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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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Chen A, Ray P, Rogers H, Bialowas C, Butala P, Chen M, Daveluy SD, Davidson C, Faringer P, Guarda H, Kantor J, Kaweski S, Lawrence N, Lickstein D, Lomax J, Parra S, Retson N, Suryadevara A, Smith R, Tollefson TT, Wisco OJ. Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set. Plast Reconstr Surg 2024; 153:424e-441e. [PMID: 38266139 DOI: 10.1097/prs.0000000000010916] [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: 01/26/2024]
Abstract
BACKGROUND The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative. METHODS Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins. RESULTS All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies. CONCLUSION The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.
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Affiliation(s)
| | - Peter Ray
- East Hills Professional Center and Marshall University Joan C. Edwards School of Medicine
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3
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Zitelli JA, Stiegel E, Brodland DG. The Controversy and Value of Mohs Micrographic Surgery for Melanoma and Melanoma in Situ on the Trunk and Extremities. Dermatol Surg 2023; 49:1061-1065. [PMID: 37962134 DOI: 10.1097/dss.0000000000004002] [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: 11/15/2023]
Abstract
BACKGROUND The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world. OBJECTIVE The purpose of this article is to expose the value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines. MATERIALS AND METHODS This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery. RESULTS The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma. CONCLUSION Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression.
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Affiliation(s)
- John A Zitelli
- Department of Dermatology, Otolaryngology, Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Evan Stiegel
- Wilson Dermatology Clinic, The Skin Surgery Center, Wilson, North Carolina
| | - David G Brodland
- Department of Dermatology, Otolaryngology, Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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A Cost Comparison Between Mohs Micrographic Surgery and Conventional Excision for the Treatment of Head and Neck Melanomas In Situ and Thin Melanomas. Dermatol Surg 2023; 49:445-450. [PMID: 36877120 DOI: 10.1097/dss.0000000000003751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Variation in operative setting and surgical technique exists when treating specialty site melanomas. There are limited data comparing costs among surgical modalities. OBJECTIVE To evaluate the costs of head and neck melanoma surgery performed with Mohs micrographic surgery or conventional excision in the operating room or office-based settings. METHODS A retrospective cohort study was performed on patients aged 18 years and older with surgically treated head and neck melanoma in 2 cohorts, an institutional cohort and an insurance claims cohort, for the years 2008-2019. The primary outcome was total cost of care for a surgical encounter, provided in the form of insurance reimbursement data. A generalized linear model was used to adjust for covariates affecting differences between treatment groups. RESULTS In the institutional and insurance claims cohorts, average adjusted treatment cost was highest in the conventional excision-operating room treatment group, followed by the Mohs surgery and conventional excision-office setting (p < .001). CONCLUSION These data demonstrate the important economic role the office-based setting has for head and neck melanoma surgery. This study allows cutaneous oncologic surgeons to better understand the costs of care involved in head and neck melanoma treatment. Cost awareness is important for shared decision-making discussions with patients.
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Young JN, Nguyen TA, Freeman SC, Hill E, Johnson M, Gharavi N, Bar A, Leitenberger J. Permanent section margin concordance after Mohs micrographic surgery with immunohistochemistry for invasive melanoma and melanoma in situ: A retrospective dual-center analysis. J Am Acad Dermatol 2023; 88:1060-1065. [PMID: 36720365 DOI: 10.1016/j.jaad.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) for melanoma practices vary among dermatologic surgeons. The implementation of immunohistochemical staining in MMS for melanoma mitigates challenges associated with slide interpretation; however, the reliability of melanoma antigen recognized by T cells 1 (MART-1), the preferred immunostain for melanoma, has yet to be compared with permanent section pathology. OBJECTIVE To assess concordance rates of MART-1 frozen sections and permanent section pathologic interpretation of melanoma treated with MMS. METHODS A dual-center retrospective analysis was conducted to collect concordance and demographic data. Chi-square tests were performed for group comparisons of categorical variables. RESULTS Of the 379 permanent sections sent, 367 were concordant with frozen section pathology for an overall concordance rate of 96.8%. Cases were stratified into indeterminately concordant and indisputably concordant. Twenty-two (6%) of cases were indeterminately concordant, whereas 345 (94.0%) of cases were indisputably concordant. LIMITATIONS The concordance rate is derived from a comparison of adjacent tissue margins, an inevitable consequence of utilizing 2 techniques. CONCLUSION To the author's knowledge, this study represents the largest investigation examining concordance rates of MART-1 frozen sections in Mohs for melanoma. High concordance disputes the ongoing need for additional permanent margins when using MART-1 in routine cases.
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Affiliation(s)
- Jade N Young
- School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Tuyet A Nguyen
- Department of Dermatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - S Caleb Freeman
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Emma Hill
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | | | - Nima Gharavi
- Department of Dermatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anna Bar
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Justin Leitenberger
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon.
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Mohs Micrographic Surgery for Melanoma. Dermatol Clin 2022; 41:79-88. [DOI: 10.1016/j.det.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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Yong ASJ, Lim YH, Cheong MWL, Hamzah E, Teoh SL. Willingness-to-pay for cancer treatment and outcome: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1037-1057. [PMID: 34853930 DOI: 10.1007/s10198-021-01407-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Understanding patient preferences in cancer management is essential for shared decision-making. Patient or societal willingness-to-pay (WTP) for desired outcomes in cancer management represents their preferences and values of these outcomes. OBJECTIVE The aim of this systematic review is to critically evaluate how current literature has addressed WTP in relation to cancer treatment and achievement of outcomes. METHODS Seven databases were searched from inception until 2 March 2021 to include studies with primary data of WTP values for cancer treatments or achievement of outcomes that were elicited using stated preference methods. RESULTS Fifty-four studies were included in this review. All studies were published after year 2000 and more than 90% of the studies were conducted in high-income countries. Sample size of the studies ranged from 35 to 2040, with patient being the most studied population. There was a near even distribution between studies using contingent valuation and discrete choice experiment. Based on the included studies, the highest WTP values were for a quality-adjusted life year (QALY) ($11,498-$589,822), followed by 1-year survival ($3-$198,576), quality of life (QoL) improvement ($5531-$139,499), and pain reduction ($79-$94,662). Current empirical evidence suggested that improvement in QoL and pain reduction had comparable weights to survival in cancer management. CONCLUSION This systematic review provides a summary on stated preference studies that elicited patient preferences via WTP and summarised their respective values. Respondents in this review had comparable WTP for 1-year survival and QoL, suggesting that improvement in QoL should be emphasised together with survival in cancer management.
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Affiliation(s)
- Alene Sze Jing Yong
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia
| | - Yi Heng Lim
- School of Biosciences, Taylor's University, Subang Jaya, Selangor, Malaysia
| | - Mark Wing Loong Cheong
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia
| | | | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia.
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8
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Vieira C, Jennings T, Renzi MA, Lawrence N, Decker A. Recurrence Rate for Melanoma Excised by Mohs Micrographic Surgery Without Immunostaining. Dermatol Surg 2022; 48:492-497. [PMID: 35298442 DOI: 10.1097/dss.0000000000003435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) is becoming increasingly popular for the treatment of cutaneous melanoma (CM) as multiple studies have demonstrated favorable outcomes for local recurrence and overall survival. OBJECTIVE To analyze the outcomes of noninvasive (NIM) and invasive melanomas (IM) using MMS with fresh frozen sections. The primary outcome was local recurrence. The secondary outcome was to identify mean surgical margins based on tumor type and location. METHODS Retrospective cohort study of 224 cases of CM treated from 2006 to 2016 at a tertiary academic center with MMS and fresh frozen sections by a single Mohs surgeon. RESULTS The overall recurrence rate was 2.6% with a mean follow-up of 36.2 months. The recurrence rate for NIM versus IM was 1.6% and 7%, respectively. The mean margins for NIM and IM were 7.9 mm and 10.1 mm, respectively. These varied by tumor site and location. CONCLUSION This study supports the use of MMS in the treatment of CM and highlights how narrower surgical margins for NIM of the head and neck can be achieved without increasing risk of local recurrence.
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Affiliation(s)
- Carlos Vieira
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Tara Jennings
- Cooper Center for Dermatologic Surgery, Evesham, New Jersey
| | | | - Naomi Lawrence
- Cooper Center for Dermatologic Surgery, Evesham, New Jersey
| | - Ashley Decker
- Cooper Center for Dermatologic Surgery, Evesham, New Jersey
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9
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Jacobsen ES, Soleymani T. Mohs Micrographic Surgery for the Treatment of Cutaneous Melanomas of the Head and Neck. Oral Maxillofac Surg Clin North Am 2022; 34:263-271. [PMID: 35428505 DOI: 10.1016/j.coms.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Surgical excision achieving clear histologic margins remains the mainstay treatment for primary cutaneous melanoma. Tumors of the head and neck, particularly those arising in chronically sun-damaged skin, often demonstrate extensive and asymmetric subclinical extension. Over the decades, this has proven to be a significant problem for tumors arising on the head and neck, as anatomic and functional complexities of these areas have led to suboptimal surgical treatment, yielding unacceptably high rates of local recurrence and persistently positive margins with traditional wide local excision. Patients who undergo Mohs micrographic surgery may have improved survival over those who undergo wide local excision.
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Affiliation(s)
- Emilie S Jacobsen
- Division of Dermatologic Surgery, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Teo Soleymani
- Division of Dermatologic Surgery, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Mohs Micrographic and Reconstructive Surgery, Dermatologic Oncology, Pigmented Lesion and Melanoma Clinic, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
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10
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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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11
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Aizman L, Barbieri JS, Feit EM, Lukowiak TM, Perz AM, Shin TM, Miller CJ, Golda N, Leitenberger JJ, Carr DR, Nijhawan RI, Hasan A, Eisen DB, Etzkorn JR. Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment. Dermatol Surg 2021; 47:1214-1219. [PMID: 34081047 DOI: 10.1097/dss.0000000000003113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS Multi-center, prospective discrete choice experiment (DCE). RESULTS Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.
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Affiliation(s)
- Leora Aizman
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - John S Barbieri
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elea M Feit
- LeBow College of Business, Drexel University, Philadelphia, Pennsylvania
| | - Tess M Lukowiak
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Allison M Perz
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Thuzar M Shin
- 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
| | - Nicholas Golda
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Justin J Leitenberger
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - David R Carr
- Division of Dermatology, the Ohio State University Medical Center, Columbus, Ohio
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aliza Hasan
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Daniel B Eisen
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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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: 30] [Impact Index Per Article: 10.0] [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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Miller CJ, Bichakjian CK. Mohs Micrographic Surgery for Melanoma-Do Outcomes Vary Among Treatment Facilities? JAMA Dermatol 2021; 157:513-515. [PMID: 33787822 DOI: 10.1001/jamadermatol.2021.0022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christopher J Miller
- Penn Dermatology Oncology Center, Hospital of the University of Pennsylvania, Philadelphia
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14
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Patients Value Low Local Recurrence Rates and Prevention of Re-excisions With High-Risk Tumors. Dermatol Surg 2021; 47:410-412. [PMID: 32205756 DOI: 10.1097/dss.0000000000002372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Patient Satisfaction With Mohs Surgery for Melanoma In Situ. Dermatol Surg 2021; 47:288-290. [PMID: 31809345 DOI: 10.1097/dss.0000000000002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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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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Commentary on Recurrence and Mortality of Melanoma in Situ of the Trunk or Extremities. Dermatol Surg 2021; 47:6-7. [PMID: 33347001 DOI: 10.1097/dss.0000000000002626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Affiliation(s)
- Christopher J. Miller
- Penn Dermatology Oncology Center, Hospital of the University of Pennsylvania, Philadelphia
| | - Cerrene N. Giordano
- Department of Dermatology, Mount Sinai Icahn School of Medicine, New York, New York
| | - H. William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Okubo Y, Ho KA, Fifer S, Fujita H, Oki Y, Taguchi Y. Patient and physician preferences for atopic dermatitis injection treatments in Japan. J DERMATOL TREAT 2019; 31:821-830. [DOI: 10.1080/09546634.2019.1623860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yukari Okubo
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Kerrie-Anne Ho
- Community and Patient Preference Research Pty Ltd (CaPPRe), Sydney, Australia
| | - Simon Fifer
- Community and Patient Preference Research Pty Ltd (CaPPRe), Sydney, Australia
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20
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Lee MP, Zullo SW, Sobanko JF, Etzkorn JR. Patient-Centered Care in Dermatologic Surgery: Practical Strategies to Improve the Patient Experience and Visit Satisfaction. Dermatol Clin 2019; 37:367-374. [PMID: 31084730 DOI: 10.1016/j.det.2019.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patient-centered care in dermatologic surgery emphasizes addressing the preferences, values, and concerns of the surgical patient in an effort to improve the overall experience. Impediments affecting the delivery of Mohs micrographic surgical treatment of skin cancers are present throughout the perioperative period. Defining actionable strategies to improve outcomes can be challenging due to sparse literature and minimal high-quality scientific studies. This review focuses on the current evidence supporting practical recommendations in each surgical setting to improve the patient experience and increase visit satisfaction.
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Affiliation(s)
- Michael P Lee
- Department of Dermatology, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330S, Philadelphia, PA 19104, USA.
| | - Shannon W Zullo
- Department of Dermatology, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330S, Philadelphia, PA 19104, USA
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330S, Philadelphia, PA 19104, USA
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330S, Philadelphia, PA 19104, USA
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21
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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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22
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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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23
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Commentary: Moving beyond surveys to assess patient preferences. J Am Acad Dermatol 2018; 79:220. [PMID: 29627337 DOI: 10.1016/j.jaad.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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