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Shah P, Trepanowski N, Grant-Kels JM, LeBoeuf M. Mohs micrographic surgery in the surgical treatment paradigm of melanoma in situ and invasive melanoma: A clinical review of treatment efficacy and ongoing controversies. J Am Acad Dermatol 2024; 91:499-507. [PMID: 38768857 DOI: 10.1016/j.jaad.2024.05.024] [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: 12/17/2023] [Revised: 04/06/2024] [Accepted: 05/11/2024] [Indexed: 05/22/2024]
Abstract
Mohs Micrographic Surgery (MMS) for treatment of melanoma offers several advantages over wide local excision (WLE), including complete histologic margin evaluation, same-day resection and closure, and sparing of healthy tissue in critical anatomic sites. Recently, a large volume of clinical data demonstrating efficacy in MMS treatment of melanoma was published, leading to emerging patient safety considerations of incurred treatment costs, risk of tumor upstaging, and failure of care coordination for sentinel lymph node biopsy (SLNB). MMS offers a safe, effective, and value-based treatment for both melanoma in situ (MIS) and invasive melanoma (IM), particularly with immunohistochemistry use on frozen sections. Compared to wide local excision, MMS treatment demonstrates similar or improved outcomes for local tumor recurrence, melanoma-specific survival, and overall survival at long-term follow-up. Tumor upstaging risk is low, and if present, alteration to clinical management is minimal. Discussion of SLNB for eligible head and neck IM cases should be done prior to MMS. Though challenging, successful multidisciplinary coordination of SLNB with MMS has been demonstrated. Herein, we provide a detailed clinical review of evidence for MMS treatment of cutaneous melanoma and offer recommendations to address current controversies surrounding the evolving paradigm of surgical management for both MIS and invasive melanoma (IM).
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Affiliation(s)
- Payal Shah
- Department of Dermatology, Dartmouth Health, Lebanon, New Hampshire
| | - Nicole Trepanowski
- Department of Dermatology, Dartmouth Health, Lebanon, New Hampshire; Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Jane M Grant-Kels
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida; Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Matthew LeBoeuf
- Department of Dermatology, Dartmouth Health, Lebanon, New Hampshire.
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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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3
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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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Williams GJ, Quinn T, Lo S, Guitera P, Scolyer RA, Thompson JF, Ch'ng S. Mohs micrographic surgery for the treatment of invasive melanoma: A systematic review with meta-analyses. J Eur Acad Dermatol Venereol 2024. [PMID: 38842170 DOI: 10.1111/jdv.20138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/13/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The use of Mohs micrographic surgery (MMS) in melanoma treatment has divided opinion and evidence-based guidelines are lacking. OBJECTIVES This systematic review aimed to analyse clinical outcomes for patients with invasive melanomas treated with Mohs rather than wide local excision (WLE). METHODS Embase, MEDLINE and Cochrane databases (to 30 August 2023) were searched for studies using Mohs to treat invasive melanoma. Outcomes of interest were local recurrence and death from melanoma. RESULTS Thirty-five articles involving 41,499 patients with invasive melanoma treated with Mohs were identified. Sixteen studies compared Mohs with WLE and 19 were Mohs-only, non-comparative studies. Patients treated with Mohs differed significantly from those undergoing WLE, in particular Mohs patients were older and had thinner melanomas. Two comparative studies using the same data source reported adjusted hazard ratios for melanoma-specific death and both showed no significant difference between Mohs and WLE-treated patients; 0.87 (95% CI 0.55-1.35) and 1.20 (95% CI 0.71-20.36). There was also no statistically significant difference in local recurrence risk; the unadjusted risk ratio for patients treated with Mohs was 0.46 (95% CI 0.14-1.51 p = 0.20) with moderate heterogeneity (I2 = 62%). No studies reported multivariable analyses for risk of local recurrence. Many studies generated from relatively few and often overlapping data sets have reported the use of Mohs to treat patients with invasive melanoma. Fewer studies were comparative between Mohs and WLE and these reported substantially different baseline risks of recurrence and death from melanoma between the groups. Mohs has generally been used for thinner melanomas in older patients; therefore, comparisons based on univariable analyses are likely to have been misleading. CONCLUSIONS On the basis of currently available data, it is not possible to reliably assess whether outcomes differ if invasive melanomas with comparable features are treated with Mohs or WLE, and randomized trial evidence will be required for reliable conclusions to be reached.
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Affiliation(s)
- G J Williams
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - T Quinn
- The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - S Lo
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - P Guitera
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - R A Scolyer
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- NSW Health Pathology, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Mater Hospital, North Sydney, Sydney, New South Wales, Australia
- Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - S Ch'ng
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Mater Hospital, North Sydney, Sydney, New South Wales, Australia
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Ungureanu L, Vasilovici AF, Trufin II, Apostu AP, Halmágyi SR. Lentigo Maligna Treatment-An Update. J Clin Med 2024; 13:2527. [PMID: 38731056 PMCID: PMC11084749 DOI: 10.3390/jcm13092527] [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: 03/11/2024] [Revised: 04/06/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Lentigo maligna (LM) is a melanoma in situ that is prevalent in chronically sun-damaged skin. Characterized by a slow growth pattern and high mutation rates due to chronic UV exposure, LM poses diagnostic and therapeutic challenges, particularly given its tendency to mimic other skin lesions and its occurrence in cosmetically sensitive areas. Its diagnosis is based on an integrated approach using dermoscopy and reflectance confocal microscopy (RCM). Despite its slow progression, LM can evolve into lentigo maligna melanoma (LMM), making its treatment necessary. Treatment modalities encompass both surgical and non-surgical methods. Surgical treatments like Wide Local Excision (WLE) and Mohs Micrographic Surgery (MMS) aim for clear histological margins. WLE, a standard melanoma surgery, faces challenges from LM's subclinical extensions, which increase the recurrence risk. MMS, effective for large or poorly defined lesions, is defined by precise margin control while considering cosmetic outcomes. Non-surgical options, including radiotherapy and imiquimod, are alternatives for non-surgical candidates. Radiotherapy has been effective since the 1950s, offering good control and cosmetic results, especially for older patients. Imiquimod, an immunomodulator, shows promise in treating LM, though its application remains off-label. The increasing incidence of LM/LMM necessitates a balance in treatment choices to minimize recurrence and maintain cosmetic integrity. A multidisciplinary approach, integrating clinical examination with dermoscopy and RCM and histological assessment, is essential for accurate diagnosis and effective LM management.
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Affiliation(s)
- Loredana Ungureanu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Alina Florentina Vasilovici
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | | | - Adina Patricia Apostu
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
| | - Salomea-Ruth Halmágyi
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
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6
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Crum OM, Campbell EH, Chelf CJ, Demer AM, Brewer JD. Disease-specific survival of malignant melanoma after Mohs micrographic surgery is not impacted by initial margins: A systematic review and meta-analysis. JAAD Int 2023; 13:140-149. [PMID: 37823046 PMCID: PMC10562175 DOI: 10.1016/j.jdin.2023.06.009] [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: 06/18/2023] [Indexed: 10/13/2023] Open
Abstract
Background During Mohs surgery for melanoma, evidence has demonstrated that many surgeons opt for smaller initial margins than traditionally recommended (0.5 cm for in situ and 1 cm for invasive). Literature regarding surgical outcomes based on initial margin is sparse. Objective To determine differences in disease-specific survival of melanoma after Mohs micrographic surgery for varied initial surgical margins. Methods A literature search was conducted on February 14, 2022, from MEDLINE via PubMed (1946-present), Embase (1974-present), Central (1991-present), and Scopus (1960-present). The primary outcome was disease-specific mortality. Results Nineteen studies were included for final analysis. The overall disease-specific mortality rate of melanoma in all included studies was 0.5% (CI, 0.1-0.8; P, .010). Disease-specific mortality for 1 to 5, 5, and 6 to 10 mm categories were 0.4% (CI, 0.0-0.9; P, .074), 0.7% (CI, 0.2-1.3; P, .2-1.3), and 0.4% (CI, -0.9 to 1.8; P, .524), respectively. None of the variances across initial margin categories were statistically significant. Limitations Early-stage melanomas have low overall mortality rates. In our associated article, initial margins of 5 to 10 mm were shown to have the lowest rates of local recurrence. Conclusions In this systematic review and meta-analysis, melanoma-specific mortality was not significantly impacted by the initial surgical margin taken during Mohs micrographic surgery.
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Affiliation(s)
- Olivia M. Crum
- Department of Dermatology, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota
| | - Elliott H. Campbell
- Department of Dermatology, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota
| | | | - Addison M. Demer
- Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Jerry D. Brewer
- Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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7
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Abrantes T, Robbins A, Kahn B, Yumeen S, Bukoski RS, Wisco O, Robinson-Bostom L, Kawaoka J, Libby T, Goldbach H, Imbriano D, Lizbinski L, Tran M, Wahood S, Mehta A, Miner T. Understanding melanoma in situ: Lentigo maligna surgical treatment terminology and guideline adherence, a targeted review. J Am Acad Dermatol 2023; 89:734-744. [PMID: 37307991 DOI: 10.1016/j.jaad.2023.04.072] [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: 10/02/2022] [Revised: 04/18/2023] [Accepted: 04/25/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Malignant melanoma in-situ, lentigo maligna (MMIS-LM) can be successfully treated with several different surgical techniques; however, the literature is inconsistent in defining them. OBJECTIVE To comprehensively define and describe the national guideline recommended surgical techniques used to treat MMIS-LM to help clarify and standardize this terminology to ensure compliance with the guidelines. METHODS A targeted literature review was performed from 1990 to 2022 focusing on articles that discussed the national guideline recommended surgical techniques of wide local excision, Mohs micrographic surgery (MMS), modified Mohs surgery, and staged excision/Slow-Mohs for MMIS-LM, as well as the related methods of tissue processing. National Comprehensive Cancer Network and American Academy of Dermatology guidelines were reviewed to identify how the techniques need to be employed to be compliant with guideline recommendations. RESULTS We describe the various surgical and tissue processing techniques and discuss advantages and disadvantages of each. LIMITATIONS This paper was styled as a narrative review defining and clarifying terminology and technique and does not investigate these topics more broadly. CONCLUSION Understanding the methodology and terminology for these surgical procedures and tissue processing methods is critical so that both general dermatologists and surgeons can employ these techniques effectively for optimal patient care.
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Affiliation(s)
- Tatiana Abrantes
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Allison Robbins
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Benjamin Kahn
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sara Yumeen
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - R Scott Bukoski
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Oliver Wisco
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Leslie Robinson-Bostom
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John Kawaoka
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tiffany Libby
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Hayley Goldbach
- Dermatology Department, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dillon Imbriano
- University of New England, College of Osteopathic Medicine, Biddeford, Maine
| | - Leonardo Lizbinski
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Megan Tran
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Samer Wahood
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Aakash Mehta
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Thomas Miner
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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8
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O'Hern K, Liszewski W, Vidal NY, Demer A. No Survival Benefit With Wide Margin Mohs Micrographic Surgery for Melanoma: A National Cancer Database Analysis. Dermatol Surg 2023; 49:704-705. [PMID: 37040492 DOI: 10.1097/dss.0000000000003804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Affiliation(s)
- Keegan O'Hern
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Walter Liszewski
- Department of Dermatology, Northwestern University, Chicago, Illinois
| | - Nahid Y Vidal
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Addison Demer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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9
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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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10
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Local Recurrence Rates of Malignant Melanoma After Mohs Micrographic Surgery Are Lowest With 5- to 10-mm Initial Margins: A Systematic Review and Meta-Analysis. Dermatol Surg 2023; 49:119-123. [PMID: 36728060 DOI: 10.1097/dss.0000000000003683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Current consensus guidelines have discouraged the use of sub-0.5-cm (in situ) and sub-1-cm (invasive) margins when performing Mohs micrographic surgery (Mohs) for melanoma, with minimal evidence to guide this recommendation. OBJECTIVE To compare melanoma local recurrence rates after Mohs based on initial margin size. MATERIALS AND METHODS A systematic review and meta-analysis was conducted with search terms including Mohs micrographic surgery, surgical margin, recurrent disease, and melanoma. RESULTS Forty-three studies were included. The 5- to 10-mm margin category had a statistically significant lower local recurrence compared with 1- to 5-mm and 5-mm categories. Recurrence for 1- to 5-mm, 5-mm, 5- to 10-mm, and 10-mm categories were 2.3% (CI 0.8-3.5, p < .001), 1.4% (CI 0.6-2.2, p < .001), 0.3% (CI 0.2-0.5, p < .001), and 6.1% (CI -6.7 - 18.8, p = .349), respectively. Number of stages for 1 to 5, 5, 5 to 10, and 10-mm categories were 1.8, 1.8, 1.6, and 1.6, respectively. There was no statistically significant difference between the groups (p = .694). CONCLUSION Five- to 10-mm margins were associated with the lowest local recurrence rates. A 5- to 10-mm initial margin should be considered where other factors (tumor characteristics, anatomical or functional considerations) allow.
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Santamaria-Barria JA, Mammen JMV. Surgical Management of Melanoma: Advances and Updates. Curr Oncol Rep 2022; 24:1425-1432. [PMID: 35657482 DOI: 10.1007/s11912-022-01289-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To review and update surgeons about the evolving complexities in the surgical management of melanoma including lymph node staging and treatment. RECENT FINDINGS Primary resection with adequate margins continues to be the standard of care for localized cutaneous melanoma. Sentinel lymph node biopsy is confirmed to be a powerful tool due to its prognostic value and informative guidance for adjuvant treatments and surveillance. Due to the lack of benefit in melanoma-specific survival and distant metastasis-free survival, completion lymph node dissection is not performed routinely after a positive sentinel lymph node biopsy. Neoadjuvant systemic treatment approaches for advanced loco-regional disease show promise in phase I and II clinical trial data, and phase III studies. The surgical management of cutaneous melanoma continues to evolve with further de-escalation of the extent of excision of primary melanomas and the management of lymph node disease.
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Affiliation(s)
- Juan A Santamaria-Barria
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA
| | - Joshua M V Mammen
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA.
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12
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Golda N, Hruza G. Mohs Micrographic Surgery. Dermatol Clin 2022; 41:39-47. [DOI: 10.1016/j.det.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Garbe C, Amaral T, Peris K, Hauschild A, Arenberger P, Basset-Seguin N, Bastholt L, Bataille V, Del Marmol V, Dréno B, Fargnoli MC, Forsea AM, Grob JJ, Hoeller C, Kaufmann R, Kelleners-Smeets N, Lallas A, Lebbé C, Lytvynenko B, Malvehy J, Moreno-Ramirez D, Nathan P, Pellacani G, Saiag P, Stratigos AJ, Van Akkooi ACJ, Vieira R, Zalaudek I, Lorigan P. European consensus-based interdisciplinary guideline for melanoma. Part 2: Treatment - Update 2022. Eur J Cancer 2022; 170:256-284. [PMID: 35623961 DOI: 10.1016/j.ejca.2022.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A unique collaboration of multidisciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO), and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on cutaneous melanoma diagnosis and treatment, based on the systematic literature reviews and the experts' experience. Cutaneous melanomas are excised with one to 2-cm safety margins. Sentinel lymph node dissection shall be performed as a staging procedure in patients with tumor thickness ≥1.0 mm or ≥0.8 mm with additional histological risk factors, although there is as yet no clear survival benefit for this approach. Therapeutic decisions in stage III/IV patients should be primarily made by an interdisciplinary oncology team ("tumor board"). Adjuvant therapies can be proposed in stage III/completely resected stage IV patients and are primarily anti-PD-1, independent of mutational status, or alternatively dabrafenib plus trametinib for BRAF mutant patients. In distant metastases (stage IV), either resected or not, systemic treatment is always indicated. For first-line treatment particularly in BRAF wild-type patients, immunotherapy with PD-1 antibodies alone or in combination with CTLA-4 antibodies shall be considered. In stage IV melanoma with a BRAF-V600 E/K mutation, first-line therapy with BRAF/MEK inhibitors can be offered as an alternative to immunotherapy. In patients with primary resistance to immunotherapy and harboring a BRAF-V600 E/K mutation, this therapy shall be offered as second-line therapy. Systemic therapy in stage III/IV melanoma is a rapidly changing landscape, and it is likely that these recommendations may change in the near future.
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Affiliation(s)
- Claus Garbe
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany.
| | - Teresa Amaral
- Center for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Ketty Peris
- Institute of Dermatology, Università Cattolica, Rome, Italy; Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Axel Hauschild
- Department of Dermatology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Petr Arenberger
- Department of Dermatovenereology, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nicole Basset-Seguin
- Université Paris Cite, AP-HP, Department of Dermatology INSERM U 976 Hôpital, Saint Louis Paris France
| | - Lars Bastholt
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Veronique Bataille
- Twin Research and Genetic Epidemiology Unit, School of Basic & Medical Biosciences, King's College London, London, SE1 7EH, United Kingdom
| | - Veronique Del Marmol
- Department of Dermatology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Dréno
- Dermatology Department, CHU Nantes, CIC 1413, CRCINA, University Nantes, Nantes, France
| | - Maria C Fargnoli
- Dermatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Ana-Maria Forsea
- Dermatology Department, Elias University Hospital, Carol Davila University of Medicine and Pharmacy Bucharest, Romania
| | | | | | - Roland Kaufmann
- Department of Dermatology, Venereology and Allergology, Frankfurt University Hospital, Frankfurt, Germany
| | | | - Aimilios Lallas
- First Department of Dermatology, Aristotle University, Thessaloniki, Greece
| | - Celeste Lebbé
- Université Paris Cite, AP-HP, Department of Dermatology INSERM U 976 Hôpital, Saint Louis Paris France
| | - Bodhan Lytvynenko
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Josep Malvehy
- Melanoma Unit, Department of Dermatology, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - David Moreno-Ramirez
- Medical-&-Surgical Dermatology Service, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Paul Nathan
- Mount-Vernon Cancer Centre, Northwood United Kingdom
| | | | - Philippe Saiag
- University Department of Dermatology, Université de Versailles-Saint Quentin en Yvelines, APHP, Boulogne, France
| | - Alexander J Stratigos
- First Department of Dermatology, University of Athens School of Medicine, Andreas Sygros Hospital, Athens, Greece
| | - Alexander C J Van Akkooi
- Melanoma Institute Australia, The University of Sydney, and Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Ricardo Vieira
- Department of Dermatology and Venereology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy
| | - Paul Lorigan
- The University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
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14
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Council ML. Commentary on "Recurrence Rate for Melanoma Excised by Mohs Micrographic Surgery Without Immunostaining". Dermatol Surg 2022; 48:500-501. [PMID: 35389921 DOI: 10.1097/dss.0000000000003449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Martha Laurin Council
- Division of Dermatology Department of Internal Medicine Washington University, St. Louis, Missouri
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15
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Commentary on Systematic Review of Technical Variations for "Mohs Micrographic Surgery for Melanoma". Dermatol Surg 2021; 47:1545-1546. [PMID: 34818270 DOI: 10.1097/dss.0000000000003262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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