Current Controversies in Melanoma Treatment

Brunelli (Dorsoulnar) Flap for the Reconstruction of Defect of the Thumb Nail Unit After Oncological Resections With Mohs Micrographic Surgery

Background

The Brunelli flap is an option in the reconstruction of the thumb after trauma or oncological resections. The arc of movement of the flap makes it possible to resolve defects in the proximal, palmar, dorsal, and lateral regions.

Methods

We present a case series of 11 patients in whom a Brunelli flap was performed for postoncological reconstruction, melanoma in situ, and invasive squamous cell carcinoma of the thumb nail unit associated with Mohs micrographic surgery. This combination has not been described before.

Results

The reconstruction was carried out using a Brunelli flap, incorporating certain variations to the original technique. Clinical follow-up was performed during a 1-year period. All flaps showed good viability. In 3 flaps, there was mild distal suffering that resolved with local healing. Three patients presented hypersensitivity in the distal part, which was managed with physical therapy. The functionality of the thumb was not altered in any case, and there were no complications in the donor site. No tumor recurrence was documented in any patient.

Conclusions

The use of the Brunelli flap to reconstruct the nail unit after an oncological resection with Mohs surgery is a good alternative. The advantages include a dorsal artery as a constant vessel and a homodigital flap that does not cause morbidity in the donor area, and with Mohs surgery, amputation is avoided. Disadvantages include lack of sensation of the flap. Some limitations of our study are the sample size and lack of long-term follow-up.

Establishment and Validation of Prognostic Nomograms for Nonmetastatic Melanoma of the Limbs-A SEER-Based Study

BACKGROUND

Malignant melanoma, a highly aggressive skin cancer, has remarkable incidence and mortality nowadays. This study aims to explore prognostic factors associated with nonmetastatic cutaneous melanoma of the limbs and to develop nomograms for predicting overall survival (OS) and cancer-specific survival (CSS).

METHODS

The study cohort was derived from the Surveillance, Epidemiology, and End Results database. Univariate Cox regression, Lasso regression, and multivariate Cox regression analyses were conducted to identify prognostic factors and construct nomograms. The receiver operating characteristic (ROC) curve, time-dependent C-index, calibration curve, decision curve analysis (DCA) and Kaplan-Meier method were used to evaluate the accuracy and clinical applicability of the nomograms.

RESULTS

A total of 15,606 patients were enrolled. Multivariate analysis identified several prognostic factors for OS and CSS including age, sex, histologic type, N stage, tumor thickness, depth of invasion, mitotic rate, ulceration, surgery of primary site, systemic therapy, race, and number of lymph nodes examined. A nomogram incorporating 12 independent predictors for OS was developed, with a C-index of 0.866 (95% confidence interval [CI]: 0.858-0.874) in the training cohort and 0.853 (95% CI: 0.839-0.867) in validation. For CSS, 10 independent predictors and one related factor were included, yielding a C-index of 0.913 (95% CI: 0.903-0.923) in the training cohort and 0.922 (95% CI: 0.908-0.936) in validation. The ROC curve, time-dependent C-index, calibration curve, DCA, and K-M plot demonstrated favorable discrimination, calibration, and clinical utility.

CONCLUSION

The developed nomograms provide a precise and personalized predictive tool for risk management of patients with nonmetastatic limb melanoma.

Malignant melanoma in the hand: current evidence and recommendations

Malignant melanoma is the leading cause of death from skin cancer. In spite of significant advances in the management of melanoma with the advent of sentinel lymph node biopsy (SLNB) and adjuvant oncological therapies, the death rate continues to increase worldwide. Melanoma in the hand poses additional diagnostic and management challenges. Consequently, these tend to present at a later stage and are associated with a poorer prognosis. It is imperative that hand surgeons treat any pigmented hand lesion with suspicion to ensure rapid diagnosis and treatment. This article outlines the presentation of melanoma, and how to investigate suspicious pigmented lesions of the hand and digits. It guides hand surgeons in their approach to melanoma of the hand, outlining the multidisciplinary team approach as well as current standard surgical and reconstructive options to optimize outcomes.

Sentinel lymph node biopsy for melanoma in the older population: A prospective analysis of outcomes

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) in the older population, defined as those over 70 years old, has been debated since the adoption of SLNB into routine practice. Interestingly, there remains a paucity of evidence, especially regarding the rates of SLNB positivity, complications, and subsequent adjuvant therapy in those with node positivity.

METHOD

Data on patient's comorbidities, positivity rates, complication rates, and subsequent adjuvant treatments were collected prospectively from 998 patients (644 patients < 70 and 354 patients ≥ 70 years old) between 2016 and 2022.

RESULTS

Patients aged ≥ 70 were found to have a higher prevalence of comorbidities, including hypertension, diabetes and hyperlipidaemia. The mean Breslow thickness was 2.2 and 2.5 in the under and over 70 groups respectively (p = 0.03). The mean mitotic rate was found to be 3.3 in the under 70 s and 4.1 in the over 70 s (p = 0.02). Despite these results, no significant differences were observed in the positivity rates of sentinel lymph node biopsies or in the treatment options selected for positive results. The under 70 s were more likely to experience loss of sensation (p < 0.01), but no difference was found in the total number of complications between the two groups.

CONCLUSION

Although patients aged 70 and above had a greater incidence of comorbidities, the study revealed that they had lower complications rates and there was no significant variation in the SLNB positivity rate or chosen treatment options between the two age groups. This study supports the move to physiological rather than chronological age assessments in SLNB of the elderly.