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Carmona-Rocha E, Rusiñol L, García-Melendo C, Iznardo H, Mozos A, López-Sánchez C, Yélamos O. Lentigo maligna: a comprehensive review on diagnosis and treatment. Ital J Dermatol Venerol 2024; 159:390-411. [PMID: 39069838 DOI: 10.23736/s2784-8671.24.07837-x] [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: 07/30/2024]
Abstract
Lentigo maligna (LM), a form of melanoma in situ, and LM melanoma (LMM), its invasive counterpart, exhibit distinctive epidemiology, risk factors, and clinical features compared to other melanoma subtypes. Notably, LM occurs on chronically sun-damaged skin presenting as a slow-growing, ill-defined patch which makes it difficult to diagnose and to treat. Additionally, while LM generally presents a favourable prognosis, it can also lead to dermal invasion and behave similarly to other melanomas with the same Breslow thickness. Hence, surgery continues to be the cornerstone treatment. Wide excisions are often necessary, but challenges arise when these lesions manifest in cosmetically sensitive regions, limiting the feasibility and desirability of large excisions. Specialized approaches, including margin-controlled surgery and image-guided treatment with reflectance confocal microscopy, have been developed to address these issues. Other non-surgical treatments such as cryosurgery, imiquimod, radiotherapy, or photodynamic therapy, may also be used but commonly present with recurrent/persistent disease. Herein we comprehensively review the existing literature on the management of LM/LMM, and discus the potential new advances on managing this challenging skin cancer.
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Affiliation(s)
- Elena Carmona-Rocha
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Lluís Rusiñol
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
| | | | - Helena Iznardo
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Anna Mozos
- Anatomical Pathology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cristina López-Sánchez
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
| | - Oriol Yélamos
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain -
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
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2
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Bakeman AE, Tong L, Rhee JS, Friedland DR, Adams JA, Luo J, Kasprzak JM, Pawar SS. Wound Healing Complications Associated with Staged Reconstruction after Facial Lentigo Maligna Resection. Facial Plast Surg Aesthet Med 2024. [PMID: 39056115 DOI: 10.1089/fpsam.2023.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
Background: The rates and risk factors for wound complications following staged reconstruction after facial lentigo maligna (LM) resection have not been well described. Objectives: (1) To identify the rate and types of wound complications, including infection, graft necrosis, distal flap necrosis, hematoma, superficial epidermolysis, and seroma among patients undergoing staged reconstruction after resection of LM as documented in the surgeon's clinical notes within 30 days of the procedure. (2) To determine a threshold defect size that may predict the development of wound complications. Design and Outcomes: Retrospective review at an academic medical center of patients who underwent staged reconstruction after facial LM resection over a 5-year period. Results: Ninety-eight patients were identified with a mean age of 69.2 ± 13.6 years; 37% of patients were female. The most common defect sites were the cheek (n = 41; 42%) and nose (n = 22; 22%). Twenty-five of 98 patients (26%) demonstrated complications, with the most common being wound infection (36%) and graft necrosis (24%). Those receiving perioperative antibiotics had lower rates of complication (odds ratio [OR]: 0.36; 95% confidence interval [CI]: 0.13,0.96; p = 0.041). Defects greater than 2.7 cm in maximal diameter had the highest sensitivity for predicting complications. Conclusions: Patients undergoing staged reconstruction after facial LM resection have a high rate of wound complication (26%) and defect size > 2.7 cm may be an important risk factor.
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Affiliation(s)
- Anna E Bakeman
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ling Tong
- Department of Health Informatics and Administration, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - John S Rhee
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David R Friedland
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jazzmyne A Adams
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jake Luo
- Department of Health Informatics and Administration, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julia M Kasprzak
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sachin S Pawar
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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3
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Contestable JJ, Lim GFS, Willenbrink T, Zitelli JA, Brodland DG. Mohs for Melanoma: A Review of MART-1 Frozen Section Interpretation. Dermatol Surg 2024:00042728-990000000-00867. [PMID: 38975654 DOI: 10.1097/dss.0000000000004312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
BACKGROUND Mohs surgery for melanoma has been performed for many decades, but advances in the use of immunohistochemistry with frozen sections during Mohs surgery have allowed for more accurate, reliable, and efficient margin assessment with improved local control of the disease. OBJECTIVE To describe the use of MART-1 in treating melanoma with Mohs surgery and serve as a primer for the Mohs surgeon adding melanoma cases to their repertoire. MATERIALS AND METHODS Review of the literature and discussion of experience with Mohs for melanoma. RESULTS Practical approach and pitfalls when assessing margins using MART-1 immunohistochemistry during Mohs surgery for the treatment of melanoma. CONCLUSION Mohs for melanoma is an expanding field-education of Mohs surgeons and increasing the practice of this technique has the potential to improve patient outcomes.
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Affiliation(s)
- James J Contestable
- Department of Dermatology, Uniformed Services University, Bethesda, Maryland
| | - Geoffrey F S Lim
- Department of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tyler Willenbrink
- Department of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John A Zitelli
- Department of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David G Brodland
- Department of Dermatology, Otolaryngology, and Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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4
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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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5
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Freeman SC, Dacy NN, Neill BC, Chisholm C, Tolkachjov SN. Intraneural Melanoma Identified With MART-1 Immunostaining in Mohs Micrographic Surgery. Cureus 2024; 16:e58920. [PMID: 38800274 PMCID: PMC11121584 DOI: 10.7759/cureus.58920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Mohs micrographic surgery (MMS) utilizing melanoma antigen recognized by T-cells (MART-1) immunostaining is an increasingly common method of treatment for minimally invasive melanoma in anatomically constrained areas such as the face, ears, or acral sites. Neurotropic melanoma, also known as neurotrophism in melanoma, refers to the invasion of melanoma cells into the nerves. As such, these tumors can extend well beyond anticipated clinical tumor margins which can increase the risk of local recurrence. Here, we present a case of neurotropic melanoma successfully identified during MMS using MART-1 immunostaining, which was then confirmed with permanent sectioning.
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Affiliation(s)
- S Caleb Freeman
- Dermatology, Oregon Health & Science University, Portland, USA
| | - Nicole N Dacy
- Dermatology, Baylor Scott & White Medical Center, Temple, USA
| | - Brett C Neill
- Dermatology and Mohs Micrographic Surgery, Swann Dermatology, Springfield, USA
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6
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Hirotsu KE, Kibbi N, Rieger KE, Aasi SZ. Histopathologic Characterization of Incidental Lesions Encountered During Mohs Micrographic Surgery With MART-1 Immunohistochemistry. Dermatol Surg 2024; 50:234-240. [PMID: 38064448 DOI: 10.1097/dss.0000000000004048] [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: 03/02/2024]
Abstract
BACKGROUND As the use of melanoma antigen recognized by T cells (MART-1) immunohistochemistry (IHC) with Mohs surgery increases for the treatment of melanoma in situ and invasive melanoma, surgeons should be aware of MART-1 staining patterns of incidental lesions often encountered on frozen sections. Lack of this knowledge can lead to unnecessary additional surgery, increased health care costs, and loss of valuable laboratory staff time and resources. OBJECTIVE To characterize the histopathologic features of incidental lesions encountered during Mohs surgery for melanoma. To review key diagnostic and differentiating features on hematoxylin and eosin staining (H&E) and MART-1 IHC of these lesions. METHODS A comprehensive review of frozen-section histopathology slides from Mohs cases with MART-1 IHC at our institution was conducted from 2021 to 2023. RESULTS Incidental benign and malignant lesions were identified and characterized on H&E frozen sections and MART-1 IHC. Although such entities can share MART-1 staining characteristics with melanoma in situ or melanoma, distinguishing characteristics on H&E and lack of histopathologic criteria for melanoma on MART-1 IHC can be used to distinguish these incidental lesions from melanoma. CONCLUSION Staining of frozen sections for Mohs micrographic surgery with H&E and MART-1 IHC together can differentiate common incidental benign and malignant cutaneous lesions from melanoma.
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Affiliation(s)
- Kelsey E Hirotsu
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Kerri E Rieger
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Sumaira Z Aasi
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
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7
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Pakhchanian H, Aizman L, Raiker R, Ng E. Top 100 Most Cited Articles in Mohs Micrographic Surgery: A Bibliometric Analysis. Dermatol Surg 2024; 50:137-143. [PMID: 37994504 DOI: 10.1097/dss.0000000000004023] [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: 11/24/2023]
Abstract
BACKGROUND Bibliometric analysis is a scientific method that can derive insights into major publications' trends within a field. Currently, no bibliometric study has been conducted for Mohs micrographic surgery (MMS). OBJECTIVE To characterize the most frequently cited articles in MMS. METHODS Web of Science was used to identify the 100 most cited publications on MMS between 1970 and 2022. Articles were analyzed by title, authorship, institution, journal, year, citation frequency, originating country, funding, citation index, Altmetric score, impact factor, Eigenfactor score, and article influence score. RESULTS Since January 2023, the top 100 articles had 9,096 total citations, ranging from 47 to 304. The top cited publication was "Mohs surgery is the treatment of choice for recurrent (previously treated) basal-cell carcinoma" in 1989. The top contributing organization was Harvard University (17%) and top contributing authors were Brodland, DJ (12%) and Zitelli, JA (11%). The year 2005 accounted for most of the articles (12%). Most articles were from the Journal of the American Academy of Dermatology (32%) and Dermatologic Surgery (27%). The United States contributed to 76% of the top articles. CONCLUSION This bibliometric analysis offers researchers a detailed overview of important MMS publications and provides useful data into current findings steering MMS research and practice.
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Affiliation(s)
- Haig Pakhchanian
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Leora Aizman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rahul Raiker
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Elise Ng
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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8
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Elgash M, Young J, White K, Leitenberger J, Bar A. An Update and Review of Clinical Outcomes Using Immunohistochemical Stains in Mohs Micrographic Surgery for Melanoma. Dermatol Surg 2024; 50:9-15. [PMID: 37738278 DOI: 10.1097/dss.0000000000003945] [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: 09/24/2023]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) provides optimal margin control through complete peripheral and deep margin assessment. The treatment of melanoma using MMS has historically been limited by difficulty in interpreting melanocytes using frozen sections. Immunohistochemical (IHC) staining, a technique whereby chromogen-tagged antibodies are used to detect antigens of interest, has revolutionized the surgical treatment of melanoma. OBJECTIVES This article provides an update and literature review of current IHC stains used in MMS for melanoma, their sensitivities and specificities, and clinical outcomes. MATERIALS AND METHODS A PubMed search was performed using keywords including "immunohistochemistry," "staining," and "Mohs surgery." Articles related to the use of IHC staining for the treatment of melanoma with MMS were included. RESULTS Six IHC stains met the criteria for the review including melanoma antigen recognized by T cells (MART-1), SRY-related HMG-box (SOX10), microphthalmia-associated transcription factor, HMB-45, MEL-5, S-100, and preferentially expressed antigen in melanoma. CONCLUSION The adaptation of IHC methods to frozen sections has enabled MMS to become a preferred treatment option for melanoma in special-site areas. Future studies are needed to standardize IHC techniques and to define best practices when using frozen section in the treatment of melanoma.
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Affiliation(s)
- May Elgash
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Jade Young
- Oregon Health and Science University, School of Medicine, Portland, Oregon
| | - Kevin White
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Justin Leitenberger
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Anna Bar
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
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9
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Xia J, Patel H, Guo L, Hsu C, Revankar R, Torbeck R. The use of immunohistochemical staining in Mohs micrographic surgery for melanoma: a systematic review. Arch Dermatol Res 2023; 315:2769-2772. [PMID: 37603089 DOI: 10.1007/s00403-023-02711-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/27/2023] [Accepted: 08/13/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Joyce Xia
- Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd., Stony Brook, NY, 11794, USA.
| | - Heli Patel
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Lily Guo
- Chicago Medical School at Rosalind Franklin University, North Chicago, IL, USA
| | - Cynhia Hsu
- Chicago Medical School at Rosalind Franklin University, North Chicago, IL, USA
| | - Rishab Revankar
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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10
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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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11
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Beal BT, Udkoff J, Aizman L, Etzkorn J, Zitelli JA, Miller CJ, Shin TM, Sobanko JF, Brodland DG. Outcomes of invasive melanoma of the head and neck treated with Mohs micrographic surgery - A multicenter study. J Am Acad Dermatol 2023; 89:544-550. [PMID: 36642331 DOI: 10.1016/j.jaad.2022.12.038] [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: 07/05/2021] [Revised: 11/16/2022] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Brandon T Beal
- St. Louis Dermatology & Cosmetic Surgery, St. Louis Skin Cancer Specialists, Troy, Missouri.
| | - Jeremy Udkoff
- Department of Dermatology, University of Pittsburgh Medical Center, Philadelphia, Pennsylvania
| | - Leora Aizman
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jeremy Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John A Zitelli
- University of Pittsburgh Medical Center, Zitelli & Brodland, PC, Pittsburgh, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - 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
| | - David G Brodland
- University of Pittsburgh Medical Center, Zitelli & Brodland, PC, Pittsburgh, Pennsylvania
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12
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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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13
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Miller CJ, Etzkorn JR, Leitenberger JJ, Bar A, Baum CL, Brewer JD, Srivastava D, Nijhawan RI. Commentary on "Limitations in the literature regarding Mohs surgery and staged excision for melanoma: A critical review of quality and data reporting". J Am Acad Dermatol 2023; 88:511-512. [PMID: 33872720 DOI: 10.1016/j.jaad.2021.03.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Christopher J Miller
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anna Bar
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | | | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Divya Srivastava
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
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14
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Elshot YS, Tio DCKS, van Haersma-de With ASE, Ouwerkerk W, Zupan-Kajcovski B, Crijns MB, Limpens CEJM, Klop WMC, Bekkenk MW, Balm AJM, de Rie MA. Lentigo maligna (melanoma): A systematic review and meta-analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy. J Eur Acad Dermatol Venereol 2023; 37:871-883. [PMID: 36652277 DOI: 10.1111/jdv.18880] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non-Randomized Studies instrument. Meta-analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline-recommended margin was insufficient in 21.6%-44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%-1.9%), and highest for WLE (13%; 95% CI, 7.2%-21.6%). The mean follow-up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld-RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma-associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH-RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
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Affiliation(s)
- Y S Elshot
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - D C K S Tio
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - W Ouwerkerk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection & Immunity Institute, Cancer Center, University of Amsterdam, Amsterdam, The Netherlands.,National Heart Centre Singapore, Singapore, Singapore
| | - B Zupan-Kajcovski
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M B Crijns
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - C E J M Limpens
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W M C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Bekkenk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Rie
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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15
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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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16
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Ahn GS, Pousti B, Singh G, Elsensohn A, Jiang SIB. No Recurrence in Primary Invasive Stage 1a and 1b Melanoma and Melanoma in Situ Treated With Serial Disk Staged Excision. Dermatol Surg 2022; 48:276-282. [PMID: 34935746 DOI: 10.1097/dss.0000000000003357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal surgical treatment modality for invasive melanoma (IM) and melanoma in situ (MIS) has been debated with proponents for standard wide local excision (WLE), serial disk staged excision, and Mohs micrographic surgery. OBJECTIVE The purpose of this study is to identify the recurrence rates and surgical margins of invasive stage 1 melanoma and MIS lesions using serial disk staged excision technique with rush permanent processing and "bread loafing" microscopic analysis. MATERIALS AND METHODS Recurrence rates and surgical margins of 63 IM and 207 MIS at the University of California Dermatology Surgery Unit were retrospectively reviewed. RESULTS No recurrences were observed with average follow-up of 34 and 36 months for IM and MIS, respectively (range, 10-92 months). Average surgical margins were 19.8 mm (SD 9.7) for IM and 12.1 mm (SD 12.2) for MIS. CONCLUSION This SSE technique for the treatment of IM and MIS is comparable in efficacy to other SSE techniques, and it offers physicians a simple and accessible alternative to WLE and MMS.
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Affiliation(s)
- Grace Sora Ahn
- All authors are affiliated with the Department of Dermatology, University of California San Diego, La Jolla, California
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17
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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: 4] [Impact Index Per Article: 1.3] [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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18
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MacArthur KM, Baumann BC, Sobanko JF, Etzkorn JR, Shin TM, Higgins HW, Giordano CN, McMurray SL, Krausz A, Newman JG, Rajasekaran K, Cannady SB, Brody RM, Karakousis GC, Miura JT, Cohen JV, Amaravadi RK, Mitchell TC, Schuchter LM, Miller CJ. Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery. Cancer 2021; 127:3591-3598. [PMID: 34292585 DOI: 10.1002/cncr.33651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/30/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen-section MART-1 immunohistochemical stains (MMS-IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS-IHC. METHODS This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS-IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes. RESULTS In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a-T4b) were treated with MMS-IHC. The median patient age was 69 years (range, 25-101 years). Ninety-two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB-eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB-eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%). CONCLUSIONS Combining SLNB and MMS-IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS-IHC.
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Affiliation(s)
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - H William Higgins
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Cerrene N Giordano
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Stacy L McMurray
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Aimee Krausz
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Robert M Brody
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Justine V Cohen
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ravi K Amaravadi
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Tara C Mitchell
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Lynn M Schuchter
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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