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Duncan JR, Beal LL, Daugherty A, Elston C, Contreras C, Phillips CB, Huang C. Management of Transected Invasive Melanoma: A Single Institution Retrospective Review. Dermatol Surg 2022; 48:47-50. [PMID: 34743122 DOI: 10.1097/dss.0000000000003283] [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: 10/19/2022]
Abstract
BACKGROUND Deep transection of invasive melanoma precludes accurate measurement of Breslow depth, which may affect tumor staging. OBJECTIVE To determine the frequency of upstaging of transected invasive melanomas after excision, characterize the impact on National Comprehensive Cancer Network (NCNN)-recommended treatment, and determine predictors of subsequent upstaging. MATERIALS AND METHODS A retrospective review of invasive melanomas between January 2017 and December 2019 at a single institution. Deeply transected biopsy reports were compared with subsequent excisions to calculate the frequency of upstaging. RESULTS Three hundred sixty (49.6%) of 726 invasive melanomas identified were transected. Forty-nine (13.6%) transected tumors had upstaging that would have altered NCCN-recommended management. "Broadly" transected tumors had upstaging that would have resulted in a change in the management in 5/23 cases (21.7%) versus 2/41 cases (4.9%) for "focally" transected tumors (p = .038). Breslow depth increased by 0.59 mm on average for "broad" transection versus 0.06 mm for "focal" transection (p =< .01). Of the 89 transected pT1a melanomas, specimens with gross residual tumor or pigment after biopsy were upstaged in 8/17 (47.1%) of cases versus 5/72 (6.9%) of specimens without (p =< .01). CONCLUSION Upstaging of deeply transected invasive melanomas that would alter NCCN-recommended management occurred in 13.6% of cases. Broad transection and gross residual tumor or pigment after biopsy predicted higher likelihood of upstaging.
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Affiliation(s)
- James Robert Duncan
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | - Lauren L Beal
- McGovern Medical School at University of Texas Health, School of Medicine, Houston, Texas
| | - Andrew Daugherty
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | - Carly Elston
- Department of Surgical Oncology, The Ohio State University, James Comprehensive Cancer Center, Columbus, Ohio
| | - Carlo Contreras
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
| | | | - Conway Huang
- Department of Dermatology, University of Alabama Birmingham, Birmingham, Alabama
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Ahmadi O, Mathy JA. Reply to "Base Transection with Shaves: An Avoidable Shortcoming". Ann Surg Oncol 2021; 28:823-824. [PMID: 34368930 DOI: 10.1245/s10434-021-10182-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Omid Ahmadi
- Department of Otolaryngology and Head and Neck Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jon A Mathy
- Auckland Regional Plastic, Reconstructive and Hand Surgery Unit, Middlemore Hospital, Auckland, New Zealand. .,Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand.
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Narang J, Hue JJ, Bingmer K, Hardacre JM, Winter JM, Ocuin LM, Ammori JB, Mangla A, Bordeaux J, Rothermel LD. Sentinel lymph node biopsy guideline concordance in melanoma: Analysis of the National Cancer Database. J Surg Oncol 2021; 124:669-678. [PMID: 34109633 DOI: 10.1002/jso.26565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES This study investigated the impact of treating facility type on guideline-concordant sentinel lymph node biopsy (SLNB) management in T1a* (defined as a Breslow depth <0.76 mm without ulceration or mitoses) and T2/T3 melanoma. METHODS This was a retrospective cohort study utilizing the National Cancer Database from 2012 to 2016. RESULTS Our cohort included 109,432 patients. For T1a* melanomas, 85% of patients received guideline-concordant SLNB management at community and academic facilities versus 75% of patients at integrated network facilities (p < .001). Over 83% of patients with T2/T3 melanoma treated at an academic facility received guideline-concordant SLNB management versus 77% treated at a community facility (p < .001). Adjusting for demographic and clinical factors, integrated (adjusted odds ratio, aOR = 0.54), and comprehensive community (aOR = 0.74) facilities were less likely to provide guideline-concordant SLNB management in patients with T1a* melanoma compared to academic facilities. Community facilities (aOR = 0.72) were less likely to provide guideline-concordant SLNB management in patients with T2/T3 melanoma compared to academic facilities. CONCLUSION Academic facilities provide the highest rate of guideline-concordant sentinel lymph node management. Comparatively, community programs may underutilize SLNB in T2/T3 disease, while integrated and comprehensive community facilities may over-utilize SLNB in T1a* disease.
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Affiliation(s)
- Jatin Narang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan J Hue
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | | | - Jordan M Winter
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Lee M Ocuin
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - John B Ammori
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ankit Mangla
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jeremy Bordeaux
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luke D Rothermel
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Shao E, Blake T, Po-Chao F, Pool L, Carew B, Yong-Gee S, Wheller L, De'Ambrosis B, Muir J. Prospective study of pigmented lesions managed by shave excision with no deep margin transection of melanomas. Australas J Dermatol 2020; 61:269-272. [PMID: 32419172 DOI: 10.1111/ajd.13312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/30/2022]
Abstract
Shave excision is a simple and cost-effective technique for the removal of suitable skin lesions. We performed a prospective study over six months, collecting data from pigmented lesions that were treated with shave excision by dermatologists. Only shave excisions with the intent to remove the lesion in toto were included. A total of 349 lesions were included in this study, 50 (14%) of these were melanomas and no melanoma diagnosed had deep margin involvement, while 13 (26%) had lateral margin involvement.
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Affiliation(s)
- Emily Shao
- Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia.,Mater Hospital, South Brisbane, Queensland, Australia
| | - Tony Blake
- Mater Hospital, South Brisbane, Queensland, Australia
| | - Frank Po-Chao
- Mater Hospital, South Brisbane, Queensland, Australia
| | - Louis Pool
- Sullivan Nicolaides Pathology, Bowen Hills, Queensland, Australia
| | - Benjamin Carew
- Mater Hospital, South Brisbane, Queensland, Australia.,South East Dermatology Stafford, Stafford, Queensland, Australia
| | | | - Laura Wheller
- Mater Hospital, South Brisbane, Queensland, Australia.,South East Dermatology Stafford, Stafford, Queensland, Australia
| | - Brian De'Ambrosis
- Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia.,South East Dermatology, Annerley, Queensland, Australia.,Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - James Muir
- Mater Hospital, South Brisbane, Queensland, Australia.,South East Dermatology, Annerley, Queensland, Australia
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Klapperich ME, Bowen GM, Grossman D. Current controversies in early-stage melanoma: Questions on management and surveillance. J Am Acad Dermatol 2019; 80:15-25. [PMID: 30553299 DOI: 10.1016/j.jaad.2018.03.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/12/2018] [Accepted: 03/18/2018] [Indexed: 12/24/2022]
Abstract
There are a number of controversies and uncertainties relating to the management and surveillance of patients with early-stage, localized (ie, stage 0, I, and II) cutaneous melanoma. While tumor stage is a critical predictor of clinical outcome and guides treatment, accurate determination of stage may be affected by the biopsy technique used and the method of sectioning before histologic review. A new molecular prognostic test is available but has not been formally incorporated into staging or treatment guidelines. There are no randomized controlled clinical trials to support guidelines for surveillance following the treatment of early-stage melanoma. In the second article in this continuing medical education series, we review the controversies and uncertainties relating to these issues. The questions we address are controversial because they speak to clinical scenarios for which there are no evidence-based guidelines or randomized clinical trials with the consequence of considerable variability in clinical practice. Our goal is to provide the clinician with up-to-date contextual knowledge to appreciate the multiple sides of each controversy and to suggest pathways to resolution.
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Affiliation(s)
- Marki E Klapperich
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Glen M Bowen
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Douglas Grossman
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah.
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Stiegel E, Vij A. Reply to: "Comment on 'Prognostic value of sentinel lymph node biopsy according to Breslow thickness for cutaneous melanoma'". J Am Acad Dermatol 2018; 79:e55-e56. [PMID: 29787839 DOI: 10.1016/j.jaad.2018.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Evan Stiegel
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Alok Vij
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
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Circulating tumor DNA analysis as a real-time method for monitoring tumor burden in melanoma patients undergoing treatment with immune checkpoint blockade. J Immunother Cancer 2014; 2:42. [PMID: 25516806 PMCID: PMC4267741 DOI: 10.1186/s40425-014-0042-0] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 11/27/2014] [Indexed: 12/21/2022] Open
Abstract
Background Assessment of therapeutic activity of drugs blocking immune checkpoints such as CTLA-4 and PD-1/PD-L1 can be challenging, as tumors may seem to enlarge or appear anew before regressing, due to intratumoral inflammation. We assessed whether circulating tumor DNA (ctDNA) levels could serve as an early indicator of true changes in tumor burden in patients undergoing treatment with these agents. Findings Tumors from 12 patients with metastatic melanoma undergoing treatment with checkpoint blocking drugs were analyzed for the presence of hotspot somatic mutations in BRAF, cKIT, NRAS, and TERT. Plasma was collected serially from each patient and levels of ctDNA were compared with radiologic and clinical outcomes. In 5 of 10 patients studied, mutations were detected in BRAF(1), NRAS(2), TERT(1) and ALK(1). Analysis of plasma from 4 of 5 patients identified mutations identical to those found in tumor specimens. Plasma ctDNA levels ranged from undetectable (<0.01%) to 5.5% of total circulating cell-free DNA. In 3 patients, increasing ctDNA levels correlated with progressive disease assessed by radiography. In one patient, ctDNA levels increased after undergoing a needle biopsy of a tumor deposit. In another patient, ctDNA levels increased initially as lymphadenopathy progressed by examination, but then became undetectable 3 weeks prior to clinical improvement. Conclusions Levels of ctDNA correlated with clinical and radiologic outcomes, and, in one case, preceded eventual tumor regression. Further prospective analysis is required to assess the utility of ctDNA as an early biomarker of clinical outcomes in patients receiving immune checkpoint blocking drugs. Electronic supplementary material The online version of this article (doi:10.1186/s40425-014-0042-0) contains supplementary material, which is available to authorized users.
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Nemeth-Ochoa S. Commentary: prognosis of patients with transected melanomas. Dermatol Surg 2013; 39:618-9. [PMID: 23551556 DOI: 10.1111/dsu.12139] [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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Grossman D, Bowen GM. Commentary: transecting melanomas: does it matter? Dermatol Surg 2013; 39:616-7. [PMID: 23551555 DOI: 10.1111/dsu.12132] [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]
Affiliation(s)
- Douglas Grossman
- Hutsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
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