Association of Mohs Micrographic Surgery vs Wide Local Excision With Overall Survival Outcomes for Patients With Melanoma of the Trunk and Extremities

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors

Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.

Clinical Characteristics of Marginally Recurrent Melanoma After Primary Excision: A Multisite Retrospective Analysis of 140 Cases Referred for Mohs Surgery

BACKGROUND

Marginally recurrent melanoma (MRM) manifests immediately adjacent to or within a scar and arises from incomplete tumor clearance after primary treatment. Little is known about the progression and treatment of MRM after all forms of excision.

OBJECTIVE

To determine the invasive growth potential, tumor-stage progression, and outcomes of those with MRM.

METHODS

One hundred forty patients with MRM were collected from 5 practice databases. All patients were treated with Mohs micrographic surgery. They were evaluated for Breslow depth and tumor stage change from the time of primary treatment and recurrent treatment.

RESULTS

Of 101 cases initially treated as melanoma in situ, 13 (12.9%) marginally recurred with invasive disease at the time of Mohs micrographic surgery. The median thickness of these recurrent melanomas was 0.58 mm. Of 39 cases initially treated as invasive melanoma, 10 (25.6%) marginally recurred with a greater Breslow depth. The median increase in thickness from initial treatment to recurrence was 1.31 mm.

CONCLUSION

Marginally recurrent melanoma retains its invasive growth potential. This can lead to Breslow depth increase, tumor-stage progression, and a worse prognosis on recurrence. Obtaining tumor-free margins is critical in initial and recurrence treatments.

Disease-specific survival of malignant melanoma after Mohs micrographic surgery is not impacted by initial margins: A systematic review and meta-analysis

Background

During Mohs surgery for melanoma, evidence has demonstrated that many surgeons opt for smaller initial margins than traditionally recommended (0.5 cm for in situ and 1 cm for invasive). Literature regarding surgical outcomes based on initial margin is sparse.

Objective

To determine differences in disease-specific survival of melanoma after Mohs micrographic surgery for varied initial surgical margins.

Methods

A literature search was conducted on February 14, 2022, from MEDLINE via PubMed (1946-present), Embase (1974-present), Central (1991-present), and Scopus (1960-present). The primary outcome was disease-specific mortality.

Results

Nineteen studies were included for final analysis. The overall disease-specific mortality rate of melanoma in all included studies was 0.5% (CI, 0.1-0.8; P, .010). Disease-specific mortality for 1 to 5, 5, and 6 to 10 mm categories were 0.4% (CI, 0.0-0.9; P, .074), 0.7% (CI, 0.2-1.3; P, .2-1.3), and 0.4% (CI, -0.9 to 1.8; P, .524), respectively. None of the variances across initial margin categories were statistically significant.

Limitations

Early-stage melanomas have low overall mortality rates. In our associated article, initial margins of 5 to 10 mm were shown to have the lowest rates of local recurrence.

Conclusions

In this systematic review and meta-analysis, melanoma-specific mortality was not significantly impacted by the initial surgical margin taken during Mohs micrographic surgery.

From Centimeters to Millimeters: The Evolution of the Surgical Margins for Melanoma-A Historical Review

BACKGROUND

With an improved understanding of tumor biology and behavior, the recommended margins for the surgical treatment of melanoma have evolved.

OBJECTIVE

We describe the progression of these surgical margins, detailing the historical basis for the 5-cm margin and transitioning to current practice, in which Mohs micrographic surgery (MMS) with immunohistochemistry (IHC) has become increasingly used.

METHODS/MATERIALS

We searched PubMed and Google Scholar for articles published between January 2019 and April 2023 describing the use of MMS for melanoma in situ (MIS) and invasive melanomas.

RESULTS

We identified 12 articles focusing on the use of MMS for MIS and invasive melanomas: 3 meta-analyses and 9 retrospective studies. Two retrospective analyses documented no differences in overall survival between MMS and wide local excision (WLE) and 2 found improved overall survival for MMS compared with WLE. Three retrospective analyses and 3 meta-analyses demonstrated low recurrence rates after the use of MMS for both MIS and invasive melanomas. Finally, 2 retrospective studies documented the success of MMS with IHC using MART-1.

CONCLUSION

Over the past century, the surgical margins for the treatment of melanoma have undergone a marked transformation. MMS with IHC has become increasingly popular given its ability to reliably produce superior clinical outcomes.

Surgical resection margin for T3-T4 primary acral melanoma: a multicenter retrospective cohort study

Although the National Comprehensive Cancer Network (NCCN) guidelines include clear recommendations for the appropriate resection margins in non-acral cutaneous melanoma, the required margin for acral melanoma is controversial. In this retrospective study, we aimed to investigate whether narrow-margin excision is warranted for thick acral melanoma. Records from 277 melanoma patients with stage T3-T4 disease who underwent radical surgery in three centers in China from September 2010 to October 2018 were reviewed. Clinicopathologic data, including age, gender, excision margin (1-2 cm versus ≥ 2 cm), Clark level, Breslow thickness, ulceration, N stage and adjuvant therapy, were included for survival analysis. The patients were followed up until death or March 31, 2021. Log-rank and Cox regression analyses were used to identify prognostic factors for overall survival (OS), disease-free survival (DFS) and local and in-transit recurrence-free survival (LITRFS). Among all enrolled patients, 207 (74.7%) had acral melanoma, and 70 (25.3%) had non-acral cutaneous melanoma. No significant difference in baseline characteristics was identified between non-acral and acral melanoma, except for age (p = 0.004), gender (p = 0.009) and ulceration (p = 0.048). In non-acral melanoma, a resection margin of 1-2 cm was a poor independent prognostic factor for OS [p = 0.015; hazard ratio (HR) (95% CI), 0.26 (0.009-0.77)] and LITRFS [p = 0.013; HR (95% CI), 0.19 (0.05-0.71)] but not for DFS [p = 0.143; HR (95% CI), 0.51 (0.21-1.25)]. Forty-three (20.8%) patients in the acral melanoma group had a 1-2-cm resection margin. The resection margin was not correlated with patients' OS (p = 0.196 by log-rank analysis, p = 0.865 by multivariate survival analysis), DFS (p = 0.080 by log-rank analysis, p = 0.758 by multivariate survival analysis) or LITRFS (p = 0.354 by log-rank analysis) in acral melanoma. As recommended in the NCCN guidelines, a resection margin ≥ 2 cm is required for non-acral cutaneous melanoma. Meanwhile, a narrow resection margin (1-2 cm) may be safe for patients with acral melanoma.

Dermatosurgery - from surgical option to integral part of dermatologic therapy

Dermatosurgery was long considered an isolated, and not always important, discipline within dermatology. As a therapeutic option, it was considered either the gold standard of first-line therapy, for example in basal cell carcinoma surgery and treatment of early-stage melanoma, or the last option, for instance in the treatment of warts. The fact that a profound change has taken place and that dermatosurgery is now an integral, equal, sometimes leading and always significant component of dermatology will be demonstrated in this review using three examples from geriatric dermatology, the treatment of hidradenitis suppurativa (acne inversa), and melanoma therapy. This review is supplemented by a section on the most important technique in dermatosurgery: microscopic (micrographic) surgery or Mohs Surgery.

The end of wide local excision (WLE) margins for melanoma ?

CLINICAL QUESTION

Is there nowadays any benefit of continuing the practice of routine wide local excision (WLE) for primary stage I/II cutaneous melanoma?

BACKGROUND

WLE aims to eradicate potential microsatellites around melanomas and thereby reduce local recurrence rates and improve overall survival. Six large prospective randomised trials investigated WLE versus wider WLE, they all failed to show any effect on overall survival (OS).

METHODS

A literature search was performed to identify data on outcome after omitting WLE. Additionally circumstantial evidence was gathered from pathology studies and outcomes of modified surgical techniques, as well as publications on morbidity.

RESULTS

No prospective and one retrospective study was found. The retrospective study showed no difference in OS after correction for confounding factors. Pathology studies showed a low incidence of residual melanoma in WLE specimen (0-4.2%). Mohs surgery does not show a difference in recurrence rates or OS. WLE is associated with considerable postoperative morbidity, which increases with wider excision margins.

CONCLUSION

There is no solid prospective evidence to support the classic dogma of a 2-step approach with the use of WLE for primary cutaneous melanoma that has been completely excised on diagnostic excision biopsy. We recommend to setup and conduct a prospective randomised trial to compare the classical 2-step approach with WLE to a complete diagnostic excision only to abolish the routine practice of WLE in the future.

Establishment and validation of a nomogram for predicting immune-related prognostic features in trunk melanoma-specific death

Background

Trunk melanoma is one of the most common and deadly types of melanomas. Multiple factors are associated with the prognosis of patients with trunk melanoma. Currently, direct, and reliable clinical tools for early assessment of individual specific risk of death are limited, and most of them are prediction models for all-cause death. Their accuracy in predicting competitiveness events, which make up a relatively large portion, may be substantially compromised. Hence, we conducted this study to investigate the risk factors of trunk melanoma-specific death to establish a comprehensive prediction model suitable for clinical application.

Methods

Patients with trunk melanoma analyzed in this study were from the SEER program [2010-2015]. The random sampling method was used to split the included cases into the training and validation cohorts at a ratio of 7:3. Univariate and multivariate competing risk models were used to screen the independent influencing factors of specific death, and then a nomogram covering these independent predictors was constructed. The concordance index (C-index) and a calibration curve were used to evaluate the calibration degree and accuracy of the nomogram.

Results

We identified 21,198 patients with trunk melanoma from the SEER database, and 3,814 of them died (17.99%). Among the death cases, deaths from other causes accounted for 66.50%The prognostic nomogram included 8 variables and 16 independent influencing factors. The overall C-index in the training set was 0.89, and the receiver operating characteristic (ROC) curve for predicting 1-, 3-, and 5-year survival was 0.928 [95% confidence interval (CI): 0.911-0.945], 0.907 (95% CI: 0.895-0.918), and 0.891 (95% CI: 0.879-0.902), respectively. The C-index of the model in the validation set was 0.89, and the area under the ROC curve (AUC) for predicting 1-, 3-, and 5-year cancer-specific death (CSD) was 0.927 (95% CI: 0.899-0.955), 0.916 (95% CI: 0.901-0.930), and 0.905 (95% CI: 0.899-0.921). Both the training set and the validation set showed the ideal calibration degree.

Conclusions

This model can be used as a potential tool for prognostic risk management of trunk melanoma in the presence of many competing events.

Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer

Simple Summary

Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Abstract

Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Modern views on skin biopsy in the diagnostic algorithm of dermatooncological diseases

Background. Malignant neoplasms of the skin are fairly common tumors in the world population and among the population of Ukraine. The main method of diagnosing skintumors is a biopsy, which allows establishing a diagnosis at an early stage and ensures the cure of most patients. Purpose. To evaluate modern recommendations for skin biopsy in the diagnosis of dermato-onсological diseases. Materials and methods. The search for sources of information was conducted using the MEDLINE/PubMed, EMBASE/ExcerptaMedica, CochraneLibrary, PubMed та Google Scholar databases using the following keywords: skin biopsy, skin tumors, diagnosis, melanoma. Among the identified sources, works without statistical analysis, descriptions of individual cases, articles without conclusions, and sources with duplicate results were excluded. The search depth was 10 years. Results. As a result of the conducted search, 57 publications were found that corresponded to the declared purpose. The most common methods are: puncture, shaving, excisional and incisional biopsy. Most guidelines recommend full-thickness excisional biopsy as the preferred procedure for the diagnosis of suspected melanoma. It is indicated that a statistically significant mortality rate was found in the puncture biopsy group. Most observations showed no significant differences in melanoma recurrence between excisional biopsy and puncture groups. Given the clinical diversity of melanoma, there is no uniformity in the types of biopsies performed to diagnose melanoma. The most inaccurate method turned out to be the punch biopsy method, which is associated with an increased risk of underdiagnosis of melanoma. Conclusions. A skin biopsy is a mandatory first step to establish a definitive diagnosis of a skin tumor. Excisional complete biopsy is the most justified in most cases of diagnosis. Rational biopsy technique remains an issue that needs further study.

Morbidity and Mortality of Melanoma on the Trunk and Extremities Treated With Mohs Surgery Versus Wide Excision: A Systematic Review

BACKGROUND

Recommendations for the approved use of Mohs surgery for cutaneous melanoma on the trunk and extremities remain uncertain.

OBJECTIVE

To compare survival and recurrence between patients treated with Mohs surgery versus wide excision for melanoma on the trunk and extremities.

METHODS

The databases Medline, Embase, Web of Science, CENTRAL, and EMCare were searched from inception on January 11, 2021. Contemporary comparisons were included exclusively. Meta-analysis was conducted using generic inverse variance and a fixed effects model.

RESULTS

Four studies were eligible for inclusion. The study population (n = 279,556) was 52.1% men and 97.2% White. There were no observed differences in 5-year overall survival (hazard ratio 0.98, 95% confidence interval 0.90-1.07, I2 = 0%), disease-free survival (HR 0.89, 95% CI 0.12-6.47, I2 = 0), or local recurrence among patients treated with Mohs surgery relative to wide excision. Quality of the evidence was very low.

CONCLUSION

This systematic review found survival and local recurrence were comparable among patients treated with Mohs surgery or wide excision for melanoma on the trunk and extremities. Future prospective contemporary studies with more diverse representation that report surgical complications and costs may facilitate more definitive recommendations.

A review of Mohs Micrographic Surgery for skin cancer: Part 1 - melanoma and rare skin cancers

Mohs micrographic surgery is a precise and effective method commonly used to treat high risk basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) on the head and neck. Whilst the majority of evidence for Mohs relates to keratinocyte cancers, there is published evidence for other types of skin cancer. This review aims to discuss the evidence for using MMS to treat six different types of skin cancer, including melanoma, lentigo maligna, dermatofibrosarcoma protuberans, atypical fibroxanthoma, microcystic adnexal carcinoma and pleomorphic dermal sarcoma, particularly in the context of survival rates and cancer recurrence. These cancers were chosen as there was sufficient literature for inclusion and given MMS is most useful when cancers are contiguous, rather than for cancers with marked metastatic potential such as angiosarcoma or merkel cell carcinoma. We searched Medline, Pubmed and Embase using the keywords: 'melanoma', 'mohs micrographic surgery', 'lentigo maligna', 'dermatofibrosarcoma protuberans', 'atypical fibroxanthoma', 'microcystic adnexal carcinoma' and 'pleomorphic dermal sarcoma' along with their appropriate synonyms, to identify the relevant English-language articles from the year 2000 onwards given that literature for Mohs on non-keratinocyte is sparse prior to this date. A MeaSurement Tool to Assess systematic Reviews (AMSTAR) was used to assess the validity of systematic reviews. Further high-quality, multi-centre randomised trials are necessary to establish the indications and efficacy of MMS for rarer cancers, particularly for AFX and PDS, where limited studies were identified.

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

BACKGROUND

Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen-section MART-1 immunohistochemical stains (MMS-IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS-IHC.

METHODS

This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS-IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes.

RESULTS

In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a-T4b) were treated with MMS-IHC. The median patient age was 69 years (range, 25-101 years). Ninety-two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB-eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB-eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%).

CONCLUSIONS

Combining SLNB and MMS-IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS-IHC.

Treatment of Cutaneous Melanoma of the Head and Neck With Wide Local Excision Versus Mohs

OBJECTIVES

Determine if Mohs micrographic surgery (MMS) is associated with improved overall survival compared to wide local excision (WLE) when treating cutaneous melanoma of the head and neck (CMHN) and to report the proportion of patients treated with MMS versus WLE who also underwent sentinel lymph node biopsy (SLNB).

METHODS

Retrospective cohort study of the National Cancer Database (NCDB) analyzing the overall survival of patients diagnosed with T1 to T4 CMHN between 2004 and 2016 who were treated with either WLE or MMS.

RESULTS

On multivariable analysis, treatment with WLE versus MMS was not significantly associated with overall survival (HR, 1.094; 95% CI, 0.997-1.201). On multivariable analysis, lower Charlson-Deyo score (HR, 0.489; 95% CI, 0.427-0.560), negative margins (HR, 0.754; 95% CI, 0.705-0.807), and N0 classification (HR 0.698; 95% CI, 0.668-0.730) were associated with improved overall survival. Seventy-seven percent of patients treated with MMS did not undergo SLNB, while 45% of patients treated with WLE did not undergo SLNB (P < .001).

CONCLUSIONS

No difference in overall survival between MMS and WLE when treating CMHN. Patients treated with MMS were significantly less likely to undergo SLNB, suggesting an opportunity for enhancement of multidisciplinary care.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.