymph node biopsy during the same operation, to assess nodal involvement and guide adjuvant therapy decisions.^[46] Cosmetic outcomes have been enhanced since the 2010s through oncoplastic techniques, which incorporate plastic surgery principles like volume displacement or replacement to reshape the breast, enabling wider excisions in larger tumors while maintaining aesthetics and reducing deformity rates.^[47]^[48]

Skin Cancers

Wide local excision (WLE) is a primary surgical approach for treating cutaneous malignancies, including melanoma and non-melanoma skin cancers such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), aiming to remove the tumor with adequate surrounding normal tissue to achieve clear margins while preserving function and cosmesis.^[49] For melanoma, WLE is performed following an initial diagnostic biopsy that confirms the diagnosis and measures the Breslow depth, the tumor's vertical thickness, which guides margin selection to minimize local recurrence risk.^[18] In melanoma management, surgical margins are determined by Breslow depth according to the National Comprehensive Cancer Network (NCCN) 2025 guidelines: 0.5–1 cm for in situ lesions, 1 cm for tumors less than 1 mm thick, 1–2 cm for 1–2 mm thick tumors, and 2 cm for thicker tumors (>2 mm).^[18] These margins balance tumor clearance with tissue preservation, as evidenced by randomized trials showing equivalent local control rates between 1 cm and 2 cm margins for intermediate-depth melanomas in low-risk cases.^[49] For non-melanoma skin cancers, WLE margins are typically narrower due to the less aggressive behavior of BCC and low-risk SCC: 4 mm clinical margins are standard for low-risk BCC and 4–6 mm for low-risk SCC, extending to the subcutaneous fat or deeper to the fascial plane if there is evidence of subcutaneous involvement to prevent recurrence.^[23]^[24] In cases of high-risk features, such as perineural invasion or larger size, margins may be expanded, but WLE remains suitable for accessible sites. Site-specific adaptations influence WLE application; on the trunk and extremities, wider margins are feasible due to ample tissue, facilitating straightforward closure, whereas on the face and other cosmetically sensitive areas, Mohs micrographic surgery is often preferred for precise margin control and tissue sparing, though WLE is employed for larger lesions or when Mohs is unavailable.^[49] Pathologic confirmation in WLE relies on 100% evaluation of margins using permanent paraffin-embedded sections, providing comprehensive histologic assessment post-excision, in contrast to Mohs surgery's intraoperative frozen section analysis for real-time margin verification.^[50]

Postoperative Management

Immediate Care

Following wide local excision, immediate postoperative care focuses on promoting wound healing, controlling pain, preventing infection, and facilitating safe early recovery, typically spanning the first 48 hours to two weeks after surgery. Patients are monitored in a recovery area for several hours post-procedure to ensure stable vital signs and adequate pain control before discharge, which is common for procedures performed under local anesthesia.^[51]^[52] Wound management begins with sterile dressings applied intraoperatively to protect the site and absorb any initial drainage. These dressings should remain intact for at least 24 to 48 hours to minimize contamination risk, during which patients are instructed to keep the site dry and avoid submerging it in water.^[51]^[53]^[54] After this period, dressings may be changed daily using an aseptic, non-touch technique; the site can then be gently cleansed with mild soap and water or tap water, patted dry, and covered with a clean, non-adherent dressing, often after applying a thin layer of petroleum jelly or antibiotic ointment like bacitracin to maintain moisture and prevent crusting.^[51]^[53]^[54] For excisions on limbs, elevation of the affected area above heart level when resting is recommended to reduce swelling.^[51] In breast procedures, if a skin graft or flap is used, additional care may involve avoiding stretching of the area. Patients are advised to monitor for infection signs such as increasing redness, warmth, swelling, purulent discharge, fever above 101°F (38.3°C), or foul odor, and to contact their healthcare provider promptly if these occur.^[51]^[53]^[52]^[54] Pain is typically most intense in the first 24 to 48 hours and is managed with oral analgesics, starting with acetaminophen (up to 1,000 mg every 6 hours, not exceeding 4,000 mg daily) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400 to 800 mg every 6 to 8 hours with food, not exceeding 3,200 mg daily) for mild to moderate discomfort.^[51]^[53] For breakthrough pain, short-term opioids may be prescribed, with instructions to taper use as symptoms improve and to avoid driving or alcohol while taking them.^[51] In breast cancer cases, wound infiltration with local anesthetics during surgery can further reduce early pain needs.^[52] Regular monitoring ensures pain remains controlled without excessive reliance on narcotics. Activity restrictions are essential to support healing and prevent complications like bleeding or seroma formation. Patients should avoid strenuous activities, heavy lifting (more than 5 pounds or a gallon of milk), bending, or excessive arm/leg use on the affected side for 1 to 2 weeks, resuming light daily tasks as tolerated while incorporating rest periods.^[51]^[52] If surgical drains such as a Jackson-Pratt bulb are placed—common in breast excisions to remove excess fluid—they require emptying and measurement every 4 to 8 hours, with output recorded; patients may be discharged with drains in place and taught home care, or they may be removed once drainage is minimal (under 30 mL per day).^[52] For breast procedures, wearing a soft, supportive bra is encouraged to minimize movement and swelling.^[52] Discharge typically occurs the same day for outpatient cases under local anesthesia, once pain is managed, voids normally, and ambulates without issue, with most patients able to return to non-physical work within a few days.^[51]^[52] Follow-up is scheduled in 7 to 14 days for wound assessment and suture removal (if non-absorbable stitches were used), allowing early detection of healing issues.^[51]^[53]^[52]

Long-term Monitoring

Following wide local excision, long-term monitoring involves structured follow-up protocols to detect potential recurrence, manage late effects, and support overall survivorship. For patients treated for breast cancer, guidelines recommend medical history and physical examinations 1 to 4 times per year for the first 5 years, followed by annual visits thereafter.^[19] These visits typically include assessments for symptoms such as bone pain or shortness of breath, alongside coordination of survivorship care plans that integrate preventive health measures. Mammography is advised annually on the treated breast, with the first imaging typically 6 months after completing radiation therapy (or 12 months post-surgery if no radiation), and continuing indefinitely (unless mastectomy precludes it).^[19]^[55] In cases of skin cancers like melanoma, surveillance emphasizes more frequent initial evaluations to account for higher recurrence risks in the first few years, with frequency varying by stage and risk level. For early-stage disease (stages 0 to IIA), physical examinations and medical history reviews, focusing on the skin and regional lymph nodes, are scheduled every 6 to 12 months for the first 5 years, then annually. For higher-risk localized melanoma (stages IIB to III), every 3 to 6 months for the first 2 years, every 3 to 12 months for years 3 to 5, and annually thereafter as clinically indicated.^[18] Imaging such as ultrasound or CT scans is reserved for patients with symptoms or those receiving adjuvant therapy, rather than routine use, to minimize unnecessary exposure.^[18] Surveillance tools extend beyond clinical visits to empower patient self-management. For melanoma patients, monthly self-skin examinations are encouraged, using criteria like the ABCDE rule (asymmetry, border irregularity, color variation, diameter over 6 mm, and evolution) to identify suspicious changes early.^[56] Scar monitoring is essential across applications, involving regular inspection for signs of contracture, which can limit mobility, or ulceration indicating possible local recurrence near the excision site; patients are advised to report persistent tightness or breakdown promptly during follow-up.^[57] Integration of adjuvant therapies into monitoring ensures seamless care transitions. Follow-up schedules are coordinated with radiation or chemotherapy timelines, with visits adjusted to assess treatment tolerance and adherence, such as confirming no missed doses of endocrine therapy in hormone receptor-positive breast cancer.^[19] For patients with hereditary risks, such as BRCA mutations, genetic counseling is incorporated post-surgery to discuss implications for family members and enhanced surveillance strategies.^[58] Quality of life assessments are routinely embedded in long-term care, particularly for breast cancer cases where cosmetic outcomes impact psychosocial well-being. Tools like the BREAST-Q questionnaire evaluate satisfaction with breast appearance, comfort, and health-related quality of life, administered at intervals to track changes in cosmesis and emotional health following wide local excision and any reconstruction.^[59] This patient-reported measure helps guide interventions for issues like body image distress, ensuring holistic monitoring beyond oncologic surveillance.^[60]

Complications and Risks

Intraoperative and Early Postoperative Risks

Wide local excision (WLE) carries several intraoperative risks, primarily related to hemorrhage, which can occur due to disruption of vascular structures in the excised tissue and surrounding areas. Meticulous hemostasis using electrocautery or ligation is essential to control bleeding during the procedure, minimizing the need for transfusion or conversion to more invasive techniques.^[61] Nerve damage represents another potential intraoperative complication, particularly in excisions involving sensitive anatomical sites such as the face or extremities, leading to temporary or permanent sensory loss; for instance, studies report nerve injury in cases of melanoma WLE on the temporal region.^[62] Incomplete excision margins, where tumor cells extend to or beyond the surgical borders, occur in approximately 5-20% of cases depending on tumor type and location, often necessitating re-excision to achieve clear margins and reduce local recurrence risk.^[63] In the early postoperative period, infection at the surgical site is a common concern, with incidence rates ranging from 1-5% in clean procedures like WLE for skin cancers or breast tumors, though rates can reach 6% or higher in outpatient dermatologic surgeries.^[61] ^[64] Seroma and hematoma formation may arise from lymphatic or vascular leakage, with seroma rates around 10-16% following breast-conserving WLE and lower incidences (under 5%) in skin excisions; these collections can delay healing if not managed promptly.^[65] Wound dehiscence, involving partial or complete separation of the incision edges, affects 1-2% of cases and is more frequent in larger excisions or those on tension-prone sites like the lower extremities.^[66] ^[67] Prevention strategies focus on intraoperative and immediate postoperative measures to mitigate these risks. Antibiotic prophylaxis is recommended per surgical guidelines for select clean procedures, such as a single preoperative dose of cefazolin in high-risk patients (e.g., those with diabetes or obesity), though routine use is not advised for uncomplicated WLE due to low baseline infection rates.^[68] Thorough hemostasis during surgery reduces hematoma risk, while drains or compression dressings can prevent seroma accumulation in breast WLE.^[69] Patient education on wound hygiene, including keeping the site clean and dry, further lowers infection incidence. Procedures under local anesthesia, which facilitate over 90% outpatient performance, are associated with reduced overall complication rates compared to general anesthesia. Site-specific considerations, such as higher infection risks in lower extremity excisions (up to 5-7%), underscore the need for tailored prophylaxis and monitoring.^[70] ^[67]

Late Complications

Late complications of wide local excision (WLE) encompass adverse effects that manifest weeks to years postoperatively, including aesthetic, functional, and oncologic issues. These arise from tissue healing responses, surgical disruption of lymphatic or neural structures, and potential residual disease, particularly in breast and skin cancer contexts. Management focuses on symptomatic relief, surveillance, and supportive interventions to improve quality of life. Scarring represents a primary late complication, with hypertrophic scars forming in up to 10-15% of cases among individuals predisposed to abnormal wound healing, such as those with darker skin tones or prior keloid history. Keloids, which extend beyond the excision margins, occur less frequently but carry a high recurrence rate exceeding 50% after simple excision alone. These can impair cosmesis, leading to asymmetry or contractures that affect mobility and body image, especially in breast WLE where visible chest scarring may persist. Treatment typically involves topical silicone sheets or gel applied for 12-24 months to flatten scars and reduce pruritus, combined with intralesional corticosteroid injections (e.g., triamcinolone) every 4-6 weeks to inhibit fibroblast proliferation and collagen deposition. Functional deficits often include lymphedema, particularly following WLE with axillary sentinel lymph node biopsy (SLNB) in breast cancer, with incidence rates of 5-6% at 2-5 years post-surgery. More extensive axillary lymph node dissection elevates this to 20% or higher, resulting from lymphatic obstruction and chronic fluid accumulation in the arm, leading to swelling, heaviness, and reduced range of motion. Chronic pain or sensory changes, such as numbness or paresthesia in the breast, chest wall, or upper extremity, affect 25-60% of patients long-term due to nerve injury during dissection. These symptoms, often neuropathic in nature, can persist beyond 6 months and are managed with compression garments for lymphedema to promote lymphatic drainage, alongside physical therapy; for pain, options include gabapentinoids or topical lidocaine to alleviate neural hypersensitivity. Local recurrence risk is heightened if pathologic margins are positive (less than 1-2 mm of clear tissue), with studies showing 2-5 times increased odds of relapse within 5 years compared to negative margins, necessitating vigilant imaging and clinical follow-up. In irradiated fields post-WLE, secondary malignancies like cutaneous angiosarcoma may emerge as rare late sequelae, occurring in approximately 0.05-0.2% of breast cancer cases 5-10 years later due to radiation-induced vascular changes. Mitigation strategies include oncoplastic reconstruction techniques during WLE, such as volume displacement flaps, which reduce deformity and improve cosmesis in 80-90% of cases while maintaining low complication rates comparable to standard excision. Psychological support, including counseling for body image concerns, is integral, as up to 30% of patients report ongoing distress related to scarring or functional changes.

Outcomes and Prognosis

Efficacy and Success Rates

Wide local excision (WLE) demonstrates high efficacy in achieving local control and cure for early-stage cancers, particularly when combined with adjuvant therapies where indicated. In stage I melanoma, treated with 1 cm margins, cure rates exceed 95%, with 5-year relative survival rates approaching 99% for localized disease.^[71] For nonmelanoma skin cancers such as basal cell and squamous cell carcinoma, WLE yields cure rates of approximately 95%.^[72] In breast cancer, breast-conserving surgery (BCS) via WLE followed by radiation achieves 90-95% local control rates at 5 years, based on meta-analyses of randomized trials.^[73] Comparative efficacy trials, including the NSABP B-06 study, show equivalent overall survival to mastectomy, with 20-year rates of 46% for both approaches.^[74] Recurrence statistics further underscore WLE's effectiveness: local recurrence rates are 5-10% at 5 years for early breast cancer after BCS with radiation, and less than 5%—often under 2%—for thin melanomas (≤1 mm Breslow depth) post-WLE.^[75]^[3] Long-term data indicate 10-year survival exceeding 90% for early-stage breast and skin cancers managed with WLE, reflecting sustained disease control.^[76]

Factors Influencing Prognosis

Several tumor characteristics significantly influence prognosis following wide local excision (WLE) for breast cancer and skin cancers such as melanoma. In breast cancer, the TNM staging system assesses tumor size (T), nodal involvement (N), and metastasis (M), with advanced stages correlating to poorer disease-free survival and overall survival rates.^[77] Higher histological grade indicates more aggressive disease, independently predicting worse outcomes after breast-conserving surgery like WLE.^[77] Lymphovascular invasion, present in up to 41% of cases, markedly increases the risk of metastasis and local recurrence by facilitating tumor spread.^[78] For melanoma, Breslow thickness—the depth of tumor invasion—serves as a primary prognostic indicator, with depths greater than 2 mm associated with a hazard ratio of 4.435 for reduced overall survival post-excision.^[79] Ulceration and lymphovascular invasion further elevate metastasis risk, worsening prognosis independent of thickness.^[80] Patient-related factors also modulate outcomes after WLE. Advanced age, particularly over 70 years, is linked to higher rates of local recurrence and competing mortality risks, though breast cancer-specific survival remains favorable with appropriate management.^[81] Comorbidities such as obesity (BMI ≥30 kg/m²) elevate recurrence risk by approximately 20-30% in postmenopausal hormone receptor-positive cases, independent of treatment type, due to altered hormonal and inflammatory environments.^[82] In breast cancer, HER2 overexpression acts as a genetic marker of aggressive disease, correlating with distant metastasis and poorer survival without targeted therapy, though anti-HER2 agents like trastuzumab improve prognosis post-WLE.^[83] Procedural elements during WLE critically affect long-term results. Achieving negative margins (no tumor at resection edges) is essential, as positive margins double the risk of ipsilateral breast tumor recurrence in breast cancer and increase local failure in melanoma.^[84] Adherence to adjuvant therapies, including radiotherapy and systemic treatments, enhances disease control; non-adherence raises recurrence odds by compromising local and distant control.^[85] Emerging molecular profiling refines prognostic assessment and guides therapy after WLE. In melanoma, BRAF V600 mutations, detected in about 50% of cases, enable targeted BRAF/MEK inhibitor therapy, improving event-free survival per 2024 ESMO guidelines.^[86] For breast cancer, comprehensive profiling identifies actionable alterations beyond HER2, supporting personalized adjuvant strategies to mitigate recurrence.^[87]

References

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Definition of wide local excision - NCI Dictionary of Cancer Terms
A surgical procedure in which a scalpel (a sharp knife) is used to cut out a tumor or other abnormal lesion and some normal tissue around it.
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Feb 28, 2025 · Lumpectomy also is called partial mastectomy, wide local excision and breast-conserving surgery. These terms refer to the fact that a ...
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May 2, 2025 · Excision. The primary tumor may be treated with wide local excision with 1-cm to 2-cm margins, depending on tumor thickness and location.[1-7] ...
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Sep 23, 2024 · Local excision. This is sometimes called a wide excision. The surgeon takes out the cancer along with a nearby edge or rim of normal tissue.Hysterectomy · Surgery To Remove Lymph... · Pelvic Exenteration
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When carrying out a wide local excision, the excised specimen should extend down to the level of the underlying muscular fascia. Currently, there is no evidence ...Abstract · Introduction · Surgical Treatment of... · Clinically Apparent Regional...
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Wide Local Excision - an overview | ScienceDirect Topics
Wide local excision (WLE) is defined as the surgical removal of an entire affected anatomical region along with a wide margin of clear skin, rather than just ...
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### Summary of Lumpectomy (Breast-Conserving Surgery)
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Tests Done Before Surgery | Johns Hopkins Medicine
Complete blood count (CBC). This test checks for a low number of red blood cells (anemia), a low platelet count, and infection. Coagulation studies (PT/PTT).
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