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Vargas GM, Farooq MS, Karakousis GC. Adjuvant Therapy for High-Risk Stage II Melanoma: Current Paradigms in Management and Future Directions. Cancers (Basel) 2024; 16:2690. [PMID: 39123418 PMCID: PMC11312203 DOI: 10.3390/cancers16152690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Melanoma is the fifth most common cancer in the United States and accounts for the majority of all skin cancer-related deaths, making it the most lethal cutaneous malignancy. Systemic adjuvant therapy for stage IIB-IV melanoma is now approved for patients who have undergone surgical resection, given the appreciable risk of recurrence and mortality in this patient population. Despite the lower stage, high-risk stage II melanoma (stage IIB/IIC) can often exhibit an even more aggressive course when compared to stage IIIA/IIIB disease, thus justifying consideration of adjuvant therapy in these patients. In this review, we highlight the current standard of practice for the treatment of stage IIB/C melanoma, with a focus on adjuvant therapies supported by published landmark clinical trials, including anti-PD-1 therapy. Notably, adjuvant therapies approved thus far in this patient population have demonstrated an improvement in recurrence-free survival, while their impact on overall survival is pending. Finally, this review highlights currently ongoing trials and future directions for research and treatment possibilities for high-risk clinical stage II melanoma.
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Affiliation(s)
| | | | - Giorgos C. Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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李 思, 李 静, 杨 栖, 尹 存, 柳 斌. [Construction and Validation of Prediction Models of Risk Factors for Early Death in Patients With Metastatic Melanoma]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2024; 55:367-374. [PMID: 38645854 PMCID: PMC11026897 DOI: 10.12182/20240360101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 04/23/2024]
Abstract
Objective To construct nomogram models to predict the risk factors for early death in patients with metastatic melanoma (MM). Methods The study covered 2138 cases from the Surveillance, Epidemiology, and End Results Program (SEER) database and all these patients were diagnosed with MM between 2010 and 2015. Logistic regression was performed to identify independent risk factors affecting early death in MM patients. These risk factors were then used to construct nomograms of all-cause early death and cancer-specific early death. The efficacy of the model was assessed with receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). In addition, external validation of the model was performed with clinicopathologic data of 105 patients diagnosed with MM at Sichuan Cancer Hospital between January 2015 and January 2020. Results According to the results of logistic regression, marital status, the primary site, N staging, surgery, chemotherapy, bone metastases, liver metastases, lung metastases, and brain metastases could be defined as independent predictive factors for early death. Based on these factors, 2 nomograms were plotted to predict the risks of all-cause early death and cancer-specific early death, respectively. For the models for all-cause and cancer-specific early death, the areas under the curve (AUCs) for the training group were 0.751 (95% confidence interval [CI]: 0.726-0.776) and 0.740 (95% CI: 0.714-0.765), respectively. The AUCs for the internal validation group were 0.759 (95% CI: 0.722-0.797) and 0.757 (95% CI: 0.718-0.780), respectively, while the AUCs for the external validation group were 0.750 (95% CI: 0.649-0.850) and 0.741 (95% CI: 0.644-0.838), respectively. The calibration curves showed high agreement between the predicted and the observed probabilities. DCA analysis indicated high clinical application value of the models. Conclusion The nomogram models demonstrated good performance in predicting early death in MM patients and can be used to help clinical oncologists develop more individualized treatment strategies.
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Affiliation(s)
- 思儒 李
- 电子科技大学医学院 (成都 610054)Medical School of University of Electronic Science and Technology of China, Chengdu 610054, China
| | - 静 李
- 电子科技大学医学院 (成都 610054)Medical School of University of Electronic Science and Technology of China, Chengdu 610054, China
| | - 栖 杨
- 电子科技大学医学院 (成都 610054)Medical School of University of Electronic Science and Technology of China, Chengdu 610054, China
| | - 存俐 尹
- 电子科技大学医学院 (成都 610054)Medical School of University of Electronic Science and Technology of China, Chengdu 610054, China
| | - 斌 柳
- 电子科技大学医学院 (成都 610054)Medical School of University of Electronic Science and Technology of China, Chengdu 610054, China
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Orme SE, Moncrieff MD. A Review of Contemporary Guidelines and Evidence for Wide Local Excision in Primary Cutaneous Melanoma Management. Cancers (Basel) 2024; 16:895. [PMID: 38473257 DOI: 10.3390/cancers16050895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
Surgical wide local excision (WLE) remains the current standard of care for primary cutaneous melanoma. WLE is an elective procedure that aims to achieve locoregional disease control with minimal functional and cosmetic impairment. Despite several prospective randomised trials, the optimal extent of excision margin remains controversial, and this is reflected in the persistent lack of consensus in guidelines globally. Furthermore, there is now the added difficulty of interpreting existing trial data in the context of the evolving role of surgery in the management of melanoma, with our increased understanding of clinicopathologic and genomic prognostic markers leading to the often routine use of sentinel node biopsy (SNB) as a staging procedure, in addition to the development of adjuvant systemic therapies for high-risk disease. An ongoing trial, MelMarT-II, has been designed with the aim of achieving a definitive answer to guide this fundamental surgical decision.
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Affiliation(s)
- Sophie E Orme
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Marc D Moncrieff
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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Li S, Yin C, Yang X, Lu Y, Wang C, Liu B. Risk factors and predictive models for early death in patients with advanced melanoma: A population-based study. Medicine (Baltimore) 2023; 102:e35380. [PMID: 37800813 PMCID: PMC10552983 DOI: 10.1097/md.0000000000035380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
The prognosis for advanced melanoma (AM) is extremely poor. Some patients are already in an advanced stage at the time of their first diagnosis and face a significant risk of early death. This study predicted all-cause early death and cancer-specific early death in patients with AM by identifying independent risk factors, building 2 separate nomogram models, and validating the efficiency of the models. A total of 2138 patients diagnosed with AM from 2010 to 2015 were registered in the Surveillance, Epidemiology and End Results (SEER) database and randomly assigned to a training cohort and a validation cohort. Logistic regression models were used to identify the associated independent risk factors. These factors have also been used to build nomograms for early deaths. Next, we validated the model's predictive power by examining subject operating characteristic curves, then applied calibration curves to assess the accuracy of the models, and finally, tested the net benefit of interventions based on decision curve analysis. The results of the logistic regression model showed that marital status, primary site, histological type, N stage, surgery, chemotherapy, bone, liver, lung and brain metastases were significant independent risk factors for early death. These identified factors contributed to the creation of 2 nomograms, which predict the risk of all-cause early death and cancer-specific early death in patients with AM. In the all-cause early death model, the area under the curve was 0.751 and 0.759 for the training and validation groups, respectively, whereas in the cancer-specific early death model, the area under the curve was 0.740 and 0.757 for the training and validation groups. Calibration curves indicated a high degree of agreement between the predicted and observed probabilities, and the decision curve analysis demonstrated a high value for the model in terms of its applicability in clinical settings. These nomograms have practical applications in predicting the risk of early death in patients with AM, helping oncologists to intervene early and develop more personalized treatment strategies.
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Affiliation(s)
- Siru Li
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Cunli Yin
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xi Yang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yingchun Lu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - ChunYu Wang
- School of Medical and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bin Liu
- Department of Medical Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Sun W, Xu Y, Qu X, Jin Y, Wang C, Yan W, Chen Y. Surgical resection margin for T3-T4 primary acral melanoma: a multicenter retrospective cohort study. Arch Dermatol Res 2023; 315:2305-2312. [PMID: 36988664 PMCID: PMC10462526 DOI: 10.1007/s00403-023-02609-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/01/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
Although the National Comprehensive Cancer Network (NCCN) guidelines include clear recommendations for the appropriate resection margins in non-acral cutaneous melanoma, the required margin for acral melanoma is controversial. In this retrospective study, we aimed to investigate whether narrow-margin excision is warranted for thick acral melanoma. Records from 277 melanoma patients with stage T3-T4 disease who underwent radical surgery in three centers in China from September 2010 to October 2018 were reviewed. Clinicopathologic data, including age, gender, excision margin (1-2 cm versus ≥ 2 cm), Clark level, Breslow thickness, ulceration, N stage and adjuvant therapy, were included for survival analysis. The patients were followed up until death or March 31, 2021. Log-rank and Cox regression analyses were used to identify prognostic factors for overall survival (OS), disease-free survival (DFS) and local and in-transit recurrence-free survival (LITRFS). Among all enrolled patients, 207 (74.7%) had acral melanoma, and 70 (25.3%) had non-acral cutaneous melanoma. No significant difference in baseline characteristics was identified between non-acral and acral melanoma, except for age (p = 0.004), gender (p = 0.009) and ulceration (p = 0.048). In non-acral melanoma, a resection margin of 1-2 cm was a poor independent prognostic factor for OS [p = 0.015; hazard ratio (HR) (95% CI), 0.26 (0.009-0.77)] and LITRFS [p = 0.013; HR (95% CI), 0.19 (0.05-0.71)] but not for DFS [p = 0.143; HR (95% CI), 0.51 (0.21-1.25)]. Forty-three (20.8%) patients in the acral melanoma group had a 1-2-cm resection margin. The resection margin was not correlated with patients' OS (p = 0.196 by log-rank analysis, p = 0.865 by multivariate survival analysis), DFS (p = 0.080 by log-rank analysis, p = 0.758 by multivariate survival analysis) or LITRFS (p = 0.354 by log-rank analysis) in acral melanoma. As recommended in the NCCN guidelines, a resection margin ≥ 2 cm is required for non-acral cutaneous melanoma. Meanwhile, a narrow resection margin (1-2 cm) may be safe for patients with acral melanoma.
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Affiliation(s)
- Wei Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - Yu Xu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - XingLong Qu
- Department of Oncological Surgery, Minhang Branch, Shanghai Cancer Center, Fudan University, Shanghai, 200240, People's Republic of China
| | - YongJia Jin
- Shanghai Electric Power Hospital, Shanghai, 200050, People's Republic of China
| | - ChunMeng Wang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
| | - WangJun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
| | - Yong Chen
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, People's Republic of China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
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Wang S, Chen Y, Sun J, Mo R, Tan Q. Development and validation of two online dynamic nomograms for patients with non-distant metastatic cutaneous melanoma based on surgical approaches. Cancer Med 2023; 12:18479-18490. [PMID: 37592896 PMCID: PMC10557963 DOI: 10.1002/cam4.6448] [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: 04/02/2023] [Revised: 07/17/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Surgery is an essential treatment for non-distant metastatic cutaneous melanoma (NMCM). We aim to construct and validate prognostic nomograms based on surgical approaches and the clinicopathological characteristics of NMCM patients. METHODS Data of patients diagnosed with cutaneous melanoma from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Two online nomograms were constructed to predict the 3, 5-year melanoma-specific survival (MSS) for NMCM patients based on the surgical approaches. These nomograms were evaluated by the dynamic Harrell's concordance index (C-index), decision curve analysis and clinical impact curve. Both internal and external data verification were conducted. RESULTS A total of 14,091 NMCM cases were included in this study. The C-index of the nomograms for the excisional surgery group and amputation group were 0.818 and 0.806, respectively, and 0.763 and 0.731, respectively, in our hospital data validation. After internal and bootstrap verification, our two nomograms showed good accuracy and practicality. CONCLUSION NMCM patients exhibited equal survival rates independent of resection margin size, while those who needed amputation had worse survival rates. We generated two online nomograms distinguished by surgical approach to predict NMCM patient survival based on clinicopathological characteristics.
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Affiliation(s)
- Shiqi Wang
- Department of Burns and Plastic SurgeryAffiliated Drum Tower Hospital, Medical School of Nanjing UniversityNanjingPeople's Republic of China
- Department of Burns and Plastic SurgeryAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingPeople's Republic of China
| | - Yuedong Chen
- Diabetic Foot CenterNanjing Junxie HospitalNanjingPeople's Republic of China
| | - Jiawei Sun
- Department of Burns and Plastic SurgeryAffiliated Drum Tower Hospital, Medical School of Nanjing UniversityNanjingPeople's Republic of China
| | - Ran Mo
- Department of Burns and Plastic SurgeryAffiliated Drum Tower Hospital, Medical School of Nanjing UniversityNanjingPeople's Republic of China
| | - Qian Tan
- Department of Burns and Plastic SurgeryAffiliated Drum Tower Hospital, Medical School of Nanjing UniversityNanjingPeople's Republic of China
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Assessing Rates of Positive Surgical Margins After Standard Excision of Vulvar Melanomas. Dermatol Surg 2023; 49:437-444. [PMID: 36857160 DOI: 10.1097/dss.0000000000003734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Vulvar melanoma is a rare malignancy with frequent recurrence and poor prognosis. National guidelines recommend wide local excision of these tumors with allowances for narrower margins for anatomic and functional limitations, which are common on specialty sites. There is presently a lack of data of margin positivity after standard excision of vulvar melanomas. OBJECTIVE We aim to evaluate the rate of positive margins after standard excision of vulvar melanomas. MATERIALS AND METHODS Retrospective cohort study of surgically excised vulvar melanomas from the NCDB diagnosed from 2004 to 2019. RESULTS We identified a total of 2,226 cases. Across surgical approaches and tumor stages, 17.2% (Standard Error [SE]: 0.8%) of cases had positive surgical margins. Among tumor stages, T4 tumors were most commonly excised with positive margins (22.9%, SE: 1.5%). On multivariable survival analysis, excision with positive margins was associated with significantly poorer survival (Hazard Ratio 1.299, p = .015). CONCLUSION We find that positive margin rates after standard excision of vulvar malignancies are higher than for other specialty site melanomas. Our data suggest that use of surgical approaches with complete margin assessment may improve local control and functional outcomes for patients with vulvar melanoma as they have for patients with other specialty site melanomas.
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Ding F, Ye P. Primary malignant melanoma of the right sole: A case report. Asian J Surg 2023; 46:651-652. [PMID: 35850898 DOI: 10.1016/j.asjsur.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Feng Ding
- People's Hospital of Guoyang County, Guoyang Branch of Anhui Provincial Hospital, Guoyang, 233600, Anhui, China.
| | - Peng Ye
- Wannan Medical College, Wuhu, 241000, Anhui, China
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Clinical Trials in Melanoma: Margins, Lymph Nodes, Targeted and Immunotherapy. Surg Oncol Clin N Am 2023; 32:47-63. [PMID: 36410921 DOI: 10.1016/j.soc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Multiple randomized controlled trials have influenced the current standard of care for patients with cutaneous melanoma. Since the development of targeted and immune therapy, studies of adjuvant therapy for patients with resected stage III/IV melanoma have led to the approval of combined B-raf proto-oncogene (BRAF) and mitogen-activated protein kinase kinase inhibitors for patients with a BRAF mutation, and cytotoxic T-lymphocyte associated protein-4 or antiprogrammed cell death-1 therapy for patients without a BRAF mutation. This article discusses the details of the trials that have influenced these treatment decisions, in addition to discussing ongoing trials and possible future directions.
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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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11
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Coit DG, Ariyan CE. Fifty years of progress in surgical oncology: Melanoma. J Surg Oncol 2022; 126:888-895. [PMID: 36087090 PMCID: PMC9473298 DOI: 10.1002/jso.27081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022]
Abstract
This paper outlines the scientific and clinical advances in the treatment of melanoma over the past 50 years. Among the highlights of progress, the dominant themes include evidence-based reduction in the extent and morbidity of surgical procedures in patients with local or regional melanoma without compromising end results, and the introduction of effective systemic therapy, specifically targeted therapy matched to patients based on specific tumor mutations, and immune checkpoint blockade. Management of advanced disease has also changed dramatically, due to improved understanding of the genomic variability of the disease as well as continuing improvements in imaging.
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Affiliation(s)
- Daniel G Coit
- Department of Surgery, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Charlotte E Ariyan
- Department of Surgery, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer. Cancers (Basel) 2022; 14:cancers14153835. [PMID: 35954498 PMCID: PMC9367341 DOI: 10.3390/cancers14153835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 01/20/2023] Open
Abstract
Simple Summary Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery. Abstract Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.
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Aslanyan S, Gumeniuk K, Lysenko D. Modern views on skin biopsy in the diagnostic algorithm of dermatooncological diseases. УКРАЇНСЬКИЙ РАДІОЛОГІЧНИЙ ТА ОНКОЛОГІЧНИЙ ЖУРНАЛ 2022. [DOI: 10.46879/ukroj.2.2022.62-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background. Malignant neoplasms of the skin are fairly common tumors in the world population and among the population of Ukraine. The main method of diagnosing skintumors is a biopsy, which allows establishing a diagnosis at an early stage and ensures the cure of most patients.
Purpose. To evaluate modern recommendations for skin biopsy in the diagnosis of dermato-onсological diseases.
Materials and methods. The search for sources of information was conducted using the MEDLINE/PubMed, EMBASE/ExcerptaMedica, CochraneLibrary, PubMed та Google Scholar databases using the following keywords: skin biopsy, skin tumors, diagnosis, melanoma. Among the identified sources, works without statistical analysis, descriptions of individual cases, articles without conclusions, and sources with duplicate results were excluded. The search depth was 10 years.
Results. As a result of the conducted search, 57 publications were found that corresponded to the declared purpose. The most common methods are: puncture, shaving, excisional and incisional biopsy. Most guidelines recommend full-thickness excisional biopsy as the preferred procedure for the diagnosis of suspected melanoma. It is indicated that a statistically significant mortality rate was found in the puncture biopsy group. Most observations showed no significant differences in melanoma recurrence between excisional biopsy and puncture groups. Given the clinical diversity of melanoma, there is no uniformity in the types of biopsies performed to diagnose melanoma. The most inaccurate method turned out to be the punch biopsy method, which is associated with an increased risk of underdiagnosis of melanoma.
Conclusions. A skin biopsy is a mandatory first step to establish a definitive diagnosis of a skin tumor. Excisional complete biopsy is the most justified in most cases of diagnosis. Rational biopsy technique remains an issue that needs further study.
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Tian H, Wang X, Lian B, Si L, Gao M, Zheng H, Chi Z, Kong Y, Mao L, Bai X, Tang B, Yan X, Li S, Zhou L, Dai J, Sun Y, Wu L, Guo J, Cui C. Surgical Outcomes of Vaginal or Cervical Melanoma. Front Surg 2022; 8:771160. [PMID: 35047550 PMCID: PMC8761811 DOI: 10.3389/fsurg.2021.771160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To evaluate the effectiveness of radical resection compared with non-radical resection for vaginal or cervical melanoma. Methods: We retrospectively analysed the clinical data of post-operative patients with primary lower genital tract melanoma hospitalised at Peking University Cancer Hospital between Jan 2014 and Dec 2020. The study endpoints were recurrence-free survival (RFS) and overall survival (OS). Kaplan–Meier method-plotted survival curves and univariate and multivariate Cox proportional hazards regression models were used to identify the factors associated with RFS and OS, and to calculate hazard ratios (HRs) and associated 95% confidence intervals (95% CIs). Results: A total of 80 patients were included. Thirty-one patients had received non-radical resection, and 49 patients had received radical resection. The median patient age was 55.5 (IQR 45.3–60.0) years. Sixty-two (77.5%) patients had vaginal melanoma. Sixty-four patients (80.0%) had received post-operative adjuvant therapy. The median follow-up time was 36.0 months (95% CI 10.1–62.1 months). Sixty-four patients developed recurrence, and 44 patients died. The median RFS (mRFS) was 6.0 months (95% CI 3.4–8.6 m), and the RFS for the radical resection group was longer than that for the non-radical resection group (9.5 vs. 5.3 m), with no significant difference (P > 0.05). The median OS (mOS) was 25.9 months (95% CI 14.4–37.4 m). The mOS was 24.6 months (95% CI 10.3–38.9 m) and 25.9 months (95% CI 10.9–40.9 m) in the non-radical resection group and the radical resection group, respectively. Multivariate Cox regression analysis showed that surgical approach, infiltration depth of the tumour, lymph node metastasis, and post-operative adjuvant therapy were independent risk factors for RFS and that post-operative adjuvant therapy was an independent risk factor for OS. Conclusion: By performing multivariate analysis, which corrected for potential confounding factors, we identified surgical procedures that were associated with RFS, and we found that RFS and OS in patients with vaginal melanoma and cervical melanoma benefitted from post-operative adjuvant therapy.
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Affiliation(s)
- Hui Tian
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Xuan Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Bin Lian
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Lu Si
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Min Gao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gynecologic Oncology, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Hong Zheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gynecologic Oncology, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Zhihong Chi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Yan Kong
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Lili Mao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Xue Bai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Bixia Tang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Xieqiao Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Siming Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Li Zhou
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Jie Dai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Yangchun Sun
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingying Wu
- Department of Gynecologic Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Guo
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
| | - Chuanliang Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Renal Cancer and Melanoma, Peking University Cancer Hospital and Research Institute, Beijing, China
- *Correspondence: Chuanliang Cui
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Sharib J, Slingluff CL, Beasley GM. Melanoma trials that defined surgical management: Overview of trials that established NCCN margin guidelines. J Surg Oncol 2022; 125:28-33. [PMID: 34897715 PMCID: PMC8682801 DOI: 10.1002/jso.26717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/06/2021] [Indexed: 01/03/2023]
Abstract
Since the observation that clearance of all visible and microscopic tumors from cutaneous melanoma is critical to prevent a recurrence, wide surgical margins have been central to surgical dogma. In the last several decades, more conservative margin widths have been vigorously studied by surgical investigators to lessen wound complications, the need for reconstruction, and healthcare costs. This review summarizes surgeon-led clinical trials that define current guidelines and highlights the challenges to initiate and perform trials today.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Craig L Slingluff
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
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16
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Newcomer K, Robbins KJ, Perone J, Hinojosa FL, Chen D, Jones S, Kaufman CK, Weiser R, Fields RC, Tyler DS. Malignant melanoma: evolving practice management in an era of increasingly effective systemic therapies. Curr Probl Surg 2022; 59:101030. [PMID: 35033317 PMCID: PMC9798450 DOI: 10.1016/j.cpsurg.2021.101030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Ken Newcomer
- Department of Surgery, Barnes-Jewish Hospital, Washington University, St. Louis, MO
| | | | - Jennifer Perone
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - David Chen
- e. Department of Medicine, Washington University, St. Louis, MO
| | - Susan Jones
- f. Department of Pediatrics, Washington University, St. Louis, MO
| | | | - Roi Weiser
- University of Texas Medical Branch, Galveston, TX
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX.
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17
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Xu MN, Rao Q. Excision Margin and Survival in Patients with High-Risk, Primary Cutaneous Melanoma: A Retrospective Study Based on Surveillance Epidemiology and End Result (SEER) Database. Dermatology 2021; 238:534-541. [PMID: 34818654 DOI: 10.1159/000517828] [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: 12/01/2020] [Accepted: 06/05/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The optimal excision margin of primary cutaneous melanoma greater than 2 mm in thickness is still a controversial topic. The aim of the present study was to compare the long-term survival between narrow and wide excision margins in the surgical excision of patients with high-risk primary melanoma. METHODS We chose the patients with primary melanoma of the skin thicker than 2 mm in The Surveillance, Epidemiology, and End Results database. Patients were divided into a narrow margin group (1-2 cm) and a wide margin group (>2 cm) according to the resection margin information. The primary outcome was overall survival and disease-specific survival. RESULTS From 2004 to 2015, a total of 2,772 patients diagnosed as having melanoma of the skin were recruited into this study and were assigned to the narrow margin group (n = 1996) and the wide margin group (n = 776). A total of 1,098 patients died during the follow-up, and 681 of these were due to melanoma. There were 779 deaths in the narrow margin group and 319 deaths in the wide margin group (HR: 0.96, 95% CI: 0.84-1.10, p = 0.26). A total of 490 melanoma-specific deaths were reported in the narrow margin group and 191 were reported in the wide margin group (HR: 1.01, 95% CI: 0.85-1.19, p = 0.91). CONCLUSIONS Wider excision margin greater than 2 cm did not provide any additional therapeutic benefits compared to narrow excision margin between 1 and 2 cm. A 2-cm margin is adequate and safe for high-risk primary melanoma of the skin thicker than 2 mm.
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Affiliation(s)
- Meng-Nan Xu
- Department of Plastic Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China,
| | - Qiu Rao
- Department of Pathology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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18
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Melanoma In Situ: A Critical Review and Re-Evaluation of Current Excision Margin Recommendations. Adv Ther 2021; 38:3506-3530. [PMID: 34047915 PMCID: PMC8280024 DOI: 10.1007/s12325-021-01783-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/07/2021] [Indexed: 11/02/2022]
Abstract
Most international clinical guidelines recommend 5-10 mm clinical margins for excision of melanoma in situ (MIS). While the evidence supporting this is weak, these guidelines are generally consistent. However, as a result of the high incidence of subclinical extension of MIS, especially of the lentigo maligna (LM) subtype, wider margins will often be needed to achieve complete histologic clearance. In this review, we assessed all available contemporary evidence on clearance margins for MIS. No randomized trials were identified and the 31 non-randomized studies were largely retrospective reviews of single-surgeon or single-institution experiences using Mohs micrographic surgery (MMS) for LM or staged excision (SE) for treatment of MIS on the head/neck and/or LM specifically. The available data challenge the adequacy of current international guidelines as they consistently demonstrate the need for clinical margins > 5 mm and often > 10 mm. For LM, any MIS on the head/neck, and/or ≥ 3 cm in diameter, all may require wider clinical margins because of the higher likelihood of subclinical spread. Histologic clearance should be confirmed prior to undertaking complex reconstruction. However, it is not clear whether wider margins are necessary for all MIS subtypes. Indeed, it seems that this is unlikely to be the case. Until optimal surgical margins can be better defined in a randomized trial setting, ideally controlling for MIS subtype and including correlation with histologic excision margins, techniques such as preliminary border mapping of large, ill-defined lesions and, most importantly, sound clinical judgement will be needed when planning surgical clearance margins for the treatment of MIS.
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Hanna S, Lo SN, Saw RP. Surgical excision margins in primary cutaneous melanoma: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1558-1574. [PMID: 33722422 DOI: 10.1016/j.ejso.2021.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The main treatment of primary cutaneous melanoma is surgery. This review aims to assess the width of excision margin that minimises the risk of adverse outcome from surgery, locoregional recurrence, distant recurrence, and death. METHODS PRISMA guidelines were followed. MEDLINE, EMBASE, and four other databases were searched by using the term "melanoma", "margin", and limiting the search to randomised clinical trials (RCTs). RESULTS Seven RCTs involving 4579 patients data were analysed. No statistically significant difference was found in locoregional recurrence RR 1.09 (95%CI 0.98-1.22, p = 0.12), local recurrence RR 1.20 (95%CI 0.66-2.21, p = 0.55), in-transit metastasis RR1.30 (95%CI 0.86-1.97, p = 0.21), regional nodal metastasis RR 1.04 (95%CI 0.91-1.18, p = 0.56), distant metastasis RR 0.95 (95%CI 0.72-1.24, p = 0.68), death RR 1.00 (95%CI 0.93-1.07, p = 0.97), death from melanoma RR 1.11 (95%CI 0.96-1.28, p = 0.16), wound infection RR 1.22 (95%CI 0.68-2.17, p = 0.50), and wound dehiscence RR 0.96 (95%CI 0.54-1.71, p = 0.88) when narrow (1-2 cm) versus wide (3-5 cm) excision margins were compared. In contrast, patients with narrow excision margins had a significant reduction in complex surgical reconstruction RR 0.30 (95%CI 0.19-0.49, p < 00001). When studies were excluded because of high risk of bias the only significant difference was death due to melanoma RR 1.25 (95%CI1.01-1.55, P = 0.04). CONCLUSIONS No significant difference between narrow and wide excision margins in locoregional or distant recurrence, metastasis, death, or death due to melanoma. Wide margins (2-5 cm) increased the need for surgical reconstruction. Further studies are needed to assess optimal excision margins with regards to Breslow thickness and other prognostic factors and are in progress.
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Affiliation(s)
- Sarah Hanna
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Health and Medicine, The University of Sydney, Sydney, NSW, Australia.
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Health and Medicine, The University of Sydney, Sydney, NSW, Australia
| | - Robyn Pm Saw
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Health and Medicine, The University of Sydney, Sydney, NSW, Australia
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20
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NAGORE E, MORO R. Surgical procedures in melanoma: recommended deep and lateral margins, indications for sentinel lymph node biopsy, and complete lymph node dissection. Ital J Dermatol Venerol 2021; 156:331-343. [DOI: 10.23736/s2784-8671.20.06776-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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21
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Stachyra-Strawa P, Ciesielka M, Janiszewski M, Grzybowska-Szatkowska L. The role of immunotherapy and molecular‑targeted therapy in the treatment of melanoma (Review). Oncol Rep 2021; 46:158. [PMID: 34109986 DOI: 10.3892/or.2021.8109] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/23/2021] [Indexed: 11/05/2022] Open
Abstract
Skin melanomas are malignant neoplasms originating from neuroectodermal melanocytes. Compared to other neoplasms, melanomas have a high rate of growth. Their incidence is highest in Australia and New Zealand, in high‑income European countries (Switzerland, Norway, Sweden) and in the US. In Poland, the standardized incidence rate is approximately 5/100,000. Melanomas are typically highly radioresistant and chemoresistant. Before the era of immunotherapy, inoperable lesions were treated using chemotherapy based mainly on dacarbazine, temozolomide or fotemustine, which did not yield the expected results in terms of extending survival time or improving patient comfort. Therefore, there has emerged a need to seek other solutions. In most cases, the use of immunological treatment or targeted therapy has had a positive impact on survival time and relapse‑free survival. However, these periods are still relatively short, hence the need for further research and improvement of treatment. The most promising strategies appear to be antibodies that block programmed death receptor‑1 (PD‑1) and programmed death receptor ligand‑1 (PD‑L1) molecules, anti‑CTLA4 antibodies (cytotoxic T‑lymphocyte antigen 4) and therapy with BRAF and MEK inhibitors.
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Affiliation(s)
| | - Marzanna Ciesielka
- Department of Forensic Medicine, Medical University of Lublin, 20‑093 Lublin, Poland
| | - Michał Janiszewski
- Department of Radiotherapy, Medical University of Lublin, 20‑093 Lublin, Poland
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22
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Mo R, Chen C, Jiang Y, Ma Z, Meng X, Tan Q. Sex-specific survival benefit in early skin melanoma based on 8th AJCC edition: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:53. [PMID: 33553346 PMCID: PMC7859735 DOI: 10.21037/atm-20-3845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Females have been found to have a survival benefit over males in past studies. However, in early melanoma patients, this benefit occurred in only those aged >60 years. The 8th edition of the American Joint Committee on Cancer (AJCC) readjusted the melanoma staging system, specifically stage I. This study aims to verify whether the sex-specific benefit in females exists in different age groups according to the 8th edition of the staging system. Methods We collected the data of individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Based on the 8th edition of the melanoma staging system, patients diagnosed with pathological stage T1a-T3a, N0 and M0 melanoma were enrolled. Results A total of 115,576 patients, including 62,938 male patients and 52,638 female patients, were enrolled in this study. The survival rates of males and females in each stage from IA–IIA were significantly different (P<0.001). In further analyses of each age group, it was found that the proportions of patients with stages IA, IB and IIA were significantly different in each age group. Cox analysis showed that females with stage IA in all age groups benefited significantly, but those in stage IB benefited only when they were aged >60 years. In stage IIA patients, there were significant differences between the <50 and 61–70 years age groups. Conclusions Based on data from the SEER database, we found that according to the 8th edition of the AJCC melanoma staging system, females had a higher survival rate than males, and this difference was significant in all age groups in the stage IA group but fluctuated with age in the stage IB and IIA groups.
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Affiliation(s)
- Ran Mo
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Chen Chen
- Department of Nutrition, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yanan Jiang
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Zhouji Ma
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Xueyong Meng
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
| | - Qian Tan
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University, Nanjing, China
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23
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Lee AY, Friedman EB, Sun J, Potdar A, Daou H, Farrow NE, Farley CR, Vetto JT, Han D, Tariq M, Shapiro R, Beasley G, Contreras CM, Osman I, Lowe M, Zager JS, Berman RS. The Devil's in the Details: Discrepancy Between Biopsy Thickness and Final Pathology in Acral Melanoma. Ann Surg Oncol 2020; 27:5259-5266. [PMID: 32529271 DOI: 10.1245/s10434-020-08708-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE We hypothesized that initial biopsy may understage acral lentiginous melanoma (ALM) and lead to undertreatment or incomplete staging. Understanding this possibility can potentially aid surgical planning and improve primary tumor staging. METHODS A retrospective review of primary ALMs treated from 2000 to 2017 in the US Melanoma Consortium database was performed. We reviewed pathology characteristics of initial biopsy, final excision specimens, surgical margins, and sentinel lymph node biopsy (SLNB). RESULTS We identified 418 primary ALMs (321 plantar, 34 palmar, 63 subungual) with initial biopsy and final pathology results. Median final thickness was 1.8 mm (range 0.0-19.0). There was a discrepancy between initial biopsy and final pathology thickness in 180 (43%) patients with a median difference of 1.6 mm (range 0.1-16.4). Final T category was increased in 132 patients (32%), including 47% of initially in situ, 32% of T1, 39% of T2, and 28% of T3 lesions. T category was more likely to be increased in subungual (46%) and palmar (38%) melanomas than plantar (28%, p = 0.01). Among patients upstaged to T2 or higher, 71% had ≤ 1-cm margins taken. Among the 27 patients upstaged to T1b or higher, 8 (30%) did not have a SLNB performed, resulting in incomplete initial staging. CONCLUSIONS In this large series of ALMs, final T category was frequently increased on final pathology. A high index of suspicion is necessary for lesions initially in situ or T1 and consideration should be given to performing additional punch biopsies, wider margin excisions, and/or SLNB.
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Affiliation(s)
- Ann Y Lee
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA.
| | - Erica B Friedman
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Aishwarya Potdar
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Clara R Farley
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - John T Vetto
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Dale Han
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Marvi Tariq
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Richard Shapiro
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
| | | | - Carlo M Contreras
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Iman Osman
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, NY, USA
| | - Michael Lowe
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Russell S Berman
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
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Alves Wainstein AJ, Flores Ferrão EO, Virgílio Alves AC, Borges Murta MC, Drummond-Lage AP. Assessment of retraction in surgical specimens in melanoma patients submitted to oncological amplification of margins. Surg Oncol 2020; 36:106-112. [PMID: 33340807 DOI: 10.1016/j.suronc.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/07/2020] [Accepted: 11/16/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Skin cancer is the most common type of cancer and represents more than half of the diagnosed malignant tumors. There are more than one million new cases per year in the United States and about 120.000 new cases in Brazil. Cutaneous melanoma represents 5% of all primary cutaneous neoplasms; however, it has a worse prognosis. Adequate treatment of the primary lesion is the main cure factor, with free surgical margins, thus avoiding recurrences of the lesion. OBJECTIVES The present study aims to evaluate and quantify the retraction of the surgical specimen in three moments, in-vivo, ex-vivo and in-vitro, and also evaluating possible factors related to retraction, such as formalin fixation, age, patient's gender, and lesion location. METHODS This is a prospective, single-center cohort that evaluated 145 surgical specimens from patients who underwent oncological surgery of cutaneous melanoma margins enlargement. Lesions were marked with a standard brush, and surgical margins were measured with a sterile ruler, according to their initial staging. After resection, new surgical specimens measurements were obtained, and, after fixation in formalin, the last measurement was performed. The same oncological surgeon performed all procedures, and the same pathologist analyzed the specimens. RESULTS Regarding the area of the specimens, there was a general median retraction of 38.15% between in-vivo and ex-vivo (p < 0.001), and 43.97% between in-vivo and in-vitro. When the measure of the specimen length (L) was evaluated, there was a 17% retraction between in-vivo and ex-vivo, and 20.42% between in-vivo and in-vitro, with statistical significance. The younger population has a higher rate of retraction, and lesions on the back have a lower rate of shrinkage on the opposite of lower limbs that had higher shrinkage. DISCUSSION Corroborating the literature, this study showed an average shrinkage of 20.42% for length measurements between in-vivo and in-vitro, and the main predictors of greater or lesser retraction were age and location of the lesion. It is also noted that the most considerable retraction occurs immediately after surgical resection, indicating that skin characteristics, such as degree of elasticity and tension, are determinant for the retraction. Formalin action does not significantly impact retraction. This study shows the importance of adequate treatment of the primary lesion, with adequate surgical margins, and that the measure measured by the pathologist, in general, represents 80% of the margins performed in the perioperative time.
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25
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Mo R, Chen C, Mi L, Ma Z, Tan Q. Skin melanoma survival is not superior in females in the new stage IIID of the 8th edition of the staging system: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1381. [PMID: 33313126 PMCID: PMC7723544 DOI: 10.21037/atm-20-3332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background In the 8th edition of the melanoma staging system, stage III was divided into stages IIIA-IIID. Previous studies have found that the long-term survival rate of females is much higher than that of males. This study was designed to explore whether this sex-specific advantage still exists in the new staging subgroups. Methods We obtained data from individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8,726 patients with stage III disease were enrolled in the study (5,370 males and 3,356 females). Among these patients, 505 had stage IIID disease (370 males and 135 females). Results In the 7th edition of the staging system, there were significant sex-specific differences in overall survival (OS) and melanoma-specific survival (MSS) in each subgroup of stage III. In stages IIIA-IIIC in the 8th edition, there were also significant differences between males and females (P<0.001), but in stage IIID patients, there were no significant differences in either OS (P=0.312) or MSS (P=0.288). Cox analysis confirmed that stage IIID does not affect prognosis in males. Further research found no difference between males and females with stage IIID disease in any age subgroup. Conclusions We compared sex-specific survival differences in patients with stage III disease according to the 8th edition of the staging system. Females with stage IIIA-IIIC disease have better survival rates than males. However, among patients with stage IIID disease, there is no significant difference in survival between males and females.
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Affiliation(s)
- Ran Mo
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Chen Chen
- Department of Nutrition, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lin Mi
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhouji Ma
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Qian Tan
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China.,Department of Burns & Plastic Surgery, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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26
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Angeles CV, Wong SL, Karakousis G. The Landmark Series: Randomized Trials Examining Surgical Margins for Cutaneous Melanoma. Ann Surg Oncol 2020; 27:3-12. [PMID: 31562600 DOI: 10.1245/s10434-019-07866-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Indexed: 12/17/2023]
Abstract
Between 1980 and 2004, six randomized, controlled trials (RCTs) have been performed to evaluate the width of surgical margin excision for primary cutaneous melanoma and its influence on recurrence and survival. These trials have led to the current recommendation of not more than a 2-cm margin excision and have allowed reduced morbidity of surgery for primary melanoma. Long-term follow-up data has been published which has led to impactful knowledge of the natural history of this disease, yet controversy remains for 1- to 2-mm thickness melanomas. Interpretation of these trials must be done in light of them enrolling patients before the use of sentinel node biopsy and contemporary immunotherapy regimens. These RCTs as well as a contemporary, actively enrolling trial are summarized and discussed in this review.
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Affiliation(s)
- C V Angeles
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - S L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - G Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
PURPOSE OF REVIEW This review describes the long scientific background followed to design guidelines and everyday clinical practice applied to melanoma patients. Surgery is the first option to cure melanoma patients (PTS) at initial diagnosis, since primary cutaneous lesions are usually easily resectable. An excisional biopsy of the lesion, with minimal clear margins, can be obtained in the vast majority of cases. Punch biopsies may be proposed only in case of large lesions located on specific cosmetic or functional areas like the face, extremities, or genitals where a mutilating complete resection would not be performed without prior histological diagnosis. RECENT FINDINGS After the histologic confirmation of melanoma, definite surgical excision of the scar and surrounding tissue is planned, to obtain microsatellite free margins. The width of these margins has been identified following the results of several clinical trials and it is either 1 or 2 cm, depending on the Breslow thickness of the primary tumor. Following the latest staging system proposed by the American Joint Cancer commission (AJCC), a sentinel node biopsy (SNB) is usually performed in case of a primary lesion > 0.8 mm thickness or for high-risk thinner lesions, if no evidence of nodal involvement has been identified clinically or radiographically. Surgical management of primary melanoma is well established. There is debate on the optimal surgical margins for 1-2 mm melanomas. There are specific considerations for special primaries (bulky, extremity, mucosal). Sentinel node (SN) evaluation does not improve survival, but is routinely used as staging.
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Affiliation(s)
- Alessandro A E Testori
- Dermatology, Fondazione IRCCS policlinico San Matteo, Fondazione IRCCS San Matteo, Pavia, Italy.
| | - Stephanie A Blankenstein
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
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28
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Angeles CV, Wong SL, Karakousis G. ASO Author Reflections: Surgical Margins for Melanoma-What's Next? Ann Surg Oncol 2019; 27:13-14. [PMID: 31654159 DOI: 10.1245/s10434-019-08015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/18/2022]
Affiliation(s)
- C V Angeles
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - S L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - G Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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29
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Scientific Surgery. Br J Surg 2019. [DOI: 10.1002/bjs.11407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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30
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Thompson JF, Friedman EB. Appropriate excision margins for cutaneous melanomas. Lancet 2019; 394:445-446. [PMID: 31280970 DOI: 10.1016/s0140-6736(19)31272-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/19/2022]
Affiliation(s)
- John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW 2060, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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