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

Implications of Malignancy, Radiation, and Timing of Major Nasal Reconstruction

Owing to the complex, multilayered anatomy of the nose in the central face, major nasal reconstruction can pose a significant challenge for reconstructive surgeons. It is the responsibility of reconstructive surgeons to have an understanding of the most common cutaneous malignancies and excisional techniques that may lead to complex nasal defects. The purpose of this article is to discuss these malignancies, excisional techniques, and impacts of radiation on tissue that has implications for reconstructive surgeons.

Outcomes of invasive melanoma of the head and neck treated with Mohs micrographic surgery - A multicenter study

BACKGROUND

There are no randomized controlled trials to guide surgical margins for invasive head and neck (H&N) melanoma using conventional excision. Mohs micrographic surgery (MMS) has shown improved local recurrence rates and survival for invasive H&N melanomas.

OBJECTIVE

Determine local recurrence (LR), nodal recurrence, and distant recurrence rates, and disease specific survival for invasive melanoma of the H&N treated with MMS.

METHODS

A retrospective multicenter study of 785 cases of invasive H&N melanoma treated with MMS using frozen sections with melanoma antigen recognized by T-cells 1 immunohistochemical staining was performed to evaluate long-term outcomes over 12-years.

RESULTS

785 melanomas (thickness: 0.3 mm-8.5 mm) were treated with MMS. LR, nodal recurrence, and distant recurrence rates were 0.51% (4/785), 1.0% (8/785), and 1.1% (9/785) respectively. For T1, T2, T3, and T4 tumors LR was 0.16% (1/636), 1.18% (1/85), 2.22% (1/45), and 5.26% (1/19), respectively. Five and 10-year disease specific survival were 96.8% (95% CI 95.0% to 98.5%) and 93.4% (95% CI 88.5% to 98.3%).

LIMITATIONS

A nonrandomized retrospective study.

CONCLUSION

MMS achieves significant improvements in LR compared to a meta-analysis of historical cohorts of patients treated with conventional excision. MMS should be considered an important surgical option for invasive H&N melanoma.

Slow Mohs micrographic surgery for nail apparatus melanoma in situ

BACKGROUND

Nail apparatus melanoma is a malignant tumor with a high incidence in Chinese melanoma patients. Slow Mohs micrographic surgery is an emerging technique for treating nail apparatus melanoma in situ (NAMIS).

OBJECTIVE

This study evaluated the efficacy and safety of slow Mohs micrographic surgery for treating NAMIS.

METHODS

Patients were enrolled in this retrospective study and treated in a single center from October 1, 2016, to June 30, 2022. Each patient underwent standard slow Mohs micrographic surgery, and follow-up was regularly conducted at clinics.

RESULTS

Ten patients were enrolled in the study. Two patients underwent one Mohs stage, seven underwent two Mohs stages, and one underwent seven Mohs stages. The resection margin ranged from 5 to 25 mm. No severe complications were reported in the treatment, and recurrence of NAMIS was not observed during the follow-up period.

CONCLUSION

Slow Mohs micrographic surgery is a valuable surgical method to treat NAMIS that preserves digit function and can be well tolerated by patients.

Association of Excision Margin Size With Local Recurrence and Survival in Patients With T1a Melanoma at Critical Structures

Importance

Melanoma guidelines recommend surgical excision with 10-mm margins for T1 melanoma. However, this procedure may be problematic at sites close to critical structures such as the scalp, face, external genitalia, acral, periumbilical, and perineal areas.

Objective

To compare outcomes of wide (10-mm margins) vs narrow (5-mm margins) excision in patients with T1a melanoma near critical structures.

Design, Setting, and Participants

This cohort study was a retrospective comparison of 1341 consecutive patients aged 18 years or older from the National Cancer Institute of Milan, Italy, diagnosed between 2001 and 2020 with T1a cutaneous melanoma close to critical structures who accepted wide excision vs narrow excision.

Exposures

Local recurrence and melanoma-specific mortality (MSM) rates with 5-mm vs 10-mm excision margins.

Main Outcomes and Measures

The primary aim of the study was to ascertain whether a narrower (5-mm) vs wider (10-mm) excision margin was associated with local recurrence and MSM. The secondary aim was to compare the need for reconstructive surgery in the groups defined by excision margin width. Between April 28 and August 7, 2022, associations were assessed by weighted Cox and Fine-Gray univariable and multivariable models.

Results

A total of 1179 patients met the inclusion criteria (median [IQR] age, 50.0 [39.5-63.0] years; female, 610 [51.7%]; male, 569 [49.3%]). Six hundred twenty-six patients (53.1%) received a wide excision (434 [69.3%] with linear repair and 192 [30.7%] with flap or graft reconstruction) and 553 (46.9%) received a narrow excision (491 [88.8%] with linear repair and 62 [11.2%] with flap or graft reconstruction). The weighted 10-year MSM was 1.8% (95% CI, 0.8%-4.2%) in the wide group and 4.2% (95% CI, 2.2%-7.9%) in the narrow group; the weighted 10-year local recurrence rate was 5.7% (95% CI, 3.9%-8.3%) in the wide group and 6.7% (95% CI, 4.7%-9.5%) in the narrow group. Breslow thickness greater than 0.4 mm (subdistribution hazard ratio [sHR] for 0.6 vs 0.4 mm, 2.42; 95% CI, 1.59-3.68; P < .001) and mitotic rate greater than 1/mm2 (sHR for a single increment, 3.35; 95% CI, 2.59-4.32; P < .001) were associated with worse MSM. Multivariable analysis showed that acral lentiginous melanoma, lentigo maligna melanoma, and increasing Breslow thickness were associated with a higher incidence of local recurrence.

Conclusions and Relevance

The study's findings suggest that local excision with 5-mm margins for T1a melanoma may not be associated with an increased risk of local recurrence. Breslow thickness greater than 0.4 mm, mitotic rate greater than 1/mm2, and acral lentiginous melanoma and lentigo maligna melanoma subtypes were associated with a higher risk of recurrence. These findings may be useful for future melanoma treatment guidelines.

Permanent section margin concordance after Mohs micrographic surgery with immunohistochemistry for invasive melanoma and melanoma in situ: A retrospective dual-center analysis

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.

Lentigo Maligna of the head and neck: A retrospective study assessing surgical excision margins in a South African population

Background

Lentigo maligna (LM) is a subtype of melanoma in situ that occurs on sun-damaged skin and is associated with significant subclinical extension beyond the clinical margins of the lesion.

Objectives

This study aimed to determine if the standard recommended tumor excision margins for LM are adequate to achieve a 97% clearance rate and if any patient or tumor characteristics warranted wider margins.

Methods

This study is a retrospective chart review of all patients who were diagnosed with LM of the head and neck and treated with staged excision.

Results

The study included 64 patients. With a 6 mm surgical excision margin, only 60.9% of LM were completely excised. A 9 mm margin resulted in complete clearance of 71.9% of LM cases, and a 12 mm margin resulted in complete clearance in 90.6%. A surgical excision margin of 18 mm would have been required to excise 96.7% of tumors completely. Recurrent tumors (P = .01) and tumor size larger than 20 mm were associated with wider surgical excision margins (P = .154).

Conclusion

This study of LM in a South African population corroborates that the standard surgical excision margins recommended by international melanoma guidelines for LM are inadequate to achieve a 97% clearance rate.

Slow Mohs Micrographic Surgery for Acral Melanoma Treatment in Korean Patients

BACKGROUND

Obtaining conventional wide surgical margins is challenging in melanomas occurring at anatomically complex sites (e.g., hands and feet).

OBJECTIVE

We investigated the potential benefits of slow Mohs micrographic surgery (MMS) for acral melanomas.

MATERIALS AND METHODS

This single-center retrospective study investigated 210 patients who underwent slow MMS (n = 66) or wide local excision (WLE, n = 144) for melanomas during 2005 to 2015. Slow MMS was used for melanomas in anatomically complex locations and for high-risk lesions.

RESULTS

Acral melanoma (166/210) was the most common lesion observed in patients, in addition to head and neck (21/210) and trunk (23/210) melanomas. Slow MMS was more commonly performed for acral, and head and neck melanomas (32.5% and 52.4%, respectively) than for trunk melanomas (4.3%, p = .002). Local recurrence of acral melanomas occurred in 3.7% of patients after slow MMS and in 10.7% of patients after WLE. Multivariate analysis showed comparable prognostic outcomes between slow MMS and WLE used for acral melanomas. Compared with WLE, slow MMS resulted in a smaller postoperative defect after acral lesion excision (p < .001).

CONCLUSION

Slow MMS is an effective alternative to WLE for acral melanomas in anatomically complex sites, as evidenced by superior outcomes and maximum tissue conservation.