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O'Hern K, Crum OM, Demer AM, Brewer JD. Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis. Dermatol Surg 2024; 50:601-610. [PMID: 38530980 DOI: 10.1097/dss.0000000000004164] [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: 03/28/2024]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) is increasingly used to treat cutaneous melanoma. However, it is unclear whether intraoperative immunohistochemistry (IHC) improves surgical outcomes. OBJECTIVE To determine whether intraoperative IHC during MMS and staged excision is associated with a decreased risk of poor surgical outcomes. MATERIALS AND METHODS Search of 6 databases identified comparative and noncomparative studies that reported local recurrence after MMS or staged excision with or without IHC for melanoma. Random-effects meta-analysis was used to estimate pooled local recurrence rates, nodal recurrence, distant recurrence, and disease-specific mortality. RESULTS Overall, 57 studies representing 12,043 patients with cutaneous melanoma and 12,590 tumors met inclusion criteria. Combined MMS and staged excision with IHC was associated with decreased local recurrence in patients with invasive melanoma (0.3%, 95% CI: 0-0.6) versus hematoxylin and eosin alone (1.8%, 95% CI: 0.8%-2.8%) [ p < .001]. Secondary outcomes including nodal recurrence, distant recurrence, and disease-specific mortality were not significantly different between these 2 groups. Study heterogeneity was moderately-high. CONCLUSION Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC. These findings suggest that the use of intraoperative IHC during MMS or staged excision should strongly be considered, particularly for invasive melanoma.Trial Registration PROSPERO Identifier: CRD42023435630.
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Affiliation(s)
- Keegan O'Hern
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Olivia M Crum
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Addison M Demer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jerry D Brewer
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
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2
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Williams GJ, Quinn T, Lo S, Guitera P, Scolyer RA, Thompson JF, Ch'ng S. Mohs micrographic surgery for the treatment of invasive melanoma: A systematic review with meta-analyses. J Eur Acad Dermatol Venereol 2024. [PMID: 38842170 DOI: 10.1111/jdv.20138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/13/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The use of Mohs micrographic surgery (MMS) in melanoma treatment has divided opinion and evidence-based guidelines are lacking. OBJECTIVES This systematic review aimed to analyse clinical outcomes for patients with invasive melanomas treated with Mohs rather than wide local excision (WLE). METHODS Embase, MEDLINE and Cochrane databases (to 30 August 2023) were searched for studies using Mohs to treat invasive melanoma. Outcomes of interest were local recurrence and death from melanoma. RESULTS Thirty-five articles involving 41,499 patients with invasive melanoma treated with Mohs were identified. Sixteen studies compared Mohs with WLE and 19 were Mohs-only, non-comparative studies. Patients treated with Mohs differed significantly from those undergoing WLE, in particular Mohs patients were older and had thinner melanomas. Two comparative studies using the same data source reported adjusted hazard ratios for melanoma-specific death and both showed no significant difference between Mohs and WLE-treated patients; 0.87 (95% CI 0.55-1.35) and 1.20 (95% CI 0.71-20.36). There was also no statistically significant difference in local recurrence risk; the unadjusted risk ratio for patients treated with Mohs was 0.46 (95% CI 0.14-1.51 p = 0.20) with moderate heterogeneity (I2 = 62%). No studies reported multivariable analyses for risk of local recurrence. Many studies generated from relatively few and often overlapping data sets have reported the use of Mohs to treat patients with invasive melanoma. Fewer studies were comparative between Mohs and WLE and these reported substantially different baseline risks of recurrence and death from melanoma between the groups. Mohs has generally been used for thinner melanomas in older patients; therefore, comparisons based on univariable analyses are likely to have been misleading. CONCLUSIONS On the basis of currently available data, it is not possible to reliably assess whether outcomes differ if invasive melanomas with comparable features are treated with Mohs or WLE, and randomized trial evidence will be required for reliable conclusions to be reached.
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Affiliation(s)
- G J Williams
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - T Quinn
- The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - S Lo
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - P Guitera
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - R A Scolyer
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- NSW Health Pathology, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Mater Hospital, North Sydney, Sydney, New South Wales, Australia
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - S Ch'ng
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Mater Hospital, North Sydney, Sydney, New South Wales, Australia
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Pride RLD, Miller CJ, Murad MH, Erwin PJ, Brewer JD. Local Recurrence of Melanoma Is Higher After Wide Local Excision Versus Mohs Micrographic Surgery or Staged Excision: A Systematic Review and Meta-analysis. Dermatol Surg 2022; 48:164-170. [PMID: 34889212 DOI: 10.1097/dss.0000000000003309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Complete removal of melanoma is a primary goal of excision, and local recurrence is one measure to evaluate the efficacy of surgical technique. OBJECTIVE To compare published local recurrence rates for melanoma treated with Mohs micrographic surgery (MMS) or staged excision versus wide local excision (WLE). METHODS AND MATERIALS Search of 6 databases identified comparative and noncomparative studies that reported local recurrence rates after MMS, staged excision, or WLE for melanoma. Random-effects meta-analysis was used to estimate odds ratios and 95% confidence interval (CI) from comparative studies and event rates from noncomparative studies. RESULTS Of the 71 studies included (16,575 patients), 12 were comparative studies (2,683 patients) and 56 were noncomparative studies (13,698 patients). Comparative studies showed increased recurrence after WLE compared with MMS or staged excision (odds ratio [OR], 2.5; 95% CI, 1.4-4.6) and compared with MMS alone (OR, 3.3; 95% CI, 1.8-5.9). Pooled data from comparative and noncomparative studies showed a local recurrence rate of 7% after WLE (95% CI, 5%-11%), 3% after staged excision (95% CI, 2%-4%), and less than 1% after MMS (95% CI, 0%-1%). Statistical heterogeneity was moderate to high. CONCLUSION Local recurrence of melanoma is significantly lower after MMS (<1%) and staged excision (3%) compared with WLE (7%).
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Affiliation(s)
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
| | | | - Jerry D Brewer
- Department of Dermatology Mayo Clinic, Rochester, Minnesota
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Bittar PG, Bittar JM, Etzkorn JR, Brewer JD, Aizman L, Shin TM, Sobanko JF, Higgins HW, Giordano CN, Cohen JV, Pride R, Wan MT, Leitenberger JJ, Bar AA, Aasi S, Bordeaux JS, Miller CJ. Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision. J Am Acad Dermatol 2021; 85:681-692. [PMID: 33961921 DOI: 10.1016/j.jaad.2021.04.090] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. OBJECTIVE To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. METHODS A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. RESULTS Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). LIMITATIONS Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. CONCLUSION Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.
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Affiliation(s)
- Peter G Bittar
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julie M Bittar
- Section of Dermatology, Rush University Medical Center, Chicago, Illinois
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Leora Aizman
- George Washington University School of Medicine, Washington, DC
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold W Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justine V Cohen
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee Pride
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Marilyn T Wan
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anna A Bar
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Sumaira Aasi
- Department of Dermatology, Stanford Medicine, Stanford, California
| | | | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Invasive Melanoma and Melanoma in Situ Treated With Modified Mohs Micrographic Surgery With En Face Permanent Sectioning: A 10-Year Retrospective Review. Dermatol Surg 2021; 46:1004-1013. [PMID: 31714384 DOI: 10.1097/dss.0000000000002246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Successful surgical treatment of cutaneous melanoma is dependent on margin control. OBJECTIVE To determine efficacy of modified Mohs micrographic surgery (mMMS) with en face permanent margins in management of invasive melanoma (IM) and melanoma in situ (MIS). METHODS A retrospective cohort study evaluating local recurrence, 5-year recurrence-free survival, and 5-year melanoma-specific survival. Overall, 657 melanomas (128 IM and 529 MIS) from 631 patients were treated using mMMS during a 10-year period. Follow-up information was obtained from medical records and telephone encounters. RESULTS The median follow-up time was 5.18 years. Most melanomas were located on the head and neck 93.6% (615/657). Margins required for clearance were 0.77 ± 0.44 cm (mean ± SD). Local recurrence was identified in 1.98% (13/657) of melanomas with no local recurrences in IM. Five-year local recurrence-free and melanoma-specific survival rates were estimated to be 96.9% (95% confidence interval [CI]: 94.6%-98.2%) and 99.0% (95% CI: 97.7%-99.6%). There were 5 melanoma-related deaths. CONCLUSION Modified Mohs micrographic surgery is an effective treatment of melanoma as evidenced by low local recurrence rates and high melanoma-specific survival.
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Recurrence risk of early-stage melanoma of the external ear: an investigation of surgical approach and sentinel lymph node status. Melanoma Res 2020; 30:173-178. [DOI: 10.1097/cmr.0000000000000534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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National Analysis of Patients With External Ear Melanoma in the United States. J Craniofac Surg 2019; 30:e787-e790. [DOI: 10.1097/scs.0000000000005777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Han AY, Dhanjani S, Pettijohn K, Patel PB, John MAS. Optimal resection margin for head and neck cutaneous melanoma. Laryngoscope 2019; 129:1386-1394. [PMID: 30408184 DOI: 10.1002/lary.27465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 05/28/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objective of this study was to examine the difference between a narrow (between 1 and 2 cm) and a wide (>2 cm) margin in the surgical resection of head and neck cutaneous melanoma. STUDY DESIGN Population-based cohort analysis. METHODS The Surveillance, Epidemiology, and End Results database was employed to identify patients who had cutaneous melanoma of the head and neck from 2004 to 2014. Outcome measures were overall survival (OS) and disease-specific survival (DSS). RESULTS Among the total of 3,583 cases of cutaneous melanoma of the head and neck with known resection margins, 2,641 individuals had narrow resection margins, and 942 patients had wide margins. Most of the tumors presented in the skin of the scalp and neck, followed by the face, external ear, and other areas. The 5-year and 10-year Kaplan-Meier OS probabilities for narrow and wide margins were 65% and 66%, respectively, compared with 49% and 48%, respectively. The DSS probabilities exhibited similar trends between the two groups at these time points. In the Cox regression model, the patients who received narrow margins had similar OS (95% confidence interval [CI]: 0.918-1.217) and DSS (95% CI: 0.856-1.352) compared with the wide resection margin group, even when controlled for age, sex, T stage, and histology. CONCLUSIONS The survival of patients with cutaneous melanoma of the head and neck depends on age, depth of tumor invasion, and histology. Within the head and neck, a wider resection margin of >2 cm does not confer any additional survival benefit compared with a narrower margin. Future studies should examine whether wider surgical margins would confer survival benefit in local or recurrent melanoma. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1386-1394, 2019.
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Affiliation(s)
- Albert Y Han
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Suraj Dhanjani
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Kelly Pettijohn
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Pratik B Patel
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Maie A St John
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles Medical Center, Los Angeles, California
- University of California, Los Angeles Head and Neck Cancer Program, University of California, Los Angeles Medical Center, Los Angeles, California, U.S.A
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9
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Fix W, Etzkorn JR, Shin TM, Howe N, Bhatt M, Sobanko JF, Miller CJ. Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more commonly than basal cell carcinoma and squamous cell carcinoma: A comparison of indications for microscopic margin control prior to reconstruction in 13,664 tumors. J Am Acad Dermatol 2018; 85:409-418. [PMID: 30458206 DOI: 10.1016/j.jaad.2018.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND On the basis of high-local recurrence risk features and tissue-rearranging reconstruction, consensus guidelines recommend microscopic margin control for keratinocyte carcinomas (KCs) but not for cutaneous melanoma. OBJECTIVE To compare high-local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC with those for melanoma. METHODS Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery. RESULTS A total of 12,189 KCs (8743 basal cell carcinomas and 3343 squamous cell carcinomas) and 1475 melanomas (1065 melanomas in situ and 410 invasive melanomas) were identified from a prospectively updated Mohs micrographic surgery database. Compared with KCs, melanomas were significantly more likely to have high-local recurrence risk features, including larger preoperative size (2.10 cm vs 1.30 cm [P < .0001]), recurrent status (5.08% vs 3.91% [P = .031]), and subclinical spread (31.73% vs 26.52% [P < .0001]). Tissue-rearranging reconstruction was significantly more common for melanoma than for KCs (44.68% vs 33.02% [P < .0001]; odds ratio, 1.98 [P < .0001]). LIMITATIONS This was a retrospective study, and it did not compare outcomes with those of other treatment methods, such as slow Mohs or conventional excision. CONCLUSION Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more frequently than KCs do.
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Affiliation(s)
- William Fix
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Nicole Howe
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Mehul Bhatt
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia.
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10
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The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas. J Am Acad Dermatol 2018; 85:442-452. [PMID: 30447316 DOI: 10.1016/j.jaad.2018.11.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 01/01/2023]
Abstract
Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.
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11
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Etzkorn JR, Tuttle SD, Lim I, Feit EM, Sobanko JF, Shin TM, Neal DE, Miller CJ. Patients prioritize local recurrence risk over other attributes for surgical treatment of facial melanomas-Results of a stated preference survey and choice-based conjoint analysis. J Am Acad Dermatol 2018; 79:210-219.e3. [PMID: 29505861 DOI: 10.1016/j.jaad.2018.02.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/21/2017] [Accepted: 02/23/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical treatment options for facial melanomas include conventional excision with postoperative margin assessment, Mohs micrographic surgery (MMS) with immunostains (MMS-I), and slow MMS. Patient preferences for these surgical options have not been studied. OBJECTIVES To evaluate patient preferences for surgical treatment of facial melanoma and to determine how patients value the relative importance of different surgical attributes. METHODS Participants completed a 2-part study consisting of a stated preference survey and a choice-based conjoint analysis experiment. RESULTS Patients overwhelmingly (94.3%) rated local recurrence risk as very important and ranked it as the most important attribute of surgical treatment for facial melanoma. Via choice-based conjoint analysis, patients ranked the following surgical attributes from highest to lowest in importance: local recurrence rate, out-of-pocket cost, chance of second surgical visit, timing of reconstruction, travel time, and time in office for the procedure. Consistent with their prioritization of low local recurrence rates, more than 73% of respondents selected MMS-I or slow MMS as their preferred treatment option for a facial melanoma. LIMITATIONS Data were obtained from a single health system. CONCLUSION Patients prefer surgical treatment options that minimize risk for local recurrence. Logistics for travel and treatment have less influence on patient preferences. Most survey participants chose MMS-I to maximize local cure and convenience of care.
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Affiliation(s)
- Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Scott D Tuttle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ilya Lim
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Elea M Feit
- Lebow College of Business, Drexel University, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald E Neal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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A Systematic Review of Surgical Management of Melanoma of the External Ear. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1755. [PMID: 29876188 PMCID: PMC5977960 DOI: 10.1097/gox.0000000000001755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/20/2018] [Indexed: 11/26/2022]
Abstract
Background Historically, external ear melanomas have been treated aggressively, due to early perceptions suggesting they had poor prognosis and aggressive biological behavior. More recent evidence has not supported these notions. Methods We completed a complete review of the literature involving malignant melanoma of the external ear. We then completed a quantitative analysis on seventy-three cases from 8 reports that contained case-level data, assessing factors that influence recurrence, and assessing characteristics of the melanomas based on histological subtype. Baseline and outcomes data for all 20 studies were then compiled but not statistically evaluated. Results In our subanalysis, patients who had recurrence were significantly more likely to have had wedge resection versus wide-local excision, and those with no recurrence were more likely to have undergone wide local excision. Nodular tumors had significantly greater thickness. Overall, conservative excisions provided excellent outcomes. Conclusions Conservative treatment for external ear melanoma produces satisfactory outcomes. There is no evidence to support the use of radical amputation and little evidence to support the removal of cartilage or perichondrium. Sentinel lymph node biopsy is warranted only with positive nodes. There is no role for elective neck dissection. The roles for chemo/radiation therapy are unclear and guidelines for other cutaneous melanomas should be followed.
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13
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Patel TD, Chin OY, Baredes S, Eloy JA, Ying YLM. A Population Based Analysis of Melanoma of the External Ear. Otol Neurotol 2018; 39:e137-e142. [PMID: 29194224 DOI: 10.1097/mao.0000000000001645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Malignant melanoma accounts for nearly 75% of all skin cancer deaths, and the incidence is on the rise in the United States. External ear melanoma (EEM) is rare, and there is little long-term data regarding the clinical behavior of this melanoma site. This study analyzes the demographic, clinicopathologic, and survival characteristics of EEM. METHODS The SEER database was queried for EEM cases from 1973 to 2012 (8,982 cases). Data analyzed included patient demographics, incidence trends, and survival outcomes. RESULTS External ear melanoma occurred most frequently in the sixth and seventh decades of life. Mean age at diagnosis was 65.5 (±16.8) years. However, the incidence of EEM in adolescents and young adults (ages 15-39 yr) has increased by 111.9% from 1973 to 2012. There was a strong male predilection with a male-to-female ratio of 6.40:1. The most common histologic subtype was malignant melanoma, NOS (46.8%), followed by superficial spreading melanoma (21.4%), and lentigo maligna melanoma (17.9%). The majority of cases were localized at the time of presentation (88.0%), with rare distant metastasis (1.9%). The most common treatment modality was surgery alone (97.6%), followed by surgery with radiotherapy (2.3%). Ten-year disease-specific survival was better among those treated with surgery alone (90.7%), than those treated with surgery with radiotherapy (37.1%) (p < 0.0001). Increasing Breslow's thickness and presence of an ulcerating lesion were both associated with poorer survival (p < 0.0001). CONCLUSION This study represents the largest cohort of EEM. It has an excellent survival outcome with surgery being the treatment of choice.
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Affiliation(s)
- Tapan D Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Oliver Y Chin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey
- Department of Neurological Surgery
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Yu-Lan Mary Ying
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey
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14
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Deep NL, Glasgow AE, Habermann EB, Kasperbauer JL, Carlson ML. Melanoma of the external ear: A population-based study. Am J Otolaryngol 2017; 38:309-315. [PMID: 28258767 DOI: 10.1016/j.amjoto.2017.01.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/31/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary melanoma of the external ear (PMEE) is rare and therefore well-suited for large population-based registry analysis. The objective of this study was to utilize the Surveillance, Epidemiology, and End Results (SEER) set of cancer registries to determine the incidence, treatment, and survival characteristics of PMEE. METHODS A retrospective cohort analysis of SEER data from 2004 to 2013 identified all cases of PMEE stage I-IV by AJCC 7th edition guidelines. Population-based incidence was calculated. Cancer-specific survival data by stage was assessed using Kaplan-Meier analysis and the relative effects of tumor characteristics were analyzed with Cox regression models. RESULTS A total of 5481 patients were analyzed (mean age 66.7years, 86.5% male, 93.6% non-Hispanic white). The incidence of PMEE was 1.91 per 100,000 persons-per-year. At diagnosis, 68.1% were stage I, 15.2% were stage II, 4.7% were stage III, 1.5% were stage IV, and 10.8% were unknown. The five-year overall and cancer-specific survival was 78.8% and 90.0%, and, according to AJCC stage, was 85.7% and 95.3% for stage I (n=2287), 64.6% and 81.1% for stage II (n=453), 50.8% and 57.0% for stage III (n=154), 17.2% and 20.5% for stage IV (n=34), and 71.0% and 87.1% for unknown stage (n=330), respectively. The multivariable Cox model identified tumor characteristics that were independently associated with survival. CONCLUSIONS This is the first study to characterize the epidemiology, presentation and outcome of PMEE using the SEER registries. Older age, increasing Breslow thickness, stage, presence of ulceration, positive lymph nodes and distant metastasis each independently predicted time to cancer-specific death.
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Affiliation(s)
- Nicholas L Deep
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Amy E Glasgow
- Division of Health Care Policy and Research and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Division of Health Care Policy and Research and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
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15
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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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16
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Shin TM, Shaikh WR, Etzkorn JR, Sobanko JF, Margolis DJ, Gelfand JM, Chu EY, Elenitsas R, Miller CJ. Clinical and pathologic factors associated with subclinical spread of invasive melanoma. J Am Acad Dermatol 2017; 76:714-721. [PMID: 28139264 DOI: 10.1016/j.jaad.2016.11.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/23/2016] [Accepted: 11/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Indications to treat invasive melanoma with Mohs micrographic surgery (MMS) or analogous techniques with exhaustive microscopic margin assessment have not been defined. OBJECTIVE Identify clinical and histologic factors associated with subclinical spread of invasive melanoma. METHODS This retrospective, cross-sectional study evaluated 216 invasive melanomas treated with MMS and melanoma antigen recognized by T cells 1 immunostaining. Logistic regression models were used to correlate clinicopathologic risk factors with subclinical spread and construct a count prediction model. RESULTS Risk factors associated with subclinical spread by multivariate analysis included tumor localization on the head and neck (OR 3.28, 95% confidence interval [CI] 1.16-9.32), history of previous treatment (OR 4.18, 95% CI 1.42-12.32), age ≥65 (OR 4.45, 95% CI 1.29-15.39), and ≥1 mitoses/mm2 (OR 2.63, 95% CI 1.01-6.83). Tumor thickness and histologic subtype were not associated with subclinical spread. The probability of subclinical spread increased per number of risk factors, ranging from 9.22% (95% CI 2.57%-15.86%) with 1 factor to 80.32% (95% CI 68.13%-92.51%) with 5 factors. LIMITATIONS This study was conducted at a single academic institution with a small study population using a retrospective study design that was subject to potential referral bias. CONCLUSION Clinical and histologic factors identify invasive melanomas that are at increased risk for subclinical spread and might benefit from MMS or analogous techniques prior to reconstruction.
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Affiliation(s)
- Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Waqas R Shaikh
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Margolis
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel M Gelfand
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Y Chu
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosalie Elenitsas
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Toia F, Garbo G, Tripoli M, Rinaldi G, Moschella F, Cordova A. A systematic review on external ear melanoma. J Plast Reconstr Aesthet Surg 2015; 68:883-94. [PMID: 25971418 DOI: 10.1016/j.bjps.2015.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 02/01/2015] [Accepted: 04/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND External ear melanoma accounts for only 1% of all cutaneous melanomas, and data on its optimal management and prognosis are limited. AIM We aim to review the literature on external ear melanoma to guide surgeons in the treatment of this uncommon and peculiar pathology. MATERIALS AND METHODS A systematic review of English language studies on ear melanoma published from 1993 to 2013 was performed using the PubMed electronic database. Data on epidemiology, oncological treatment (tumor resection and regional lymph nodes management), and reconstruction were extrapolated from selected papers. RESULTS The total number of patients was 858 (30 studies). The helix was the most common location (57%); superficial spreading melanoma was the most common histopathological subtype (41%). The mean Breslow thickness was 2.01 mm, with 88% of stage I-II patients. Sentinel lymph node biopsy was performed in 45% of patients, with 8% of positive nodes. Available data on its prognosis are fragmentary and contrasting, but the Breslow thickness appears to be the main prognostic factor. There is a tendency towards reduced resection margins and preservation of the underlying perichondrium and cartilage. Local flaps are the most popular reconstructive option. CONCLUSION To the best of our knowledge, this systematic review presents the largest data series on external ear melanoma. There is no general agreement on its surgical management, but a favorable prognosis seems to justify the tendency towards conservative treatments.
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Affiliation(s)
- Francesca Toia
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.
| | - Giuseppe Garbo
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Massimiliano Tripoli
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Gaetana Rinaldi
- Medical Oncology, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Francesco Moschella
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Adriana Cordova
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
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18
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Etzkorn JR, Sobanko JF, Elenitsas R, Newman JG, Goldbach H, Shin TM, Miller CJ. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol 2015; 72:840-50. [PMID: 25774012 DOI: 10.1016/j.jaad.2015.01.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/20/2014] [Accepted: 01/07/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Various methods of tissue processing have been used to treat melanoma with Mohs micrographic surgery (MMS). OBJECTIVE We describe a method of treating melanoma with MMS that combines breadloaf frozen sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation, allowing detection of upstaging and comprehensive pathologic margin assessment before reconstruction. METHODS We conducted a retrospective cohort study evaluating for local recurrence and upstaging in 614 invasive or in situ melanomas in 577 patients treated with this MMS tissue processing methodology using frozen sections with melanoma antigen recognized by T cells 1 (MART-1) immunostaining. Follow-up was available in 597 melanomas in 563 patients. RESULTS Local recurrence was identified in 0.34% (2/597) lesions with a mean follow-up time of 1026 days (2.8 years). Upstaging occurred in 34 of 614 lesions (5.5%), of which 97% (33/34) were detected by the Mohs surgeon before reconstruction. LIMITATIONS Limitations include retrospective study, intermediate follow-up time, and that the recurrence status of 39.6% of patients was self-reported. CONCLUSION Treating melanoma with MMS that combines breadloaf sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation permits identification of upstaging and consideration of sentinel lymph node biopsy before definitive reconstruction and achieves low local recurrence rates compared with conventional excision.
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Affiliation(s)
| | - Joseph F Sobanko
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Rosalie Elenitsas
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jason G Newman
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | | | - Thuzar M Shin
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
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