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Gimenez AR, Winocour SJ, Chu CK. Reconstructive Techniques in Melanoma for the Surgical Oncologist. Surg Oncol Clin N Am 2021; 29:349-367. [PMID: 32482313 DOI: 10.1016/j.soc.2020.02.003] [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] [Indexed: 10/24/2022]
Abstract
Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.
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Affiliation(s)
- Alejandro R Gimenez
- Division of Plastic Surgery, Baylor College of Medicine, 6701 Fannin Street, Suite 610, Houston, TX 77030, USA. https://twitter.com/AGimenezMD
| | - Sebastian J Winocour
- Division of Plastic Surgery, Baylor College of Medicine, 1977 Butler Boulevard, Suite E6.100, Houston, TX 77030, USA. https://twitter.com/WinocourMD
| | - Carrie K Chu
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1400 Pressler Street, Unit 1488, Houston, TX 77030, USA.
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Straker RJ, Song Y, Sun J, Shannon AB, Cohen LS, Muradova E, Daou H, Krause K, Li S, Frederick DT, Rhodin KE, Brizel DM, Boland GM, Beasley GM, Wuthrick EJ, Sondak VK, Zager JS, Lin A, Lukens JN, Karakousis GC. Adjuvant Radiation Therapy for Clinical Stage III Melanoma in the Modern Therapeutic Era. Ann Surg Oncol 2020; 28:3512-3521. [PMID: 33230747 DOI: 10.1245/s10434-020-09384-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant radiation therapy (RT) can decrease lymph node basin (LNB) recurrences in patients with clinically evident melanoma lymph node (LN) metastases following lymphadenectomy, but its role in the era of modern systemic therapies (ST), immune checkpoint or BRAF/MEK inhibitors, is unclear. PATIENTS AND METHODS Patients at four institutions who underwent lymphadenectomy (1/1/2010-12/31/2019) for clinically evident melanoma LN metastases and received neoadjuvant and/or adjuvant ST with RT, or ST alone, but met indications for RT, were identified. Comparisons were made between ST alone and ST/RT groups. The primary outcome was 3-year cumulative incidence (CI) of LNB recurrence. Secondary outcomes included 3-year incidences of in-transit/distant recurrence and survival estimates. RESULTS Of 98 patients, 76 received ST alone and 22 received ST/RT. Median follow-up time for patients alive at last follow-up was 44.6 months. The ST/RT group had fewer inguinal node metastases (ST 36.8% versus ST/RT 9.1%; P = 0.04), and more extranodal extension (ST 50% versus ST/RT 77.3%; P = 0.02) and positive lymphadenectomy margins (ST 2.6% versus ST/RT 13.6%; P = 0.04). The 3-year CI of LNB recurrences was lower for the ST/RT group compared with the ST group (13.9% versus 25.2%), but this reduction was not statistically significant (P = 0.36). Groups did not differ significantly in in-transit/distant recurrences (P = 0.24), disease-free survival (P = 0.14), or melanoma-specific survival (P = 0.20). CONCLUSIONS In the era of modern ST, RT may still have value in reducing LNB recurrences in melanoma with clinical LN metastases. Further research should focus on whether select patient populations derive benefit from combination therapy, and optimizing indications for RT following neoadjuvant ST.
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Affiliation(s)
- Richard J Straker
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Adrienne B Shannon
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Leah S Cohen
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Elnara Muradova
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kate Krause
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Siming Li
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennie T Frederick
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - David M Brizel
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Genevieve M Boland
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Evan J Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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