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Burger ML, Haggerty JM, Wang S, Oxenberg JC. Deep Margins Melanoma: How Deep Is Deep Enough? Am Surg 2023; 89:5297-5303. [PMID: 36530056 DOI: 10.1177/00031348221146933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Wide excision (WE) to muscular fascia for invasive melanoma is common practice but excision to subcutaneous tissue may be adequate. We evaluated practice patterns regarding depth of biopsy and excision as well as risks for recurrence. METHODS Retrospective review of patients with pT1-4 melanoma (cN0) treated with WE at a single institution was performed. Patient factors were evaluated. Biopsy and excision techniques were compared to pathology and reviewed for recurrence. RESULTS 385 patients from 2006 to 2020 were included. Lesions were on the extremity (n = 189), head/neck (n = 48), trunk (n = 148). Biopsy techniques included shave (n = 330), excisional (n = 36), punch (n = 10), incisional (n = 9). Deep biopsy margins were positive for IM/melanoma in situ in 139 patients. WE specimens were taken to muscular fascia (n = 218) or mid/deep fat (n = 144). 51 patients had recurrent disease or a new primary lesion: locoregional (n = 31), distant (3), or new lesions (n = 17). DISCUSSION Patient characteristics associated with recurrence include older age and female gender. Tumor characteristics associated with recurrence include lesions located on the trunk, superficial spreading melanoma, ulceration, perineural invasion, and clinical T and P stage. Patients that recurred were more likely to have WE taken to or including muscular fascia. Biopsy type, deep margin on biopsy, and depth of dissection was not associated with recurrence.
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Affiliation(s)
- Megan L Burger
- Department of Surgical Oncology, Geisinger Wyoming Valley, Wilkes Barre, PA, USA
| | - James M Haggerty
- Department of Surgical Oncology, Geisinger Wyoming Valley, Wilkes Barre, PA, USA
| | - Shengxuan Wang
- Department of Surgical Oncology, Geisinger Wyoming Valley, Wilkes Barre, PA, USA
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Burgess NR, Rathore D, Gao A, Johnson A, Ahluwalia HS. To Evaluate the Efficacy of Diagnostic Periocular Punch Biopsy: Using a 4-mm Dermatology Punch. Ophthalmic Plast Reconstr Surg 2023; 39:370-373. [PMID: 36727925 DOI: 10.1097/iop.0000000000002324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE The dermatological punch biopsy is a minimally invasive procedure that provides conclusive diagnosis when managing periocular lesions. It aids with establishing histological diagnosis and subtype thereby facilitating management planning and eliminates the risk of unnecessary tissue sacrifice. The present literature provides limited evidence evaluating the value of punch biopsy in diagnosing periocular lesions. METHODS A retrospective case note analysis of 400 consecutive 4-mm periocular punch biopsies performed between 2005 and 2016, from 353 patients was undertaken at a single institution. Three hundred fifty-nine lesions had an initial definite clinical diagnosis of malignancy (group A) and the remaining 41 lesions had an uncertain clinical diagnosis with enough suspicion to merit a biopsy (group B). RESULTS In group A, 75.5% (n = 271) of the biopsies verified the clinical diagnosis of malignancy and 24.5% (n = 88) were benign. In group B, 70.7% (n = 29) of the lesions were benign and 29.3% (n = 12) were malignant and were subsequently treated as group A. Only 4, group A biopsies, which underwent formal excision, did not initially diagnose a malignancy (punch biopsy was repeated) providing a sensitivity of 98.6% and a specificity of 100%. One hundred seventeen were found to be benign avoiding unnecessary tissue sacrifice in 29.25% of cases. CONCLUSION Our study provides the largest sample size in the literature that evaluates a 4-mm diagnostic periocular punch biopsy in managing eyelid lesions. In 29.5% of punch biopsies, unnecessary tissue sacrifice was avoided as they were histologically benign. The authors found that punch biopsies for lesions <7 mm carry a risk of inadvertent excision of lesion.
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Affiliation(s)
- Nada R Burgess
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, United Kingdom
| | - Deepa Rathore
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, United Kingdom
| | - Anna Gao
- Department of Ophthalmology, South Warwickshire NHS Trust, Warwick, West Midlands, United Kingdom
| | - Andria Johnson
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, United Kingdom
| | - Harpreet S Ahluwalia
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, United Kingdom
- Aston Medical School, Aston University, Birmingham, West Midlands, United Kingdom
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Gazivoda VP, Koshenkov VP, Kangas-Dick AW, Greenbaum A, Davis C, Smith FO, Hilden PD, Berger AC. Factors Associated With Upstaging of Melanoma Thickness on Final Excision. J Surg Res 2023; 289:253-260. [PMID: 37150080 DOI: 10.1016/j.jss.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 02/19/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION The incidence and risk factors associated with upstaging from initial biopsy to definitive excision in cutaneous melanoma have not been established. The aim of this study was to determine the incidence of tumor stage upstaging and associated risk factors using the National Cancer Database. METHODS A retrospective study of the National Cancer Database between 2012 and 2016 was performed. The cohort of patients undergoing excision of melanoma with available data comprised 133,592 patients. Differences in characteristics for upstaging were determined using Wilcox rank-sum, chi-square, or Fisher's exact tests. Multivariable analysis was performed using logistic regression to determine factors associated with upstaging. RESULTS Incidence of upstaging was 5.2%. Upstaged patients were older, male, of non-White race, and of lower education level (P < 0.001). Lesions of the head/neck and lower extremity had increased incidence of upstaging compared to the trunk (P < 0.001). Nodular and acral lentiginous melanoma was associated with higher incidence of upstaging compared to superficial spreading melanoma (P < 0.001). Patients with lymphovascular invasion had increased risk of upstaging (P < 0.001). CONCLUSIONS Upstaging of melanoma is infrequent but is significantly more prevalent in non-White patients and those with lower educational status. Provider and patient education should include the higher risk of upstaging in these groups and the possible need for further surgical intervention, such as re-excision of margins and sentinel lymph node biopsy.
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Affiliation(s)
- Victor P Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Vadim P Koshenkov
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Aaron W Kangas-Dick
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Alissa Greenbaum
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Catherine Davis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Franz O Smith
- Division of Surgical Oncology, RWJ Barnabas Health, Livingston, New Jersey
| | - Patrick D Hilden
- Department of Biostatistics, RWJ Barnabas Health, Livingston, New Jersey
| | - Adam C Berger
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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4
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Ramiscal JAB, Stern SL, Wilson AK, Lorimer PD, Lee NA, Goldfarb MR, Foshag LJ, Fischer TD. Does Residual Invasive Disease in Wide Local Excision after Diagnosis with Partial Biopsy Technique Influence Survival in Melanoma? Matched-Pair Analysis of Multicenter Selective Lymphadenectomy Trial I and II. J Am Coll Surg 2022; 235:49-59. [PMID: 35703962 DOI: 10.1097/xcs.0000000000000263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current guidelines recommend excisional/complete biopsy for melanoma diagnosis, owing to high rates of residual disease found at wide local excision (WLE) after partial biopsy techniques. We sought to determine any survival disadvantage associated with the presence of residual invasive melanoma in the WLE after diagnosis with a partial biopsy technique. STUDY DESIGN Data were examined from Multicenter Selective Lymphadenectomy Trials I and II (MSLT-I and -II), 2 large melanoma trials. Patients diagnosed with excisional/complete biopsy were excluded. Clinicopathologic characteristics, melanoma-specific survival (MSS), distant disease-free survival (DDFS), and disease-free survival (DFS) of those with residual invasive melanoma in the definitive WLE and those with no residual melanoma were compared. Matched pairing was used to reduce variability between groups. RESULTS From 1994 through 2014, 3,939 patients were enrolled in these trials and 874 (22%) were diagnosed using partial biopsy techniques. Of these, 399 (46%) had residual tumor in the WLE. Only 6 patients had residual tumor in their WLE resulting in T-upstaging of their tumor. Match-pairing formed two cohorts (1:1) of patients with and without residual invasive tumor after WLE. A total of 514 patients were paired; 288 (56%) males, 148 (28.8%) aged 60 or older, 192 (37.4%) with truncal melanomas, 214 (41.6%) had Breslow thickness 2 mm or greater, and 376 (73.2%) had positive sentinel nodes. Kaplan-Meier analysis showed no statistical difference in 10-year MSS (73.6% ± 3.3% vs 73.9% ± 3.7%, p = 0.891), DDFS (68.7% ± 3.4% vs 65.3% ± 4.0%, p = 0.548), or DFS (59.6% ± 3.7% vs 59.4% ± 3.9%, p = 0.783). CONCLUSIONS Survival in patients with primary melanoma does not appear to be worse in patients who undergo a partial biopsy technique and are later found to have residual invasive tumor in the WLE specimen.
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Affiliation(s)
- Judi Anne B Ramiscal
- From Saint John's Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA
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5
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Liszewski W, Stewart JR, Vidal NY, Demer AM. Incisional Biopsy Technique Is Associated With Decreased Overall Survival for Cutaneous Melanoma. Dermatol Surg 2022; 48:486-491. [PMID: 35298451 DOI: 10.1097/dss.0000000000003430] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Previous studies examining melanoma biopsy technique have not demonstrated an effect on overall survival. OBJECTIVE To examine overall survival of patients with cutaneous melanoma diagnosed by shave, punch, incisional, or excisional techniques from the National Cancer Database (NCDB). MATERIALS AND METHODS Melanoma data from the 2004 to 2016 NCDB data set were analyzed. A Cox proportional hazards model was constructed to assess the risk of 5-year all-cause mortality. RESULTS In total, 42,272 cases of melanoma were reviewed, with 27,899 (66%) diagnosed by shave biopsy, 8,823 (20.9%) by punch biopsy, and 5,550 (13.1%) by incisional biopsy. Both the univariate and multivariate analyses demonstrated that tumors diagnosed by incisional biopsy had significantly (p = .001) lower overall 5-year survival compared with shave techniques (hazard ratio [HR] = 1.140, 95% confidence interval [CI] 1.055 to 1.231). We found no difference (p = .109) between shave and punch biopsy techniques (HR 1.062, 95% CI 0.987-1.142) or between punch and incisional techniques (HR 1.074, 95% CI 0.979-1.177, p = .131). CONCLUSION Incisional biopsies were associated with decreased overall 5-year survival in the NCDB. No difference was observed between shave and punch biopsy techniques. These findings support current melanoma management guidelines.
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Affiliation(s)
- Walter Liszewski
- Department of Dermatology, Northwestern University, Chicago, Illinois
- Department of Preventative Medicine, Division of Cancer Epidemiology and Prevention, Northwestern University, Chicago, Illinois
| | - Jacob R Stewart
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Nahid Y Vidal
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Addison M Demer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
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6
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Duncan JR, Beal LL, Daugherty A, Elston C, Contreras C, Phillips CB, Huang C. Management of Transected Invasive Melanoma: A Single Institution Retrospective Review. Dermatol Surg 2022; 48:47-50. [PMID: 34743122 DOI: 10.1097/dss.0000000000003283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Deep transection of invasive melanoma precludes accurate measurement of Breslow depth, which may affect tumor staging. OBJECTIVE To determine the frequency of upstaging of transected invasive melanomas after excision, characterize the impact on National Comprehensive Cancer Network (NCNN)-recommended treatment, and determine predictors of subsequent upstaging. MATERIALS AND METHODS A retrospective review of invasive melanomas between January 2017 and December 2019 at a single institution. Deeply transected biopsy reports were compared with subsequent excisions to calculate the frequency of upstaging. RESULTS Three hundred sixty (49.6%) of 726 invasive melanomas identified were transected. Forty-nine (13.6%) transected tumors had upstaging that would have altered NCCN-recommended management. "Broadly" transected tumors had upstaging that would have resulted in a change in the management in 5/23 cases (21.7%) versus 2/41 cases (4.9%) for "focally" transected tumors (p = .038). Breslow depth increased by 0.59 mm on average for "broad" transection versus 0.06 mm for "focal" transection (p =< .01). Of the 89 transected pT1a melanomas, specimens with gross residual tumor or pigment after biopsy were upstaged in 8/17 (47.1%) of cases versus 5/72 (6.9%) of specimens without (p =< .01). CONCLUSION Upstaging of deeply transected invasive melanomas that would alter NCCN-recommended management occurred in 13.6% of cases. Broad transection and gross residual tumor or pigment after biopsy predicted higher likelihood of upstaging.
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Affiliation(s)
- James Robert Duncan
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | - Lauren L Beal
- McGovern Medical School at University of Texas Health, School of Medicine, Houston, Texas
| | - Andrew Daugherty
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | - Carly Elston
- Department of Surgical Oncology, The Ohio State University, James Comprehensive Cancer Center, Columbus, Ohio
| | - Carlo Contreras
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | | | - Conway Huang
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
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7
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Rates of Upstaging, Between Diagnosis and Surgery, and Clinical Management of Metastatic Cutaneous Squamous Cell Carcinoma: A Case-Control Study. Dermatol Surg 2022; 48:12-16. [PMID: 34904573 DOI: 10.1097/dss.0000000000003224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cutaneous squamous cell carcinomas (cSCC) have upstage rates of approximately 10.3% to 11.1%. Data are currently limited on the rate of upstaging for metastatic cSCC. OBJECTIVE The aim of this study was to determine the rates of upstaging, between diagnosis and surgery, and differences in management for metastatic and non-metastatic high-risk cSCC. MATERIALS AND METHODS This was a retrospective, case-control, single institution, multi-center study. Univariate analysis was used. RESULTS Sixty-eight subjects (34 metastatic & 34 non-metastatic) with 69 tumors were included. The overall rate of upstaging was 46.4%. The most common reasons for upstage were undocumented tumor size and under-diagnosis of poor differentiation. There were no differences in rates of upstaging. Preoperative imaging was performed in 43.6% of wide local excisions (WLE) versus 3.3% of Mohs micrographic surgery (MMS; p < .001). The median days from surgery to sentinel lymph node biopsy (SLNB), or nodal dissection was shorter for WLE versus MMS (0 vs 221 days, p < .001). CONCLUSION Improved clinical documentation, including documenting tumor size, and the identification of pathologic risk factors, including poor differentiation and depth of invasion, are needed for proper staging. Preoperative imaging and discussion of SLNB may be beneficial for high-risk T2b and T3 tumors.
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8
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Müller CSL. [Pitfalls in dermatohistology : Stumbling blocks and problems in routine dermatopathology]. Hautarzt 2021; 73:138-145. [PMID: 34939128 DOI: 10.1007/s00105-021-04927-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Excisions and biopsies are firmly anchored in everyday dermatology. The biopsy, excision or diagnostic-therapeutic confirmation of the clinical diagnosis of neoplasms or inflammatory diseases is decisive for the dermatopathological diagnosis of tissue samples. Dermatopathology, however, is not a magic box into which a tissue sample can be placed without comment or information and receive-within 24 h at the latest-a complete, high-quality diagnosis. The present article describes problems, hurdles, and challenges in everyday dermatopathology that occur on the way to the microscope, even before the actual dermatopathological diagnosis takes place.
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Affiliation(s)
- Cornelia S L Müller
- MVZ für Histologie, Zytologie und molekulare Diagnostik Trier GmbH, Wissenschaftspark Trier, Max-Planck-Str. 5 und 17, 54296, Trier, Deutschland.
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9
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Kok Y, Scott K, Pham A, Liu W, Roberts H, Pan Y, McLean C, Chamberlain A, Kelly JW, Mar VJ. The impact of incomplete clinical information and initial biopsy technique on the histopathological diagnosis of cutaneous melanoma. Australas J Dermatol 2021; 62:e524-e531. [PMID: 34426977 DOI: 10.1111/ajd.13697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/11/2021] [Accepted: 07/27/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND/OBJECTIVES Increased rates of histopathological misdiagnosis of melanoma have been associated with incisional punch more so than shave biopsy when compared with complete excisional biopsy. It is unknown how the increasing utilisation of shave biopsy may impact melanoma diagnosis. The extent to which the provision of clinical information to the pathologist may improve diagnostic accuracy remains unclear. This study assessed the impact of both initial biopsy technique and provision of adequate clinical information to pathologists on the accuracy of histopathological diagnosis of melanoma and disease progression. METHODS We conducted a retrospective cohort with nested case-control study of all histopathological false-negative and false-positive melanoma diagnoses from January 2014 to May 2019 from the Victorian Melanoma Service electronic database. Cases were assessed for the initial biopsy type, provision of clinical information on pathology request forms and disease progression associated with false-negative diagnosis. RESULTS Partial shave biopsy had higher odds of false-negative (OR 5.19, 95% CI 2.89-9.32; P < 0.001) and false-positive diagnoses (OR 1.95, 95% CI 1.45-2.63; P < 0.001) of melanoma when compared with elliptical excisional biopsy. These odds ratios were comparable with those found with incisional punch biopsy. Providing the suspected clinical diagnosis to pathologists also reduced the odds of false-negative diagnosis with melanoma progression by 3.8-fold (P = 0.02). CONCLUSION The choice of initial biopsy technique and providing the suspected clinical diagnosis to pathologists are important for correct histopathological diagnosis of cutaneous melanoma and prevention of further disease progression.
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Affiliation(s)
- Yonatan Kok
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - Karen Scott
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - Alan Pham
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Department of Anatomical Pathology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Wenyuan Liu
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - Hugh Roberts
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Skin Health Institute, Melbourne, VIC, Australia
| | - Yan Pan
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Catriona McLean
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Department of Anatomical Pathology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Alex Chamberlain
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - John W Kelly
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Victoria J Mar
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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10
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Ahmadi O, Das M, Hajarizadeh B, Mathy JA. Impact of Shave Biopsy on Diagnosis and Management of Cutaneous Melanoma: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 28:6168-6176. [PMID: 33782802 PMCID: PMC8006869 DOI: 10.1245/s10434-021-09866-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Melanoma is the most lethal skin cancer. Excision biopsy is generally recommended for clinically suspicious pigmented lesions; however, a proportion of cutaneous melanomas are diagnosed by shave biopsy. A systematic review was undertaken to investigate the impact of shave biopsy on tumor staging, treatment recommendations, and prognosis. METHODOLOGY The MEDLINE, Embase, and Cochrane Library databases were searched for relevant articles. Data on deep margin status on shave biopsy, tumor upstaging, and additional treatments on wide local excision (WLE), disease recurrence, and survival effect were analyzed across studies. RESULTS Fourteen articles from 2010 to 2020 were included. In total, 3713 patients had melanoma diagnosed on shave biopsy. Meta-analysis revealed a positive deep margin in 42.9% of shave biopsies. Following WLE, change in tumor stage was reported in 7.7% of patients. Additional treatment was recommended for 2.3% of patients in the form of either further WLE and/or sentinel lymph node biopsy. There was high heterogeneity across studies in all outcomes. Four studies reported survival, while no studies found any significant difference in disease-free or overall survival between shave biopsy and other biopsy modalities. CONCLUSIONS Just over 40% of melanomas diagnosed on shave biopsy report a positive deep margin; however, this translated into a change in tumor stage or treatment recommendations in relatively few patients (7.7% and 2.3%, respectively), with no impact on local recurrence or survival among the studies analyzed.
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Affiliation(s)
- Omid Ahmadi
- Department of Otolaryngology and Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Moushumi Das
- Auckland Regional Plastic, Reconstructive and Hand Surgery Unit, Middlemore Hospital, Auckland, New Zealand
| | - Behzad Hajarizadeh
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jon A Mathy
- Auckland Regional Plastic, Reconstructive and Hand Surgery Unit, Middlemore Hospital, Auckland, New Zealand. .,Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand.
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11
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Greiff L, Skogvall-Svensson I, Carneiro A, Hafström A. Non-radical primary diagnostic biopsies affect survival in cutaneous head and neck melanoma. Acta Otolaryngol 2021; 141:309-319. [PMID: 33586575 DOI: 10.1080/00016489.2020.1851395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is unclear if a non-radical diagnostic biopsy entails a higher risk for metastasis and poorer survival for patients with cutaneous head and neck melanoma (cHNM). AIMS/OBJECTIVES To assess whether or not initial diagnostic biopsy modality and radicality (clear, positive, or narrow histopathological margins) influence recurrence and survival in patients with cHNM. MATERIALS AND METHODS Histopathological radicality of initial diagnostic biopsies and outcome for 368 consecutive cHNM patients, clinically asymptomatic of metastatic disease and referred to a tertiary care academic center for sentinel lymph node staging from 2004 through 2018, were retrospectively analyzed. RESULTS Patients with positive (n = 133) or narrow (0.1-0.5 mm) (n = 34) histopathological margins had significantly worse loco-regional (p=.004) and distant control (p=.004) as well as lower overall (p=.017) and melanoma specific (p=.0002) survival than 201 patients with clear margins. Multivariate analysis indicated positive or narrow histopathological margins as independent negative prognostic factors for melanoma specific survival (HR 2.16, p=.015), together with deeper Breslow (HR 1.17, p=.00001) and ulceration (HR 2.49, p=.003). CONCLUSIONS AND SIGNIFICANCE Non-radical primary diagnostic biopsies increase the risk for metastatic disease and impair survival in cHNM. Accordingly, radical melanoma diagnostic procedures should be encouraged in the head and neck region when possible.
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Affiliation(s)
- Lennart Greiff
- Department of ORL, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ingela Skogvall-Svensson
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - Ana Carneiro
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Anna Hafström
- Department of ORL, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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12
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de Menezes SL, Wolfe R, Kelly JW, Farrugia H, Mar VJ. Think before you shave: Factors influencing choice of biopsy technique for invasive melanoma and effect on definitive management. Australas J Dermatol 2020; 61:134-139. [PMID: 31869446 DOI: 10.1111/ajd.13227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE Partial biopsies are sometimes used for melanoma diagnosis with anticipated time and cost savings compared to excisional biopsy. However, their impact on subsequent melanoma management is unknown. Determine factors related to choice of partial over excisional biopsy to diagnose invasive melanoma and examine the effect of partial biopsies on definitive melanoma management. METHOD Retrospective repeated cross-sectional population-based study through the Victorian Cancer Registry of diagnosed melanomas in 2005, 2010 and 2015. A random sample of 400 patients per year, stratified by tumour thickness, was selected. RESULTS A total of 1200 patients had 833 excisional and 337 partial biopsies. Omission of suspected diagnosis on pathology requests affected 46% (532/1151) of all diagnostic biopsies. Diagnostic suspicion did not influence preference for partial over excisional biopsy [Odds Ratio (OR) 1.2, 95%CI 0.8-1.7; P = 0.40]. The partial:excisional biopsy usage ratio was higher in patients aged > 50 years than patients aged <50 years [relative risk ratios (RRR) 1.5; 95%CI 1.0 to 2.2; P = 0.03]. In 34% and 17% of tumours diagnosed with punch and shave, respectively, three procedures were required for definitive excision instead of two, compared with 5% of excisional biopsies When partial biopsy was used, patients were at greater risk of requiring three-staged excisions when controlled for age, anatomical site, melanoma subtype and thickness (RRR 6.7; 95%CI 4.4-10.1; P < 0.001). CONCLUSION Diagnostic suspicion does not appear to be a major factor influencing choice of biopsy technique. Using partial biopsy to diagnose melanoma often leads to an extra procedure for definitive treatment compared with excisional biopsy.
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Affiliation(s)
- Sara Lee de Menezes
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John William Kelly
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Farrugia
- Victorian Cancer Registry, Cancer Council Australia, Melbourne, Australia
| | - Victoria Jane Mar
- Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Skin Health Institute, Melbourne, Australia
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13
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Allard-Coutu A, Heller B, Francescutti V. Surgical Management of Lymph Nodes in Melanoma. Surg Clin North Am 2019; 100:71-90. [PMID: 31753117 DOI: 10.1016/j.suc.2019.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.
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Affiliation(s)
- Alexandra Allard-Coutu
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada
| | - Barbara Heller
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada
| | - Valerie Francescutti
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada.
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14
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Hornberger J, Siegel DM. Economic Analysis of a Noninvasive Molecular Pathologic Assay for Pigmented Skin Lesions. JAMA Dermatol 2019; 154:1025-1031. [PMID: 29998292 DOI: 10.1001/jamadermatol.2018.1764] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A recently described noninvasive gene expression test (the pigmented lesion assay [PLA]) with adhesive patch-based sampling has the potential to rule out melanoma and the need for surgical biopsy of pigmented lesions suggestive of melanoma with a negative predictive value of 99% compared with 83% for the histopathologic standard of care. The cost implications of using this molecular test vs visual assessment followed by biopsy and histopathologic assessment (VAH) have not been evaluated. Objective To determine potential cost savings of PLA use vs the VAH pathway. Design, Setting, and Participants This health economic analysis performed from a US payer perspective was based on consensus treatment guidelines and fee schedules from the Centers for Medicare & Medicaid Services. Data for model input were derived from routine use of the test in US dermatology practices and literature. Participants included patients with primary cutaneous pigmented lesions suggestive of melanoma. Data were analyzed from February 8 to December 1, 2017. Main Outcomes and Measures The primary analysis consisted of the relative reduction in costs of diagnostic surgical procedures for PLA vs VAH management. Additional analyses included stage-related treatment costs associated with delays in diagnosis. Results In the cost analysis for this economic model, the relative reduction in surgical procedure costs (biopsy and subsequent excision), assuming $0 for the PLA to facilitate multiple comparison scenarios, was -$395 compared with VAH. The relative reduction in stage-related treatment costs associated with the PLA was -$433 compared with VAH, primarily associated with avoidance of delays due to false-negative diagnoses. Surveillance costs were reduced by -$119 with the PLA. The total cost of fully adjudicating a lesion suggestive of melanoma by VAH was $947. At a mean selling price reference point for PLA of $500, cost savings of $447 (47%) per lesion tested could be realized. Conclusions and Relevance The results of this analysis suggest that the PLA reduces cost and may improve the care of patients with primary pigmented skin lesions suggestive of melanoma.
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Affiliation(s)
- John Hornberger
- Department of Internal Medicine, Stanford University, Stanford, California.,Cedar Associates, Menlo Park, California
| | - Daniel M Siegel
- Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn.,Department of Dermatology, Brooklyn Veterans Administration Medical Center, Brooklyn, New York
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15
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Moscarella E, Pampena R, Palmiotti G, Bonamonte D, Brancaccio G, Piccolo V, Longo C, Argenziano G. A meta-analysis on the influence of partial biopsy of primary melanoma on disease recurrence and patient survival. J Eur Acad Dermatol Venereol 2019; 34:279-284. [PMID: 31441557 DOI: 10.1111/jdv.15903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Complete surgical excision is the preferred biopsy type for suspicious melanocytic lesions. However, partial biopsy is sometimes used in special situations. Previous studies have explored the effect of partial biopsy of a primary melanoma on patient outcome with controversial results. OBJECTIVE We performed a meta-analysis on the influence of the type of biopsy of a primary melanoma on recurrence-free survival (RFS) and melanoma-related survival (MRS). METHODS Clinical trials, observational cohort studies and case-control studies reporting absolute number of recurrences and/or melanoma-related deaths in patients undergoing a partial or excisional biopsy of melanoma were included in the meta-analysis. RESULTS In all, the five included studies reported 3249 patients, 1121 (34.5%) of them in the partial biopsy group and 2128 (65.5%) in the excisional biopsy group. Despite a trend in favour of excisional biopsy in reducing the risk for recurrences, the forest plot related to RFS failed to demonstrate significant differences among groups (RR: 1.27; 95% CI 0.97-1.67; P: 0.09; random effects; I2 : 55%). The forest plot showed no difference in the risk of dying for melanoma-related causes for patients undergoing partial biopsy vs. excisions biopsy (RR: 1.50; 95% CI 0.98-2.30; P: 0.06; random effects; I2 : 60%). LIMITATIONS The majority of the studies were retrospective, and follow-up time was not uniform among studies and not always reported. CONCLUSION In conclusion, a partial biopsy can be performed in special situations, such as large primary tumours located in surgically sensitive areas, without altering MRS and RFS.
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Affiliation(s)
- E Moscarella
- Dermatology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - R Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - G Palmiotti
- Dermatology Unit, Medical University of Bari, Bari, Italy
| | - D Bonamonte
- Dermatology Unit, Medical University of Bari, Bari, Italy
| | - G Brancaccio
- Dermatology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - V Piccolo
- Dermatology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - C Longo
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - G Argenziano
- Dermatology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
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16
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Rtshiladze MA, Stretch JR, Scolyer RA, Guitera P. Diagnosing melanoma: the method matters. Med J Aust 2019; 211:209-210. [DOI: 10.5694/mja2.50307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jonathan R Stretch
- Melanoma Institute Australia Sydney NSW
- Sydney Medical SchoolUniversity of Sydney Sydney NSW
| | - Richard A Scolyer
- Melanoma Institute Australia Sydney NSW
- Sydney Medical SchoolUniversity of Sydney Sydney NSW
- Royal Prince Alfred Hospital Sydney NSW
| | - Pascale Guitera
- Melanoma Institute Australia Sydney NSW
- Sydney Medical SchoolUniversity of Sydney Sydney NSW
- Royal Prince Alfred Hospital Sydney NSW
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17
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Menezes SL, Kelly JW, Wolfe R, Farrugia H, Mar VJ. The increasing use of shave biopsy for diagnosing invasive melanoma in Australia. Med J Aust 2019; 211:213-218. [DOI: 10.5694/mja2.50289] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/22/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Sara L Menezes
- Victorian Melanoma ServiceAlfred Hospital Melbourne VIC
- Monash University Central Clinical School Melbourne VIC
| | - John W Kelly
- Victorian Melanoma ServiceAlfred Hospital Melbourne VIC
- Monash University Central Clinical School Melbourne VIC
| | - Rory Wolfe
- Monash University Central Clinical School Melbourne VIC
| | - Helen Farrugia
- Victorian Cancer RegistryCancer Council Victoria Melbourne VIC
| | - Victoria J Mar
- Victorian Melanoma ServiceAlfred Hospital Melbourne VIC
- Skin and Cancer Foundation Melbourne VIC
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18
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Weitman ES, Perez MC, Lee D, Kim Y, Fulp W, Sondak VK, Sarnaik AA, Gonzalez RJ, Cruse CW, Messina JL, Zager JS. Re-biopsy of partially sampled thin melanoma impacts sentinel lymph node sampling as well as surgical margins. Melanoma Manag 2019; 6:MMT17. [PMID: 31406562 PMCID: PMC6688556 DOI: 10.2217/mmt-2018-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/28/2019] [Indexed: 11/26/2022] Open
Abstract
AIM To assess the impact of re-biopsy on partially sampled melanoma in situ (MIS), atypical melanocytic proliferation (AMP) and thin invasive melanoma. MATERIALS & METHODS We retrospectively identified cases of re-biopsied partially sampled neoplasms initially diagnosed as melanoma in situ, AMP or thin melanoma (Breslow depth ≤0.75 mm). RESULTS & CONCLUSION Re-biopsy led to sentinel lymph node biopsy (SLNB) in 18.3% of cases. No patients upstaged from AMP or MIS had a positive SLNB. One out of nine (11.1%) initially diagnosed as a thin melanoma ≤0.75 mm, upstaged with a re-biopsy, had a positive SLNB. After re-biopsy 8.5% underwent an increased surgical margin. Selective re-biopsy of partially sampled melanoma with gross residual disease can increase the accuracy of microstaging and optimize treatment regarding surgical margins and SLNB.
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Affiliation(s)
- Evan S Weitman
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Matthew C Perez
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Daniel Lee
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Youngchul Kim
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - William Fulp
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Vernon K Sondak
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Amod A Sarnaik
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Ricardo J Gonzalez
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Carl W Cruse
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Jane L Messina
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
| | - Jonathan S Zager
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, FL 33602, USA
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19
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Klapperich ME, Bowen GM, Grossman D. Current controversies in early-stage melanoma: Questions on management and surveillance. J Am Acad Dermatol 2019; 80:15-25. [PMID: 30553299 DOI: 10.1016/j.jaad.2018.03.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/12/2018] [Accepted: 03/18/2018] [Indexed: 12/24/2022]
Abstract
There are a number of controversies and uncertainties relating to the management and surveillance of patients with early-stage, localized (ie, stage 0, I, and II) cutaneous melanoma. While tumor stage is a critical predictor of clinical outcome and guides treatment, accurate determination of stage may be affected by the biopsy technique used and the method of sectioning before histologic review. A new molecular prognostic test is available but has not been formally incorporated into staging or treatment guidelines. There are no randomized controlled clinical trials to support guidelines for surveillance following the treatment of early-stage melanoma. In the second article in this continuing medical education series, we review the controversies and uncertainties relating to these issues. The questions we address are controversial because they speak to clinical scenarios for which there are no evidence-based guidelines or randomized clinical trials with the consequence of considerable variability in clinical practice. Our goal is to provide the clinician with up-to-date contextual knowledge to appreciate the multiple sides of each controversy and to suggest pathways to resolution.
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Affiliation(s)
- Marki E Klapperich
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Glen M Bowen
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Douglas Grossman
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah.
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20
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King BBT, Chapman BC, Gleisner A, Stewart C, Friedman C, Kwak JJ, McCarter MD, Kounalakis N. Postbiopsy Pigmentation is Prognostic in Head and Neck Melanoma. Ann Surg Oncol 2019; 26:1046-1054. [PMID: 30706226 DOI: 10.1245/s10434-019-07185-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess postbiopsy pigmentation (PBP) as a prognostic feature in patients with cutaneous head and neck (H&N) melanoma. METHODS Retrospective review of patients undergoing sentinel lymph node biopsy (SLNB) for H&N melanoma (1998-2018). PBP was defined as visible remaining pigment at the scar or biopsy site that was documented on physical exam by both a medical oncologist and a surgeon at initial consultation. Variables associated with disease-free survival (DFS) and overall survival (OS) were analyzed using multivariable Cox proportional hazards models. RESULTS Among 300 patients, 34.3% (n = 103) had PBP and 44.7% (n = 134) had microscopic residual disease on final pathology after wide local excision. Prognostic factors associated with DFS included advanced age, tumor depth, ulceration, PBP, and positive SLNB (p < 0.05). Patients with PBP fared worse than their counterparts without PBP in 5-year DFS [44.1% (31.1-56.3%) vs. 73.0% (64.1-80.0%); p < 0.001] and 5-year OS [65.0% (50.0-76.6%) vs. 83.6% (75.7-89.2%); p = 0.005]. After multivariable adjustment, PBP remained associated with shorter DFS [hazard ratio (HR) 1.72, 95% confidence interval (CI) 1.01-2.93; p = 0.047], but was not prognostic of OS. CONCLUSIONS In patients with H&N melanoma, PBP is associated with significantly shorter DFS. Patients with PBP may warrant greater consideration for SLNB and closer postoperative surveillance.
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Affiliation(s)
- Becky B T King
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brandon C Chapman
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Camille Stewart
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chloe Friedman
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer J Kwak
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin D McCarter
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Kounalakis
- Department of Surgery, Gastrointestinal Tumor and Endocrine Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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21
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Bartlett EK. Current management of regional lymph nodes in patients with melanoma. J Surg Oncol 2018; 119:200-207. [PMID: 30481384 DOI: 10.1002/jso.25316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/11/2018] [Indexed: 01/19/2023]
Abstract
The publication of recent randomized trials has prompted a significant shift in both our understanding and the management of patients with melanoma. Here, the current management of the regional lymph nodes in patients with melanoma is discussed. This review focuses on selection for sentinel lymph node biopsy, management of the positive sentinel node, management of the clinically positive node, and the controversy over the therapeutic value of early nodal intervention.
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Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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22
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Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 2018; 80:208-250. [PMID: 30392755 DOI: 10.1016/j.jaad.2018.08.055] [Citation(s) in RCA: 320] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022]
Abstract
The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.
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Affiliation(s)
- Susan M Swetter
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, Stanford, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
| | - Hensin Tsao
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Wellman Center for Photomedicine, Boston, Massachusetts
| | - Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Clara Curiel-Lewandrowski
- Division of Dermatology, University of Arizona, Tucson, Arizona; University of Arizona Cancer Center, Tucson, Arizona
| | - David E Elder
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; Department of Cancer Biology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pathology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut
| | - Allan C Halpern
- Department of Dermatology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy M Johnson
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Arthur J Sober
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John A Thompson
- Division of Oncology, University of Washington, Seattle, Washington; Seattle Cancer Care Alliance, Seattle, Washington
| | - Oliver J Wisco
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | | | - Shasa Hu
- Department of Dermatology, University of Miami Health System, Miami, Florida
| | - Toyin Lamina
- American Academy of Dermatology, Rosemont, Illinois
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23
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Stiegel E, Vij A. Reply to: "Comment on 'Prognostic value of sentinel lymph node biopsy according to Breslow thickness for cutaneous melanoma'". J Am Acad Dermatol 2018; 79:e55-e56. [PMID: 29787839 DOI: 10.1016/j.jaad.2018.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Evan Stiegel
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Alok Vij
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
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24
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Herbert G, Karakousis GC, Bartlett EK, Zaheer S, Graham D, Czerniecki BJ, Fraker DL, Ariyan C, Coit DG, Brady MS. Transected thin melanoma: Implications for sentinel lymph node staging. J Surg Oncol 2017; 117:567-571. [PMID: 29194673 DOI: 10.1002/jso.24930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/30/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Indications for sentinel lymph node (SLN) biopsy in patients with thin melanoma (≤1 mm thick) are controversial. We asked whether deep margin (DM) positivity at initial biopsy of thin melanoma is associated with SLN positivity. METHODS Cases were identified using prospectively maintained databases at two melanoma centers. Patients who had undergone SLN biopsy for melanoma ≤1 mm were included. DM status was assessed for association with SLN metastasis in univariate and multivariate analyses. RESULTS 1413 cases were identified, but only 1129 with known DM status were included. 39% of patients had a positive DM on original biopsy. DM-positive and DM-negative patients did not differ significantly in primary thickness, ulceration, or mitotic activity. DM-positive and DM-negative patients had similar incidence of SLN metastasis (5.7% vs 3.5%; P = 0.07). Positive DM was not associated with SLN metastasis on univariate analysis (OR 1.69, 95% CI: 0.95-3.00, P = 0.07) or on multivariate analysis adjusted for Breslow depth, Clark level, mitotic rate, and ulceration (OR = 1.59, 95% CI: 0.89-2.85; P = 0.12). CONCLUSIONS For patients with thin melanoma, a positive DM on initial biopsy is not associated with risk of SLN metastasis, so DM positivity should not be considered an indication for SLN staging in an otherwise low-risk patient.
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Affiliation(s)
- Garth Herbert
- Department of Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | | | - Edmund K Bartlett
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Salman Zaheer
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danielle Graham
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian J Czerniecki
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charlotte Ariyan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel G Coit
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mary S Brady
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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25
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Namin AW, Zitsch RP. Impact of Biopsy Modality on the Management of Cutaneous Melanoma of the Head and Neck. Otolaryngol Head Neck Surg 2017; 158:473-478. [DOI: 10.1177/0194599817740568] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective The purpose of this study was to examine how biopsy modality affects the treatment course and outcomes of patients with cutaneous melanoma of the head and neck. Specifically, we investigated if partial biopsy techniques are associated with positive margins on definitive wide local excision (DWLE), the need for early reoperation to obtain adequate margins or sentinel lymph node biopsy, and survival. Study Design Retrospective case series. Setting Tertiary care academic center. Subjects and Methods Subjects (N = 170) included all patients who were surgically treated for primary cutaneous melanoma of the head and neck at the University of Missouri–Columbia between January 1, 2000, and December 31, 2015. For analysis, patients were divided into 4 groups based on biopsy modality: shave (n = 61), excisional (n = 62), punch (n = 33), and incisional (n = 14). Results The shave biopsy group ( P = .0324) and the punch biopsy group ( P = .0479) were significantly more likely to have positive margins on DWLE. The shave biopsy group ( P = .0042) and the punch biopsy group ( P = .0479) were also significantly more likely to need early reoperation. The mean number of sentinel nodes and incidence of positive sentinel nodes detected on pathologic examination did not differ significantly across biopsy modality ( P = .3600). Overall survival ( P = .4605) and disease-free survival ( P = .5011) did not differ significantly among the groups. Conclusions Patients diagnosed with shave and punch biopsy techniques are significantly more likely to have positive margins after DWLE and more frequently require early reoperation. Biopsy modality does not appear to influence the number of sentinel nodes detected, the incidence of detecting regional metastases in sentinel nodes, the overall survival, or the disease-free survival.
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Affiliation(s)
- Arya W. Namin
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
| | - Robert P. Zitsch
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri, Columbia, Missouri, USA
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26
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Woodcock JL, Eyre ZW, Stoddard GJ, Callis Duffin K, Bowen AR. Clinical and pathologic factors associated with deep transection of biopsies of invasive melanoma. J Am Acad Dermatol 2017; 77:766-768. [DOI: 10.1016/j.jaad.2017.04.1134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 04/23/2017] [Accepted: 04/30/2017] [Indexed: 11/15/2022]
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27
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Detection of High-Risk Histologic Features and Tumor Upstaging of Nonmelanoma Skin Cancers on Debulk Analysis: A Quantitative Systematic Review. Dermatol Surg 2017; 43:1003-1011. [DOI: 10.1097/dss.0000000000001146] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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28
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Etzkorn JR, Sharkey JM, Grunyk JW, Shin TM, Sobanko JF, Miller CJ. Frequency of and risk factors for tumor upstaging after wide local excision of primary cutaneous melanoma. J Am Acad Dermatol 2017; 77:341-348. [DOI: 10.1016/j.jaad.2017.03.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 12/23/2022]
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29
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Risk Factors Predicting Positive Margins at Primary Wide Local Excision of Cutaneous Melanoma. Dermatol Surg 2017; 42:646-52. [PMID: 27082057 DOI: 10.1097/dss.0000000000000702] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A small percentage of patients will have positive histological margins after primary wide local excision (WLE) of cutaneous melanoma (CM). Risk factors that predict marginal involvement at WLE remain unclear. OBJECTIVE To identify risk factors associated with positive margins after WLE of CM. MATERIALS AND METHODS A retrospective review of patients treated at a single institution for CM with sentinel lymph node biopsy from 1997 to 2011 was conducted. RESULTS Positive margins occurred in 6% of patients. Patients with positive margins were older (72.4 vs 60.7, p < .001), had thicker tumors (3.6 vs 1.9 mm, p < .001), and often involved the head and neck region (p < .001). Patients with positive margins at WLE had positive margins on initial biopsy (p = .012) and a higher rate of a melanoma in situ component on initial biopsy (24% vs 11%, p = .02). The 5-year local recurrence rate was significantly different between those with positive and negative margins at WLE (16.0% vs 6.9%; p = .047). CONCLUSION Positive margins after WLE are uncommon. When a patient has multiple risk factors for positive margins at WLE, histologically clear margins should be obtained through mapped serial excision or Mohs micrographic surgery.
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Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins. 2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient. 3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options. 4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature. 5. Discuss the medical therapies available to patients with metastatic melanoma. SUMMARY Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures-ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.
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Affiliation(s)
- Sabrina N Pavri
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - James Clune
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - Stephan Ariyan
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - Deepak Narayan
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
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Higgins HW, Lee KC, Galan A, Leffell DJ. Melanoma in situ: Part II. Histopathology, treatment, and clinical management. J Am Acad Dermatol 2015; 73:193-203; quiz 203-4. [PMID: 26183968 DOI: 10.1016/j.jaad.2015.03.057] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 03/18/2015] [Accepted: 03/31/2015] [Indexed: 11/20/2022]
Abstract
Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.
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Affiliation(s)
- H William Higgins
- Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island.
| | - Kachiu C Lee
- Department of Dermatology, Brown University School of Medicine, Providence, Rhode Island
| | - Anjela Galan
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - David J Leffell
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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Hermes HM, Sahu J, Schwartz LR, Lee JB. Clinical and histologic characteristics of clinically unsuspected melanomas. Clin Dermatol 2014; 32:324-30. [DOI: 10.1016/j.clindermatol.2013.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mills JK, White I, Diggs B, Fortino J, Vetto JT. Effect of biopsy type on outcomes in the treatment of primary cutaneous melanoma. Am J Surg 2013; 205:585-90; discussion 590. [PMID: 23592167 DOI: 10.1016/j.amjsurg.2013.01.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/22/2013] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgical excision remains the primary and only potentially curative treatment for melanoma. Although current guidelines recommend excisional biopsy as the technique of choice for evaluating lesions suspected of being primary melanomas, other biopsy types are commonly used. We sought to determine the impact of biopsy type (excisional, shave, or punch) on outcomes in melanoma. METHODS A prospectively collected, institutional review board-approved database of primary clinically node-negative melanomas (stages cT1-4N0) was reviewed to determine the impact of biopsy type on T-staging accuracy, wide local excision (WLE) area (cm(2)), sentinel lymph node biopsy (SLNB) identification rates and results, tumor recurrence, and patient survival. RESULTS Seven hundred nine patients were diagnosed by punch biopsy (23%), shave biopsy (34%), and excisional biopsy (43%). Shave biopsy results showed significantly more positive deep margins (P < .001). Both shave and punch biopsy results showed more positive peripheral margins (P < .001) and a higher risk of finding residual tumor (with resulting tumor upstaging) in the WLE (P < .001), compared with excisional biopsy. Punch biopsy resulted in a larger mean WLE area compared with shave and excisional biopsies (P = .030), and this result was sustained on multivariate analysis. SLNB accuracy was 98.5% and was not affected by biopsy type. Similarly, biopsy type did not confer survival advantage or impact tumor recurrence; the finding of residual tumor in the WLE impacted survival on univariate but not multivariate analysis. CONCLUSIONS Both shave and punch biopsies demonstrated a significant risk of finding residual tumor in the WLE, with pathologic upstaging of the WLE. Punch biopsy also led to a larger mean WLE area compared with other biopsy types. However, biopsy type did not impact SLNB accuracy or results, tumor recurrence, or disease-specific survival (DSS). Punch and shave biopsies, when used appropriately, should not be discouraged for the diagnosis of melanoma.
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Affiliation(s)
- Jane K Mills
- Department of Surgery, St. Vincent's Hospital, Melbourne, Victoria, Australia
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Current World Literature. Curr Opin Oncol 2013; 25:205-208. [DOI: 10.1097/cco.0b013e32835ec49f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Martires KJ, Nandi T, Honda K, Cooper KD, Bordeaux JS. Prognosis of patients with transected melanomas. Dermatol Surg 2013; 39:605-15. [PMID: 23379583 DOI: 10.1111/dsu.12124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The management of melanoma is directly related to Breslow's depth. Biopsying melanomas in a fashion that transects the deep margin precludes an accurate measurement of the true depth. OBJECTIVE To examine the prognosis of melanomas transected along the deep margins, as well as cases where no residual melanoma was seen on re-excision after transection. METHODS Records from a cohort of patients at one institution were examined from 1996 through 2007. Patients were considered to have "transected" melanomas if tumor cells were present on the deep margin of the biopsy. Overall survival was determined. RESULTS Seven hundred fourteen patients were examined. 171 (24%) of all melanomas were transected. 101(59%) of those lacked tumor cells on re-excision. Patients with transected melanomas were older (OR = 1.03, p < .001), and had higher Breslow's depths (OR = 1.21, p < .001) than those without transected tumors. Those with no residual melanoma after transection were younger (OR = 0.98, p = .010) and more likely to have no lymph node involvement (OR = 2.23, p = .037). Neither transection (p = .760), nor lack of residual melanoma on re-excision after transection (p = .793) influenced survival. CONCLUSION A high number of melanomas are transected at diagnosis, many of which lack visible tumor. The original Breslow's depth of transected melanomas without residual tumor on re-excision accurately predicts survival and prognosis.
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Affiliation(s)
- Kathryn J Martires
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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