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Huang Y, Carlsson L, Jogeland K, Samuelsson M, Larsson L, Jonsborg C. Management of complications after skin surgery relevant for melanoma in the trunk and extremities during the COVID-19 pandemic: a case series report. World J Surg Oncol 2023; 21:280. [PMID: 37670317 PMCID: PMC10478401 DOI: 10.1186/s12957-023-03084-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 06/18/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Patients with melanoma have been found to be at greater risk of adverse outcomes including mortality after contacting COVID-19. Management of postsurgical complications presented additional challenges by potentially increasing exposure to COVID-19 through repeated inpatient admissions to hospital during the pandemic. We report four cases for which skin flaps, lymph ligation, and split-thickness skin graft (STSG) were successfully used in the treatment of complications in the trunk and extremities after wide local excision (WLE). This study details the operative experience in management of postsurgical complications for melanoma in the trunk and extremities during a 6-month period at the height of the COVID-19 pandemic. CASE PRESENTATION We present 4 cases detailing management of complications that occurred after wide local excisions performed for melanoma during Feb. to Oct. 2020. Case 1: A 90-year-old man who experienced wound dehiscence and necrosis on the shoulder after non-radical excision for an aggressive melanoma and underwent the side-to-side closure after ellipse formed WLE with modified tangent-to-circle method. Case 2: An 80-year-old man who had undergone excision for melanoma in his left upper arm and histopathology did not show radically. Two weeks after the excision, he underwent a WLE and direct reconstruction with double rotation skin flap. Case 3: A 55-year-old man that experienced a large wound dehiscence on his back due to WLE. He underwent an advanced double skin flap operation. Case 4: A 36-year-old woman who had a lymphorrhea and graft necrosis after WLE and STSG on the right lower leg. A combination of micro lymph ligation and re-STSG was performed. One month after the operation, all wounds had healed. There was no clinical evidence of tumor recurrence after 8 months post procedure. CONCLUSIONS Severe complications (e.g., large wound dehiscence, necrosis, or lymphorrhea) following wide local excision of melanoma are infrequent but must be swiftly and appropriately managed, especially during the COVID-19 pandemic to decrease the likelihood of COVID-19 infection and impaired oncology outcomes from delaying systemic cancer therapy due to the complications in primary interventions.
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Affiliation(s)
- Yinglai Huang
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden.
| | - Lena Carlsson
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden
| | - Karin Jogeland
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden
| | - Marianne Samuelsson
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden
| | - Lars Larsson
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden
| | - Catarina Jonsborg
- Division of Breast and Endocrine Surgery, Department of Surgery, Boras Hospital, Boras, Sweden
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Intermediate-thickness melanoma: A population-based study of surgical quality metrics. Surgery 2022. [PMID: 37534705 DOI: 10.1016/j.surg.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists. METHODS T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates. RESULTS Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001). CONCLUSIONS Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.
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Clinical performance indicators for monitoring the management of cutaneous melanoma: a population-based perspective. Melanoma Res 2022; 32:353-359. [PMID: 35855661 PMCID: PMC9436025 DOI: 10.1097/cmr.0000000000000841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The prognosis of cutaneous malignant melanoma (CMM) is based on disease progression. The highly heterogeneous clinical-pathological characteristics of CMM necessitate standardized diagnostic and therapeutic interventions tailored to cancer's stage. This study utilizes clinical performance indicators to assess the quality of CMM care in Veneto (Northeast Italy). This population-based study focuses on all incidences of CMMs registered by the Veneto Cancer Registry in 2015 (1279 patients) and 2017 (1368 patients). An interdisciplinary panel of experts formulated a set of quality-monitoring indicators for diagnostic, therapeutic, and end-of-life clinical interventions for CMM. The quality of clinical care for patients was assessed by comparing the reference thresholds established by experts to the actual values obtained in clinical practice. The prevalence of stage I-CMM decreased significantly from 2015 to 2017 (from 71.8 to 62.4%; P < 0.001), and almost all the pathology reports mentioned the number of nodes dissected during a lymphadenectomy. More than 90% of advanced CMMs were promptly tested for molecular BRAF status, but the proportion of patients given targeted therapies fell short of the desired threshold (61.1%). The proportion of stage I-IIA CMM patients who inappropriately underwent computerized tomography/MRI/PET dropped from 17.4 to 3.3% ( P < 0.001). Less than 2% of patients received medical or surgical anticancer therapies in the month preceding their death. In the investigated regional context, CMM care exhibited both strengths and weaknesses. The evaluated clinical indicators shed essential insight on the clinical procedures requiring corrective action. It is crucial to monitor clinical care indicators to improve care for cancer patients and promote the sustainability of the healthcare system.
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Aslanyan S, Gumeniuk K, Lysenko D. Modern views on skin biopsy in the diagnostic algorithm of dermatooncological diseases. УКРАЇНСЬКИЙ РАДІОЛОГІЧНИЙ ТА ОНКОЛОГІЧНИЙ ЖУРНАЛ 2022. [DOI: 10.46879/ukroj.2.2022.62-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background. Malignant neoplasms of the skin are fairly common tumors in the world population and among the population of Ukraine. The main method of diagnosing skintumors is a biopsy, which allows establishing a diagnosis at an early stage and ensures the cure of most patients.
Purpose. To evaluate modern recommendations for skin biopsy in the diagnosis of dermato-onсological diseases.
Materials and methods. The search for sources of information was conducted using the MEDLINE/PubMed, EMBASE/ExcerptaMedica, CochraneLibrary, PubMed та Google Scholar databases using the following keywords: skin biopsy, skin tumors, diagnosis, melanoma. Among the identified sources, works without statistical analysis, descriptions of individual cases, articles without conclusions, and sources with duplicate results were excluded. The search depth was 10 years.
Results. As a result of the conducted search, 57 publications were found that corresponded to the declared purpose. The most common methods are: puncture, shaving, excisional and incisional biopsy. Most guidelines recommend full-thickness excisional biopsy as the preferred procedure for the diagnosis of suspected melanoma. It is indicated that a statistically significant mortality rate was found in the puncture biopsy group. Most observations showed no significant differences in melanoma recurrence between excisional biopsy and puncture groups. Given the clinical diversity of melanoma, there is no uniformity in the types of biopsies performed to diagnose melanoma. The most inaccurate method turned out to be the punch biopsy method, which is associated with an increased risk of underdiagnosis of melanoma.
Conclusions. A skin biopsy is a mandatory first step to establish a definitive diagnosis of a skin tumor. Excisional complete biopsy is the most justified in most cases of diagnosis. Rational biopsy technique remains an issue that needs further study.
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Laginha BI, Rapport F, Smith A, Wilkinson D, Cust AE, Braithwaite J. Systematic development of quality indicators for skin cancer management in primary care: a mixed-methods study protocol. BMJ Open 2022; 12:e059829. [PMID: 35725249 PMCID: PMC9214379 DOI: 10.1136/bmjopen-2021-059829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Australia has the highest incidence of skin cancer in the world, with two out of three Australians expected to be diagnosed with skin cancer in their lifetime. Such incidence necessitates large-scale, effective skin cancer management practices. General practitioners (in mainstream practice and in skin cancer clinics) play an important role in skin cancer care provision, making decisions based on relevant evidence-based guidelines, protocols, experience and training. Diversity in these decision-making practices can result in unwarranted variation. Quality indicators are frequently implemented in healthcare contexts to measure performance quality at the level of the clinician and healthcare practice and mitigate unwarranted variation. Such measurements can facilitate performance comparisons between peers and a standard benchmark, often resulting in improved processes and outcomes. A standardised set of quality indicators is yet to be developed in the context of primary care skin cancer management. AIMS This research aims to identify, develop and generate expert consensus on a core set of quality indicators for skin cancer management in primary care. METHODS This mixed-methods study involves (1) a scoping review of the available evidence on quality indicators in skin cancer management in primary care, (2) identification and development of a core set of quality indicators through interviews/qualitative proforma surveys with participants, and (3) a focus group involving discussion of quality indicators according to Nominal Group Technique. Qualitative and quantitative data will be collected and analysed using thematic and descriptive statistical analytical methods. ETHICS AND DISSEMINATION Approval was granted by the university's Research Ethics Committee (HREC no. 520211051532420). Results from this study will be widely disseminated in publications, study presentations, educational events and reports.
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Affiliation(s)
- Bela Ines Laginha
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrea Smith
- University of Sydney, a joint venture with Cancer Council NSW, The Daffodil Centre, Sydney, New South Wales, Australia
| | - David Wilkinson
- National Skin Cancer Centres, South Brisbane, Queensland, Australia
| | - Anne E Cust
- University of Sydney, a joint venture with Cancer Council NSW, The Daffodil Centre, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Buja A, Rugge M, Damiani G, De Luca G, Zorzi M, Fusinato R, De Toni C, Vecchiato A, Del Fiore P, Falasco F, Spina R, Rossi CR, Mocellin S. Impact of Wide Local Excision on Melanoma Patient Survival: A Population-Based Study. Front Public Health 2022; 10:806934. [PMID: 35433570 PMCID: PMC9008755 DOI: 10.3389/fpubh.2022.806934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Promoting standardization and quality assurance (QA) in oncology on the strength of real-world data is essential to ensure better patient outcomes. Wide excision after primary tumor biopsy is a fundamental step in the therapeutic pathway for cutaneous malignant melanoma (CMM). The aim of this population-based cohort study is to assess adherence to wide local excision in a cohort of patients diagnosed with CMM and the impact of this recommended procedure on overall and disease-specific survival. Materials and Methods This retrospective cohort study concerns CMM patients diagnosed in the Veneto region (north-east Italy) in 2017, included in the high-resolution Veneto Cancer Registry, and followed up through linkage with the regional mortality registry up until February 29th, 2020. Using population-level real-world data, linking patient-level cancer registry data with administrative records of clinical procedures may shed light on the real-world treatment of CMM patients in accordance with current guidelines. After excluding TNM stage IV patients, a Cox regression analysis was performed to test whether the completion of a wide local excision was associated with a difference in melanoma-specific and overall survival, after adjusting for other covariates. Results No wide excision after the initial biopsy was performed in 9.7% of cases in our cohort of 1,305 patients. After adjusting for other clinical prognostic characteristics, Cox regression revealed that failure to perform a wide local excision raised the hazard ratio of death in terms of overall survival (HR = 4.80, 95% CI: 2.05-11.22, p < 0.001) and melanoma-specific survival (HR = 2.84, 95% CI: 1.04-7.76, p = 0.042). Conclusion By combining clinical and administrative data, this study on real-world clinical practice showed that almost one in ten CMM patients did not undergo wide local excision surgery. Monitoring how diagnostic-therapeutic protocols are actually implemented in the real world may contribute significantly to promoting quality improvements in the management of oncological patients.
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Affiliation(s)
- Alessandra Buja
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Padua, Italy
| | - Massimo Rugge
- Veneto Tumor Registry, Azienda Zero, Padua, Italy
- Pathology and Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Giovanni Damiani
- Clinical Dermatology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
- Department of Pharmaceutical and Pharmacological Sciences, Ph.D. Degree Program in Pharmacological Sciences, University of Padua, Padua, Italy
| | - Giuseppe De Luca
- Department of Cardiologic, Vascular and Thoracic Sciences, and Public Health, University of Padova, Padua, Italy
| | - Manuel Zorzi
- Veneto Tumor Registry, Azienda Zero, Padua, Italy
| | - Riccardo Fusinato
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
| | - Chiara De Toni
- Department of Statistical Sciences, University of Padova, Padua, Italy
| | - Antonella Vecchiato
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
| | - Paolo Del Fiore
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
| | - Francesca Falasco
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
| | - Romina Spina
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
| | - Carlo Riccardo Rossi
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Simone Mocellin
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Istituto Oncologico Veneto - Istituto di Ricovero e Cura a Carattere Scientifico (IOV-IRCCS), Padua, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
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McKay DR, Nguyen P, Wang A, Hanna TP. A population-based study of administrative data linkage to measure melanoma surgical and pathology quality. PLoS One 2022; 17:e0263713. [PMID: 35180251 PMCID: PMC8856577 DOI: 10.1371/journal.pone.0263713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Continuous quality improvement is important for cancer systems. However, collecting and compiling quality indicator data can be time-consuming and resource-intensive. Here we explore the utility and feasibility of linked routinely collected health data to capture key elements of quality of care for melanoma in a single-payer, universal health care setting.
Method
This pilot study utilized a retrospective population-based cohort from a previously developed linked administrative data set, with a 65% random sample of all invasive cutaneous melanoma cases diagnosed 2007–2012 in the province of Ontario. Data from the Ontario Cancer Registry was utilized, supplemented with linked pathology report data from Cancer Care Ontario, and other linked administrative data describing health care utilization. Quality indicators identified through provincial guidelines and international consensus were evaluated for potential collection with administrative data and measured where possible.
Results
A total of 7,654 cases of melanoma were evaluated. Ten of 25 (40%) candidate quality indicators were feasible to be collected with the available administrative data. Many indicators (8/25) could not be measured due to unavailable clinical information (e.g. width of clinical margins). Insufficient pathology information (6/25) or health structure information (1/25) were less common reasons. Reporting of recommended variables in pathology reports varied from 65.2% (satellitosis) to 99.6% (body location). For stage IB-II or T1b-T4a melanoma patients where SLNB should be discussed, approximately two-thirds met with a surgeon experienced in SLNB. Of patients undergoing full lymph node dissection, 76.2% had adequate evaluation of the basin.
Conclusions
We found that use of linked administrative data sources is feasible for measurement of melanoma quality in some cases. In those cases, findings suggest opportunities for quality improvement. Consultation with surgeons offering SLNB was limited, and pathology report completeness was sub-optimal, but was prior to routine synoptic reporting. However, to measure more quality indicators, text-based data sources will require alternative approaches to manual collection such as natural language processing or standardized collection. We recommend development of robust data platforms to support continuous re-evaluation of melanoma quality indicators, with the goal of optimizing quality of care for melanoma patients on an ongoing basis.
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Affiliation(s)
- Douglas R. McKay
- Division of Plastic Surgery, Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Paul Nguyen
- ICES at Queen’s University, Kingston, Ontario, Canada
| | - Ami Wang
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Timothy P. Hanna
- ICES at Queen’s University, Kingston, Ontario, Canada
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen’s University, Kingston, Ontario, Canada
- * E-mail:
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Turner LM, He M, Piscioneri F, Read R. Improving access and ensuring the quality of melanoma sentinel node biopsy services. ANZ J Surg 2021; 91:2561-2562. [PMID: 34913565 DOI: 10.1111/ans.17338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Lauren M Turner
- Department of Surgery, Division of Critical Care, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Mike He
- Department of Surgery, Division of Critical Care, Canberra Hospital, Garran, Australian Capital Territory, Australia.,Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Frank Piscioneri
- Department of Surgery, Division of Critical Care, Canberra Hospital, Garran, Australian Capital Territory, Australia.,Calvary Public Hospital, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Canberra, Australian Capital Territory, Australia
| | - Rebecca Read
- Department of Surgery, Division of Critical Care, Canberra Hospital, Garran, Australian Capital Territory, Australia.,Calvary Public Hospital, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Canberra, Australian Capital Territory, Australia
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Extent of Groin Dissection in Melanoma: A Mixed-Methods, Population-Based Study of Practice Patterns and Outcomes. Curr Oncol 2021; 28:5422-5433. [PMID: 34940091 PMCID: PMC8700358 DOI: 10.3390/curroncol28060452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/16/2022] Open
Abstract
Melanoma metastases to the groin are frequently managed by therapeutic lymph node dissection. Evidence is lacking regarding the extent of dissection required. Thus, we sought to describe practice patterns for the use of inguinal vs. ilioinguinal dissection, as well as the perioperative/oncologic outcomes of each procedure. A mixed-methods approach was employed to evaluate surgical practice patterns. A retrospective review of three multi-site databases was carried out, together with semi-structured interviews of melanoma surgeons. A total of 347 patients who underwent dissection were reviewed. The main indications stated for adding a “deep” ilioinguinal dissection were palpable or radiologically positive disease. There was no significant difference in complications, length of stay or lymphedema between patients having inguinal vs. ilioinguinal dissection, irrespective of method of diagnosis. There was also no significant difference in recurrence, cancer-specific survival or overall survival between groups. In conclusion, ilioinguinal dissection is a safe and well-tolerated procedure, with no significant added morbidity relative to an inguinal dissection. The indications for ilioinguinal dissection currently in use produce an appropriate deep node positivity rate and ilioinguinal dissection should continue to be used selectively. Randomized data are needed to clarify the impact of ilioinguinal dissection on regional control and survival.
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Ollek S, Wen D, Ong I, Anderson W, Harman R, Martin R. Proposed Quality Performance Indicators (QPI's) for axillary lymphadenectomy in metastatic cutaneous melanoma. Eur J Surg Oncol 2021; 47:3011-3019. [PMID: 34489121 DOI: 10.1016/j.ejso.2021.07.030] [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: 01/08/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Axillary lymph node clearance (ALNC) continues to play a central role in the management of melanoma. However, what defines an adequate lymphadenectomy remains unclear. We aimed to propose Quality Performance Indicators (QPIs) for ALNC and to determine if the number of lymph nodes (LNs) removed impacts survival. METHODS We reviewed patients who underwent ALNC for melanoma at the Waitemata District Health Board and Melanoma Unit between February 2005 and October 2019, performed by two surgeons with standardized technique and surveillance. RESULTS 105 patients with stage III melanoma were included, of which 73 had clinically evident disease and 32 had clinically occult disease. The mean total number of LNs excised was 29 (SD 10.90, range 10-76). On multivariate analysis, lymph node ratio (HR 4.48, 95% CI 1.55-12.93, p = 0.006), extracapsular spread (HR 2.53, 95% CI 1.06-6.05, p = 0.036) and distant recurrence (HR 11.24, 95% CI 3.79-33.31, p < 0.001) were significant predictors of mortality. The number of LNs removed did not predict survival outcomes, while the lymph node ratio did significantly predict survival outcomes. The regional recurrence rate was 3.8%. DISCUSSION We propose that QPIs for ALNC in melanoma include a 90th percentile LN yield of greater than 15, a mean LN yield of 20, a regional recurrence rate of less than 10%, and an overall complication rate of less than 50%. CONCLUSION The establishment of QPIs can help ensure that surgical oncology patients receive the highest quality of care.
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Affiliation(s)
- Sita Ollek
- Surgical Oncology Fellow, University of British Columbia, Canada.
| | - Daniel Wen
- House Officer, North Shore Hospital, University of Auckland, New Zealand
| | - Ian Ong
- Surgical Registrar, North Shore Hospital, University of Auckland, New Zealand
| | - William Anderson
- Surgical Registrar, North Shore Hospital, University of Auckland, New Zealand
| | - Richard Harman
- Director General Surgery, Melanoma Unit, North Shore Hospital, University of Auckland, New Zealand
| | - Richard Martin
- Cutaneous Surgical Oncologist, Head/Neck and General Surgeon, Melanoma Unit, Waitemata District Health Board, University of Auckland, New Zealand
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Vecchiato A, Mocellin S, Del Fiore P, Tosti G, Ascierto PA, Corradin MT, De Giorgi V, Giudice G, Queirolo P, Ferreli C, Occelli M, Giordano M, Trevisan G, Mascheroni L, Testori A, Spina R, Buja A, Cavallin F, Caracò C, Sommariva A, Rossi CR. The surgical treatment of non-metastatic melanoma in a Clinical National Melanoma Registry Study Group (CNMR): a retrospective cohort quality improvement study to reduce the morbidity rates. BMC Cancer 2021; 21:8. [PMID: 33402122 PMCID: PMC7786513 DOI: 10.1186/s12885-020-07705-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022] Open
Abstract
Background Reproducible, high-quality surgery is a key point in the management of cancer patients. Quality indicators for surgical treatment of melanoma has been presented with benchmarks but data on morbidity are still limited. This study presents the quality indicators on morbidity after surgical treatment for non-metastatic skin melanoma in an Italian registry. Methods Data were extracted from the Central National Melanoma Registry (CNMR) promoted by the Italian Melanoma Intergroup (IMI). All surgical procedures (WE, SNLB or LFND) for non-metastatic skin melanoma between January 2011 and February 2017 were evaluated for inclusion in the study. Only centers with adequate completeness of information (> 80%) were included in the study. Short-term complications (wound infection, dehiscence, skin graft failure and seroma) were investigated. Results Wound infection rate was 1.1% (0.4 to 2.7%) in WE, 1.3% (0.7 to 2.5%) in SLNB and 4.1% (2.1 to 8.0%) in LFND. Wound dehiscence rate was 2.0% (0.8 to 5.1%) in WE, 0.9% (0.2 to 3.0%) in SLNB and 2.8% (0.9 to 8.6%) in LFND. Seroma rate was 4.2% (1.5 to 11.1%) in SLNB and 15.1% (4.6 to 39.9%) in LFND. Unreliable information was found on skin graft failure. Conclusions Our findings contribute to available literature in setting up the recommended standards for melanoma centers, thus improving the quality of surgery offered to patients. A consensus on the core issues around surgical morbidity is needed to provide practical guidance on morbidity prevention and management. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-020-07705-4.
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Affiliation(s)
- Antonella Vecchiato
- Surgical Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Simone Mocellin
- Surgical Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padova, Italy
| | - Paolo Del Fiore
- Surgical Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy.
| | - Giulio Tosti
- Division of Melanoma, Sarcoma and Rare Tumors, IRCCS, European Institute of Oncology, Milan, Italy
| | - Paolo A Ascierto
- Department of Melanoma and Cancer Immunotherapy, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Naples, Italy
| | | | - Vincenzo De Giorgi
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery and Burn Unit, University of Bari, Bari, Italy
| | - Paola Queirolo
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Caterina Ferreli
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marcella Occelli
- Medical Oncology Unit, Santa Croce and Carle Teaching Hospital, Cuneo, Italy
| | | | - Giusto Trevisan
- DSM-Department of Medical Sciences, University of Trieste, Trieste, Italy
| | | | - Alessandro Testori
- Department of Dermatology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Romina Spina
- Surgical Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy
| | - Alessandra Buja
- Department of Cardiological, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova, Italy
| | | | - Corrado Caracò
- National Cancer Institute Fondazione G. Pascale, SC Chirurgia Melanoma e dei Tumori Cutanei, Naples, Italy
| | - Antonio Sommariva
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Carlo Riccardo Rossi
- Surgical Oncology Unit, Veneto Institute of Oncology IOV - IRCCS, Padova, Italy.,Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padua, Padova, Italy
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Sommariva A, Cona C, Tonello M, Pilati P, Rossi CR. Oncological outcome of videoscopic groin dissection for lymph node metastasis from melanoma. Surg Endosc 2020; 35:2576-2582. [PMID: 32483695 DOI: 10.1007/s00464-020-07675-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/23/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Videoscopic inguinal lymphadenectomy (VIL) represents an innovative approach for patients with melanoma lymph node (LN) metastases, mainly aimed at lowering wound-related morbidity. However, long-term data on oncologic safety are still lacking. The aim of this study is to review the oncologic outcome of videoscopic groin dissection in a single institution caseload. METHODS Data were prospectively gathered on patients with inguinal melanoma metastasis who underwent VIL. Clinical data included age, race, sex, tumor histology, node counts and number of metastatic nodes. Disease-free survival and overall survival were monitored based on an institutional follow-up schedule. The study was approved by the local ethics committee (Video-SIIO II study). RESULTS We analyzed 48 videoscopic groin dissections performed in 50 patients (2 patients underwent bilateral VIL). Median age was 54.5 years. Female/male ratio was 15/33. Indication for surgery was positive inguinal sentinel biopsy and cytological confirmed clinical disease in 40 and 10 cases, respectively. Median LN retrieval count was 19. After a median follow-up of 28 months, groin recurrence (lymphatic basin) was observed in one single case. CONCLUSIONS VIL for melanoma LN metastases is associated with a favorable oncologic outcome. In particular, LN yield and locoregional recurrence rate obtained with videoscopic dissection are comparable to those reported with the open technique. Prospective studies are needed to confirm these results in a larger cohort of patients.
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Affiliation(s)
- Antonio Sommariva
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy. .,Unit of Surgical Oncology of the Esophagus and Digestive Tract, Surgical Oncology Department, Veneto Institute of Oncology IOV-IRCCS, Via dei Carpani, 16, 31033, Castelfranco, Veneto, TV, Italy.
| | - Camilla Cona
- Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Marco Tonello
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Pierluigi Pilati
- Unit of Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
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Moreno-Ramírez D, Vieira R, Kaufmann R. Surgical approach to patients with low-burden stage III melanoma: Is it time to consider conservative surgery? Eur J Surg Oncol 2020; 46:498-500. [DOI: 10.1016/j.ejso.2019.11.500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/28/2022] Open
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14
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Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions. Dermatol Surg 2019; 45:836-843. [PMID: 31021903 DOI: 10.1097/dss.0000000000001938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality. OBJECTIVE The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures. MATERIALS AND METHODS An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures. RESULTS Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements. CONCLUSION Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.
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15
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Sommariva A, Forsea AM, Agius D, Ascierto PA, Bastiaannet E, Borgognoni L, Demetriou A, Garbe C, Gavric Z, Hocevar M, Innos K, Larønningen S, Louwman M, Robsahm TE, Rutkwoski P, van Akkooi A, Zorzi M, Pasquali S, van de Velde C, Rossi CR. Quality assurance in melanoma care: The EU-MELACARE study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1773-1778. [PMID: 30001892 DOI: 10.1016/j.ejso.2018.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND A significant disparity regarding survival outcome for melanoma among European regions is well recognized and access to high quality care for European melanoma patients needs to be improved. There is an unmet need for the implementation of minimal standard of care within defined clinical pathways and Quality Assurance (QA) indicators. OBJECTIVE The EU-MELACARE study aims to identify shared variables for cutaneous melanoma cases recorded in melanoma registries across Europe. MATERIAL AND METHODS Opinion leaders involved in melanoma data registration and care quality analysis in 34 European countries were invited to respond to an expert survey covering questions regarding the melanoma registration practice in their countries and the characteristics, coverage and variables collected by the relevant melanoma registries. RESULTS Data regarding 13 melanoma registries from 11 European countries contributed to the study. The majority (61,5%) were population based registries and more than half (62%) had national coverage. The included registries collected a median of 38 variables (Interquartile Range, IRQ 21-76). We identified 24 shared variables available in >70% of registries. CONCLUSIONS This study provides valuable specific information on information recorded for melanoma cases are registered within Europe. A core of shared variables has been identified, which will constitute the basis for a standardized set of QA indicators for assessing and monitoring melanoma care across European countries.
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Affiliation(s)
| | - Ana-Maria Forsea
- Carol Davila University of Medicine and Pharmacy, Bucharest, Elias University Hospital, Bucharest, Romania
| | | | | | - Esther Bastiaannet
- Department of Surgery Leiden University Medical Center, Leiden, The Netherlands
| | - Lorenzo Borgognoni
- Department of Plastic and Reconstructive Surgery, Tuscan Cancer Institute, Italy
| | | | - Claus Garbe
- University Hospital Tuebingen, Tuebingen, Germany
| | - Zivana Gavric
- Cancer Registry Republic of Srpska, Banja Luka, Republika Srpska, Bosnia and Herzegovina
| | | | - Kaire Innos
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Siri Larønningen
- The Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
| | - Marieke Louwman
- Netherlands Comprehensive Cancer Organisation, The Netherlands
| | - Trude Eid Robsahm
- The Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
| | - Piotr Rutkwoski
- Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland
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16
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Hieken TJ, Kane JM, Wong SL. The Role of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma. Ann Surg Oncol 2018; 26:1028-1034. [PMID: 30284132 DOI: 10.1245/s10434-018-6812-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE AND METHODS Completion lymph node dissection (CLND) for sentinel lymph node (SLN)-positive melanoma patients has been guideline-concordant standard of care since adoption of lymphatic mapping and SLN biopsy for the management of clinically node-negative melanoma patients more than 20 years ago. However, a trend for omission of CLND has been observed over the past decade, and we now have randomized, controlled clinical trial data to help guide treatment recommendations. Publication of these data prompted an American Society of Clinical Oncology-Society of Surgical Oncology 2018 clinical practice guideline update for these patients. RESULTS AND CONCLUSIONS Systematic review of current evidence supports a selective, individualized approach to CLND for SLN-positive melanoma. For low-risk, low-volume micrometastatic disease, SLN biopsy may be both diagnostic and therapeutic, and close clinical follow-up with imaging or CLND are reasonable options for appropriately selected patients. For higher-risk patients, omission of CLND requires careful consideration of risks versus benefits, relevant histopathology, and individualized patient discussion. This should address patient comorbidities and life expectancy, the predicted likelihood of additional positive nodes, availability of imaging surveillance, likelihood of adherence to imaging and clinical follow-up, consequences of regional recurrence, and the prognostic value of complete nodal staging and its impact on adjuvant therapy recommendations or clinical trial participation. Data on long-term outcomes, cost, and patient-reported quality of life measures are not yet available.
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Affiliation(s)
- Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| | - John M Kane
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sandra L Wong
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Wouters MW, Michielin O, Bastiaannet E, Beishon M, Catalano O, Del Marmol V, Delgado-Bolton R, Dendale R, Trill MD, Ferrari A, Forsea AM, Kreckel H, Lövey J, Luyten G, Massi D, Mohr P, Oberst S, Pereira P, Prata JPP, Rutkowski P, Saarto T, Sheth S, Spurrier-Bernard G, Vuoristo MS, Costa A, Naredi P. ECCO essential requirements for quality cancer care: Melanoma. Crit Rev Oncol Hematol 2018; 122:164-178. [PMID: 29458785 DOI: 10.1016/j.critrevonc.2017.12.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 12/31/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ECCO essential requirements for quality cancer care (ERQCC) are explanations and descriptions of challenges, organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe. MELANOMA ESSENTIAL REQUIREMENTS FOR QUALITY CARE: CONCLUSION: Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality service for melanoma. The ERQCC expert group is aware that it is not possible to propose a 'one size fits all' system for all countries, but urges that access to multidisciplinary teams and specialised treatments is guaranteed to all patients with melanoma.
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Affiliation(s)
- Michel W Wouters
- European Society of Surgical Oncology (ESSO); Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Olivier Michielin
- European Society for Medical Oncology (ESMO); Department of Oncology, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Esther Bastiaannet
- International Society of Geriatric Oncology (SIOG); Department of Surgery/Department of Medical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Orlando Catalano
- European Society of Radiology (ESR); Department of Radiology, National Cancer Institute Fondazione Pascale, Naples, Italy
| | - Veronique Del Marmol
- Association of European Cancer Leagues (ECL); Euromelanoma, European Academy of Dermatology and Venereology (EADV); Department of Dermatology and Venereology, Erasme Hospital, ULB, Brussels, Belgium
| | - Roberto Delgado-Bolton
- European Association of Nuclear Medicine (EANM); Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, San Pedro Hospital and Centre for Biomedical Research of La Rioja (CIBIR), University of La Rioja, Logroño, La Rioja, Spain
| | - Rémi Dendale
- European Society for Radiotherapy and Oncology (ESTRO); Radiation Oncology Department, Institut Curie, Paris, France
| | - Maria Die Trill
- International Psycho-Oncology Society (IPOS); ATRIUM: Psycho-Oncology & Clinical Psychology, Madrid, Spain
| | - Andrea Ferrari
- European Society for Paediatric Oncology (SIOPE); Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Ana-Maria Forsea
- European Association of Dermato Oncology (EADO); Dermatology Department, Elias University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Hannelore Kreckel
- European Society of Oncology Pharmacy (ESOP); Pharmacy Department, University Hospital Giessen and Marburg, Giessen, Germany
| | - József Lövey
- Organisation of European Cancer Institutes (OECI); National Institute of Oncology, Budapest, Hungary
| | - Gre Luyten
- Ocular Oncology Group (OOG); Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniela Massi
- European Society of Pathology (ESP); Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Peter Mohr
- European Society of Skin Cancer Prevention (EUROSKIN); Elbe-Klinikum Buxtehude, Buxtehude, Germany
| | - Simon Oberst
- Organisation of European Cancer Institutes (OECI); Cambridge Cancer Centre, Cambridge, UK
| | - Philippe Pereira
- Cardiovascular and Interventional Radiological Society of Europe (CIRSE); Clinic for Radiology, Minimally-Invasive Therapies and Nuclear Medicine, SLK-Clinics Heilbronn, Karl-Ruprecht-University of Heidelberg, Heilbronn, Germany
| | - João Paulo Paiva Prata
- European Oncology Nursing Society (EONS); Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
| | - Piotr Rutkowski
- European Organisation for Research and Treatment of Cancer (EORTC); Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | - Tiina Saarto
- European Association for Palliative Care (EAPC); Comprehensive Cancer Center, Department of Palliative Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sapna Sheth
- European CanCer Organisation, Brussels, Belgium
| | - Gilly Spurrier-Bernard
- European CanCer Organisation (ECCO) Patient Advisory Committee; Melanoma Patient Network Europe; Paris, France
| | - Meri-Sisko Vuoristo
- Association of European Cancer Leagues (ECL); Pirkanmaa Cancer Society, Tampere, Finland
| | | | - Peter Naredi
- European CanCer Organisation (ECCO); Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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