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Novis E, van Akkooi ACJ. Management of Localized Melanoma in the Anti-PD-1 Era. Curr Oncol Rep 2024:10.1007/s11912-024-01556-z. [PMID: 38842606 DOI: 10.1007/s11912-024-01556-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The management of cutaneous melanoma has rapidly progressed over the past decade following the introduction of effective systemic therapies. Given the large number of recent clinical trials which have dramatically altered the management of these patients, an updated review of the current evidence regarding the management of localized melanoma is needed. RECENT FINDINGS The role of effective systemic therapies in earlier stages (I-III) melanoma, both in adjuvant and neoadjuvant settings is rapidly changing the role of surgery in the management cutaneous melanoma, particularly regarding surgical safety margins for wide local excision (WLE), the role of sentinel lymph node biopsy (SLNB) and the extent of lymph node dissections. The randomized phase 2 SWOG1801 trial has demonstrated superiority of neoadjuvant-adjuvant anti-PD1 therapy in improving event-free survival by 23% at 2-years over adjuvant anti-PD-1 therapy only. Furthermore, the PRADO trial has suggested a more tailored approach both the extent of surgery as well as adjuvant therapy can safely and effectively be done, depending on the response to initial neoadjuvant immunotherapy. These results await validation and it is expected that in 2024 the phase 3 Nadina trial (NCT04949113) will definitively establish neo-adjuvant combination immunotherapy as the novel standard. This will further redefine the management of localized melanoma. The use of effective systemic therapies will continue to evolve in the next decade and, together with new emerging diagnostic and surveillance techniques, will likely reduce the extent of routine surgery for stage I-III melanoma.
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Affiliation(s)
- Elan Novis
- Melanoma Institute Australia, 40 Rocklands Road, Wollstonecraft, North Sydney, Sydney, NSW, 2060, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alexander C J van Akkooi
- Melanoma Institute Australia, 40 Rocklands Road, Wollstonecraft, North Sydney, Sydney, NSW, 2060, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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Wink JD, Rhemtulla IA, Fix W, Enriquez F, Mauch J, Barbieri J, Miller CJ, Chang B, Lin IC, Kovach SJ. Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function. J Hand Microsurg 2024; 16:100001. [PMID: 38854376 PMCID: PMC11127536 DOI: 10.1055/s-0040-1714649] [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: 10/23/2022] Open
Abstract
Introduction Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma. Materials and Methods A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure. Results Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61). Conclusion Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.
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Affiliation(s)
- Jason D. Wink
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Irfan A. Rhemtulla
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - William Fix
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Fabiola Enriquez
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Jaclyn Mauch
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - John Barbieri
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Christopher J. Miller
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Benjamin Chang
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Ines C. Lin
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Stephen J. Kovach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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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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Khalid M, Sutterfield B, Minley K, Ottwell R, Abercrombie M, Heath C, Torgerson T, Hartwell M, Vassar M. The Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines Focused on the Management of Cutaneous Melanoma: Cross-Sectional Analysis. JMIR DERMATOLOGY 2023; 6:e43821. [PMID: 38060306 PMCID: PMC10739238 DOI: 10.2196/43821] [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: 10/27/2022] [Revised: 03/28/2023] [Accepted: 09/15/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) inform evidence-based decision-making in the clinical setting; however, systematic reviews (SRs) that inform these CPGs may vary in terms of reporting and methodological quality, which affects confidence in summary effect estimates. OBJECTIVE Our objective was to appraise the methodological and reporting quality of the SRs used in CPGs for cutaneous melanoma and evaluate differences in these outcomes between Cochrane and non-Cochrane reviews. METHODS We conducted a cross-sectional analysis by searching PubMed for cutaneous melanoma guidelines published between January 1, 2015, and May 21, 2021. Next, we extracted SRs composing these guidelines and appraised their reporting and methodological rigor using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklists. Lastly, we compared these outcomes between Cochrane and non-Cochrane SRs. All screening and data extraction occurred in a masked, duplicate fashion. RESULTS Of the SRs appraised, the mean completion rate was 66.5% (SD 12.29%) for the PRISMA checklist and 44.5% (SD 21.05%) for AMSTAR. The majority of SRs (19/50, 53%) were of critically low methodological quality, with no SRs being appraised as high quality. There was a statistically significant association (P<.001) between AMSTAR and PRISMA checklists. Cochrane SRs had higher PRISMA mean completion rates and higher methodological quality than non-Cochrane SRs. CONCLUSIONS SRs supporting CPGs focused on the management of cutaneous melanoma vary in reporting and methodological quality, with the majority of SRs being of low quality. Increasing adherence to PRISMA and AMSTAR checklists will likely increase the quality of SRs, thereby increasing the level of evidence supporting cutaneous melanoma CPGs.
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Affiliation(s)
- Mahnoor Khalid
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Bethany Sutterfield
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Kirstien Minley
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Ryan Ottwell
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - McKenna Abercrombie
- Dermatology Residency, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Christopher Heath
- Dermatology Residency, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Trevor Torgerson
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Micah Hartwell
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Matt Vassar
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
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Varey AHR, Thompson JF, Howle JR, Lo SN, Ch’ng S, Carlino MS. Has the advent of modern adjuvant systemic therapy for melanoma rendered sentinel node biopsy unnecessary? Eur J Cancer 2023; 186:166-171. [PMID: 37080117 DOI: 10.1016/j.ejca.2023.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/15/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023]
Abstract
The prognostic value of sentinel node biopsy (SNB) is well established and SNB was therefore adopted as a requirement for pathological staging of melanomas>1 mm thick in the American Joint Committee on Cancer (AJCC) 8th edition. Consequently, a negative SNB status became an eligibility criterion for clinical trials of adjuvant systemic therapy in resected stage IIB/C melanoma. However, since the Keynote 716 trial demonstrated an improvement in relapse-free survival (RFS) in patients with Stage IIB/C melanoma, all of whom had SNB staging, some have argued that SNB is no longer required for patients with T3 and T4 primary melanomas. The rationale for omitting SNB is that these patients will be able to access adjuvant immunotherapy regardless of SNB status, avoiding the costs and potential complications of SNB. However, this argument overlooks the prognostic value of knowing a patient's nodal status and the therapeutic benefit of SNB in regional disease control. Based on extrapolation of data from multiple sources, we demonstrate that the risk of regional node-field relapse with SNB and immunotherapy for T3b and T4 melanomas is around 7-9% but is 20-27% without SNB. Similarly, the node-field recurrence rate with SNB alone is around 14% compared to around 40% with no SNB or immunotherapy. Consequently, in the absence of prospective data, we propose that the optimal management of the regional node-field for high-risk T3b and T4 primary melanomas is likely to be achieved by combining SNB and adjuvant immunotherapy for those patients who are suitable, rather than either treatment alone.
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Gaetano L, Domenico B, Lo SN, Hamed T, Potter AJ, Thompson JF, Scolyer RA, Guitera P. Association between excision margins and local recurrence in 1407 patients with primary in situ melanomas. JAAD Int 2022; 8:102-108. [PMID: 35875393 PMCID: PMC9305371 DOI: 10.1016/j.jdin.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background Reliable evidence to guide the management of melanoma in situ (MIS) and minimize the risk of recurrence is lacking. Objective To identify clinicopathological predictors of local recurrence (LR) in patients with MIS and evaluate long-term outcomes according to pathological excision margins. Methods A case-control study of patients with MIS treated at a large Australian melanoma treatment center from January 2008 to December 2012 was undertaken. Clinicopathological characteristics of patients who developed LR and those who did not were compared. Results LR developed in 34 of 1407 patients with MIS (2.5%). Median time to LR was 20 months. The primary lesion was removed with pathological margins <4 mm (P < .001) in 67.6 % of patients with LR. Four patients died of metastatic melanoma following LR. Comparing patients with pathological margins <4 mm and ≥4 mm, the former were older (>60y, P < .001), more frequently had MIS on the head or neck (P < .001), had a greater LR rate (P < .001), and had a higher mortality from all causes (P < .001). Limitations Retrospective, single-institution study. Conclusions Pathological margins of ≥4 mm should be considered for patients with MIS who are treated with standard surgical excision and assessed by examining serial slices taken from the formalin-fixed, paraffin-embedded specimen.
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7
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Roman KM, Torabi SJ, Goshtasbi K, Kuan EC, Tjoa T, Haidar YM. Case volume regionalization and volume-based outcome differences in cutaneous head and neck melanoma. Head Neck 2022; 44:2428-2436. [PMID: 35903986 DOI: 10.1002/hed.27150] [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: 01/02/2022] [Revised: 06/06/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Hospital volume has emerged as a prognostic factor in oncology but is not currently known whether volume is associated with improved outcomes for cutaneous head and neck (HN) melanoma. METHODS A total of 556 079 cutaneous melanoma cases reported by the 2004-2016 National Cancer Database were separated into two cohorts (HN and non-HN) and facilities within each cohort were classified by case volume. Analysis employed chi-square, analysis of variance, Kaplan-Meier, and Cox proportional hazards models. RESULTS Only 41 facilities (3.1% of 1326) treating HN melanoma and 50 facilities (3.7% of 1344) treating non-HN melanoma were classified as high-volume facilities (HVFs). The estimated 5-year overall survival (OS) was 62.7% (standard error [SE]: 0.4%) for patients with HN at low-volume facilities (LVFs), 69.3% (SE: 0.4%) at IVFs, and 71.8% (SE 0.4%) at HVFs (p < 0.001). Differences in OS remained significant between HVFs versus LVFs after adjusting for confounders. CONCLUSION Volume is independently associated with OS and improved surgical outcomes for HN melanoma.
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Affiliation(s)
- Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, California, USA
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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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Cartwright JK, Snyder DH, Moreno FG. Development of metastatic Merkel cell carcinoma following the excision of same‐sided recurrent auricular melanoma. Clin Case Rep 2022; 10:e05891. [PMID: 35620264 PMCID: PMC9124612 DOI: 10.1002/ccr3.5891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/12/2022] [Accepted: 04/26/2022] [Indexed: 11/11/2022] Open
Abstract
Merkel cell carcinoma (MCC) is a rare neuroendocrine malignancy of the skin that is highly aggressive and often metastasizes early. MCC is diagnosed based on histopathological findings and is most commonly treated with surgical resection, which may be accompanied by chemotherapy and/or radiation. This report describes a 55‐year‐old male patient with the history of recurrent malignant melanoma of the right pinna and subsequent excision. Three years following the excision of melanoma, he presented with a lesion to the right forehead as well as a right‐sided neck mass that were found to be metastatic Merkel cell carcinoma.
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Affiliation(s)
- Jake K. Cartwright
- Quillen College of Medicine East Tennessee State University Mountain Home Tennessee USA
| | | | - Francisco G. Moreno
- Otolaryngology—Head and Neck Surgery Facial Plastic Surgery Knoxville Tennessee USA
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Ludzik J, Lee C, Witkowski A, Hetts J. Minimizing sampling error using a unique ink-stained reflectance confocal microscopy-guided biopsy technique to diagnose a large lentigo maligna. JAAD Case Rep 2022; 24:118-120. [PMID: 35677149 PMCID: PMC9168378 DOI: 10.1016/j.jdcr.2022.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Joanna Ludzik
- Department of Telemedicine and Bioinformatics, Jagiellonian University Medical College, Krakow, Poland
- Department of Dermatology, Oregon Health and Sciences University, Portland, Oregon
| | - Claudia Lee
- Department of Dermatology, Oregon Health and Sciences University, Portland, Oregon
- School of Medicine, University of California Riverside, Riverside, California
- Correspondence to: Claudia Lee, BS, Department of Dermatology, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239.
| | - Alexander Witkowski
- Department of Dermatology, Oregon Health and Sciences University, Portland, Oregon
| | - Jonathon Hetts
- Department of Dermatology, Oregon Health and Sciences University, Portland, Oregon
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Li Z, Li X, Yi X, Li T, Huang X, Ren X, Ma T, Li K, Guo H, Chen S, Ma Y, Shang L, Song B, Hu D. Characteristics, Prognosis, and Competing Risk Nomograms of Cutaneous Malignant Melanoma: Evidence for Pigmentary Disorders. Front Oncol 2022; 12:838840. [PMID: 35719966 PMCID: PMC9198425 DOI: 10.3389/fonc.2022.838840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Cutaneous malignant melanoma (CMM) always presents as a complex disease process with poor prognosis. The objective of the present study was to explore the influence of solitary or multiple cancers on the prognosis of patients with CMM to better understand the landscape of CMM. METHODS We reviewed the records of CMM patients between 2004 and 2015 from the Surveillance, Epidemiology, and End Results Program. The cumulative incidence function was used to represent the probabilities of death. A novel causal inference method was leveraged to explore the risk difference to death between different types of CMM, and nomograms were built based on competing risk models. RESULTS The analysis cohort contained 165,043 patients with CMM as the first primary malignancy. Patients with recurrent CMM and multiple primary tumors had similar overall survival status (p = 0.064), while their demographics and cause-specific death demonstrated different characteristics than those of patients with solitary CMM (p < 0.001), whose mean survival times are 75.4 and 77.3 months and 66.2 months, respectively. Causal inference was further applied to unveil the risk difference of solitary and multiple tumors in subgroups, which was significantly different from the total population (p < 0.05), and vulnerable groups with high risk of death were identified. The established competing risk nomograms had a concordance index >0.6 on predicting the probabilities of death of CMM or other cancers individually across types of CMM. CONCLUSION Patients with different types of CMM had different prognostic characteristics and different risk of cause-specific death. The results of this study are of great significance in identifying the high risk of cause-specific death, enabling targeted intervention in the early period at both the population and individual levels.
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Affiliation(s)
- Zichao Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xinrui Li
- Department of Health Statistics, School of Public Health, Fourth Military Medical University, Xi’an, China
| | - Xiaowei Yi
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Tian Li
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Xingning Huang
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Xiaoya Ren
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Tianyuan Ma
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Kun Li
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Hanfeng Guo
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Shengxiu Chen
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Yao Ma
- College of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Lei Shang
- Department of Health Statistics, School of Public Health, Fourth Military Medical University, Xi’an, China
- *Correspondence: Lei Shang, ; Baoqiang Song, ; Dahai Hu,
| | - Baoqiang Song
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Lei Shang, ; Baoqiang Song, ; Dahai Hu,
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Lei Shang, ; Baoqiang Song, ; Dahai Hu,
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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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Affiliation(s)
- Sarem Rashid
- Department of Dermatology, Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02466, USA; Boston University School of Medicine, Boston, MA, USA
| | - Hensin Tsao
- Department of Dermatology, Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02466, USA.
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Iacullo J, Barriera-Silvestrini P, Knackstedt TJ. Dermatologic Follow-up and Assessment of Suspicious Lesions. Clin Plast Surg 2021; 48:617-629. [PMID: 34503722 DOI: 10.1016/j.cps.2021.05.006] [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] [Indexed: 12/20/2022]
Abstract
As our knowledge and understanding of melanoma evolve, melanoma surveillance guidelines will reflect these findings. Currently, there is no consensus across international guidelines for melanoma follow-up. However, it is accepted that more aggressive surveillance is recommended for more advanced disease. When examining high-risk individuals, a systematic approach should be followed. Future considerations include the use of noninvasive imaging techniques, 'liquid biopsies,' and artificial intelligence to enhance detection of melanomas.
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Affiliation(s)
- Julie Iacullo
- Department of Dermatology, MetroHealth System, 2500 Metrohealth Drive, Cleveland, OH 44109, USA
| | | | - Thomas J Knackstedt
- Department of Dermatology, MetroHealth System, 2500 Metrohealth Drive, Cleveland, OH 44109, USA; Case Western Reserve University, School of Medicine, 2500 Metrohealth Drive, Cleveland, OH 44109, USA.
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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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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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Pandya R, Basra M, Twohig E, McVeigh K. Can we reduce excision margins for head and neck melanoma? A 12-year retrospective study. Br J Oral Maxillofac Surg 2020; 60:134-139. [PMID: 35123836 DOI: 10.1016/j.bjoms.2020.10.016] [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: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 11/18/2022]
Abstract
Although wide local excision is the standard treatment for primary melanoma, the surgical margin remains controversial. Melanomas of the head and neck exhibit higher recurrence rates and worse prognosis than lesions in other body locations, and their close proximity to critical anatomical and functional structures means that wide excision margins are often not feasible. Surgeons must therefore achieve a balance of oncological safety and functional and aesthetic needs. The aim of this study was to retrospectively analyse melanoma data over a 12-year period at a large skin surgery unit to identify potential differences in outcomes in patients who had reduced wide local excision margins for primary head and neck melanoma. The study would provide further evidence for the need for large randomised prospective trials to reduce excision margins for head and neck melanoma. Local cancer network data were retrospectively analysed over a period of 12 years (2008-2019). Data included site, initial stage, multidisciplinary team (MDT) meeting recommendations for excision margins and the actual wide local excision margin taken, recurrence rate, and disease-specific and absolute survival. A total of 222/305 patients (73%) had the recommended excision margin, while in 27% margins were reduced due to anatomical or functional considerations. Recurrence rates were similar (recommended 11.7% vs narrow 13.3% excision margins) (p = 0.64). The mean follow-up time for all patients was 48.5 months. In aesthetically and functionally sensitive areas of the head and neck, wide local excision margins need to be carefully considered after MDT discussion and discussion with the patient. This study suggests the need for further multicentre trials to address the uniqueness of head and neck melanoma.
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Affiliation(s)
- R Pandya
- Worcestershire Royal Hospital, Charles Cavell Way, Worcester, WR5 1DD.
| | - M Basra
- Worcestershire Royal Hospital, Charles Cavell Way, Worcester, WR5 1DD.
| | - E Twohig
- Worcestershire Royal Hospital, Charles Cavell Way, Worcester, WR5 1DD.
| | - K McVeigh
- Worcestershire Royal Hospital, Charles Cavell Way, Worcester, WR5 1DD.
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18
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Martinelli LP, Iermak I, Moriyama LT, Requena MB, Pires L, Kurachi C. Optical clearing agent increases effectiveness of photodynamic therapy in a mouse model of cutaneous melanoma: an analysis by Raman microspectroscopy. BIOMEDICAL OPTICS EXPRESS 2020; 11:6516-6527. [PMID: 33282505 PMCID: PMC7687942 DOI: 10.1364/boe.405039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 05/05/2023]
Abstract
Melanoma is the most aggressive type of skin cancer and a relevant health problem due to its poor treatment response with high morbidity and mortality rates. This study, aimed to investigate the tissue changes of an improved photodynamic therapy (PDT) response when combined with optical clearing agent (OCA) in the treatment of cutaneous melanoma in mice. Photodithazine (PDZ) was administered intraperitoneally and a solution of OCA was topically applied before PDT irradiation. Due to a resultant refractive index matching, OCA-treated tumors are more optically homogenous, improving the PDT response. Raman analysis revealed, when combined with OCA, the PDT response was more homogenous down to 725 µm-depth in thickness.
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Affiliation(s)
- Letícia Palombo Martinelli
- Federal University of São Carlos, Post-Graduation Program inBiotechnology, Rodovia Washington Luís km 235, SP-310, São Carlos 13565-905, Brazil
- University of São Paulo, São Carlos Institute of Physics, Avenue Trabalhador São-Carlense, 400, São Carlos, São Paulo 13566-590, Brazil
| | - Ievgeniia Iermak
- University of São Paulo, São Carlos Institute of Physics, Avenue Trabalhador São-Carlense, 400, São Carlos, São Paulo 13566-590, Brazil
| | - Lilian Tan Moriyama
- University of São Paulo, São Carlos Institute of Physics, Avenue Trabalhador São-Carlense, 400, São Carlos, São Paulo 13566-590, Brazil
| | - Michelle Barreto Requena
- University of São Paulo, São Carlos Institute of Physics, Avenue Trabalhador São-Carlense, 400, São Carlos, São Paulo 13566-590, Brazil
| | - Layla Pires
- Princess Margaret Cancer Center, University Health Network, Princess Margaret Cancer Research Tower, 101 College Street, Toronto, Ontario M5G1L7, Canada
| | - Cristina Kurachi
- Federal University of São Carlos, Post-Graduation Program inBiotechnology, Rodovia Washington Luís km 235, SP-310, São Carlos 13565-905, Brazil
- University of São Paulo, São Carlos Institute of Physics, Avenue Trabalhador São-Carlense, 400, São Carlos, São Paulo 13566-590, Brazil
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19
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Shellenberger RA, Fayyaz F, Sako Z, Schaeffer M, Tawagi K, Scheidel C, Nabhan M. Impact of Biopsy Technique on Clinically Important Outcomes for Cutaneous Melanoma: A Systematic Review and Meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2020; 4:373-383. [PMID: 32793865 PMCID: PMC7411171 DOI: 10.1016/j.mayocpiqo.2020.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We performed a systematic review and meta-analysis to examine the relationship between the type of biopsy technique employed in the diagnosis of cutaneous melanoma and 4 clinically important outcomes: melanoma-specific mortality, all-cause mortality, Breslow tumor depth, or melanoma recurrence. Our database was obtained by searching PubMed, Ovid MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Library from inception until December 6, 2019. Studies were identified that compared biopsy techniques used to diagnose cutaneous melanoma with any of our study outcomes. We included 7 observational studies for our meta-analysis after screening 3231 titles and abstracts. Pooled data identified a significantly higher all-cause mortality in the punch biopsy group (risk ratio [RR], 1.520; P=.02). A higher, but nonsignificant, rate of melanoma-specific mortality (RR, 1.96; P=.22) and melanoma recurrence (RR, 1.20; P=.186) was also found for the punch biopsy group. Breslow tumor thickness was not significantly lower for punch incision (standardized mean difference, −0.42; P=.27). We found limited evidence for differences in clinically important outcomes across the spectrum of the most common methods employed in clinical practice for the initial diagnosis of cutaneous melanoma. A small, but significant, increase (P=.02) in all-cause mortality with punch biopsies was not seen for the other outcomes and was most likely due to small sample sizes and demographic differences in the included studies and unlikely represents a clinically important outcome. Our findings support the use of existing clinical practice guidelines for evaluating pigmented lesions suspicious for cutaneous melanoma.
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Affiliation(s)
| | - Fatima Fayyaz
- Internal Medicine Residency Program, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI
| | - Zeyad Sako
- Hematology and Oncology Fellowship, Ascension St. John Hospital, Detroit, MI
| | - Madeline Schaeffer
- Department of Dermatology, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI
| | - Karine Tawagi
- Department of Hematology and Oncology, Ochsner Medical Center, New Orleans, LA
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Rawson RV, Scolyer RA. From Breslow to BRAF and immunotherapy: evolving concepts in melanoma pathogenesis and disease progression and their implications for changing management over the last 50 years. Hum Pathol 2019; 95:149-160. [PMID: 31704364 DOI: 10.1016/j.humpath.2019.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/11/2019] [Indexed: 02/03/2023]
Abstract
Since it was first recognized as a disease entity more than two centuries ago, advanced melanoma has, until recently, followed a very aggressive and almost universally fatal clinical course. However, over the past 50 years crucial ground breaking research has greatly enhanced our understanding of the etiology, risk factors, genomic pathogenesis, immunological interactions, prognostic features and management of melanoma. It is this combined body of work which has culminated in the exciting improvements in patient outcomes for those with advanced melanoma over the last ten years. In this the 50th anniversary of Human Pathology, we highlight the key developments in melanoma over this period.
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Affiliation(s)
- Robert V Rawson
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2020, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; New South Wales Health Pathology, Camperdown 2050, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2020, NSW, Australia.
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21
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Egeler SA, Huang A, Johnson AR, Ibrahim A, Bucknor A, Peymani A, Mureau MAM, Lin SJ. Regional incidence of and reconstructive management patterns in melanoma and nonmelanoma skin cancer of the head and neck: A 3-year analysis in the inpatient setting. J Plast Reconstr Aesthet Surg 2019; 73:507-515. [PMID: 31787545 DOI: 10.1016/j.bjps.2019.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 09/07/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Currently, there is limited literature on reconstructive trends for inpatient head and neck skin cancer. Rather, studies have focused primarily on patients treated on an outpatient basis. To gain a better understanding of the effect that reconstructive correction of complex skin cancer defects has on the healthcare system, we examined the existing incidence and reconstructive trends of head and neck melanoma and nonmelanoma skin cancer (NMSC) in the inpatient setting. METHOD We performed the analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database (NIS) for the years 2012-2014 of the United States (US). Adults diagnosed with melanoma skin cancer or NMSC of the head and neck region were included. Patient characteristics, reconstructive modality, surgical specifics, and outcomes were retrieved. Trends with time for reconstruction techniques were analyzed. RESULTS In total, 41,185 patients with a diagnosis of skin malignancy were identified, of whom 5,480 (13.3%) underwent reconstruction. Most patients were white (90.0%), male (71.6%), and had a diagnosis of NMSC (79.2%). An increase in flap reconstruction (p < 0.001) was observed. After population adjustment, the highest incidence of skin malignancy was found in the Northeast. CONCLUSION There has been a trending increase in inpatient NMSC and melanoma skin cancer of the head and neck region, correlating to an increase in the reconstructive procedures performed, and greater cost burden. Resources may be allocated toward early identification and treatment for skin cancer to help control the current rise in complex skin cancer cases necessitating inpatient admission.
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Affiliation(s)
- Sabine A Egeler
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Anne Huang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Anna R Johnson
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ahmed Ibrahim
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alexandra Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Abbas Peymani
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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22
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Utjés D, Malmstedt J, Teras J, Drzewiecki K, Gullestad HP, Ingvar C, Eriksson H, Gillgren P. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: long-term follow-up of a multicentre, randomised trial. Lancet 2019; 394:471-477. [PMID: 31280965 DOI: 10.1016/s0140-6736(19)31132-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/03/2019] [Accepted: 04/24/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND The optimal surgical excision margins are uncertain for patients with thick (>2 mm) localised cutaneous melanomas. In our previous report of this multicentre, randomised controlled trial, with a median follow-up of 6·7 years, we showed that a narrow excision margin (2 cm vs 4 cm) did not affect melanoma-specific nor overall survival. Here, we present extended follow-up of this cohort. METHODS In this open-label, multicentre randomised controlled trial, we recruited patients from 53 hospitals in Sweden, Denmark, Estonia, and Norway. We enrolled clinically staged patients aged 75 years or younger diagnosed with localised cutaneous melanoma thicker than 2 mm, and with primary site on the trunk or upper or lower extremities. Patients were randomly allocated (1:1) to treatment either with a 2-cm or a 4-cm excision margin. A physician enrolled the patients after histological confirmation of a cutaneous melanoma thicker than 2 mm. Some patients were enrolled by a physician acting as responsible for clinical care and as a trial investigator (follow-up, data collection, and manuscript writing). In other cases physicians not involved in running the trial enrolled patients. Randomisation was done by telephone call to a randomisation office, by sealed envelope, or by computer generated lists using permuted blocks. Patients were stratified according to geographical region. No part of the trial was masked. The primary outcome in this extended follow-up study was overall survival and the co-primary outcome was melanoma-specific survival. All analyses were done on an intention-to-treat basis. The study is registered with ClinicalTrials.gov, number NCT03638492. FINDINGS Between Jan 22, 1992, and May 19, 2004, 936 clinically staged patients were recruited and randomly assigned to a 4-cm excision margin (n=465) or a 2-cm excision margin (n=471). At a median overall follow-up of 19·6 years (235 months, IQR 200-260), 621 deaths were reported-304 (49%) in the 2-cm group and 317 (51%) in the 4-cm group (unadjusted HR 0·98, 95% CI 0·83-1·14; p=0·75). 397 deaths were attributed to cutaneous melanoma-192 (48%) in the 2-cm excision margin group and 205 (52%) in the 4-cm excision margin group (unadjusted HR 0·95, 95% CI 0·78-1·16, p=0·61). INTERPRETATION A 2-cm excision margin was safe for patients with thick (>2 mm) localised cutaneous melanoma at a follow-up of median 19·6 years. These findings support the use of 2-cm excision margins in current clinical practice. FUNDING The Swedish Cancer Society, Stockholm Cancer Society, the Swedish Society for Medical Research, Radiumhemmet Research funds, Stockholm County Council, Wallström funds.
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Affiliation(s)
- Deborah Utjés
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jüri Teras
- North Estonia Regional Hospital, Tallinn, Estonia; Tallinn University of Technology, Tallinn, Estonia
| | - Krzysztof Drzewiecki
- Department of Plastic Surgery and Burns Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Christian Ingvar
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hanna Eriksson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Oncology/Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Gillgren
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden.
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23
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Kitchener S, Pinidiyapathirage J, Hunter K, Cochrane L, Gederts S, Sy T, Watts B, Murray A, Poologasundrum M, Bose S, Do A, Hall J, Reedy A, Hudson L, Masel M. Epidemiology of melanoma in rural southern Queensland. Aust J Rural Health 2019; 27:386-391. [DOI: 10.1111/ajr.12545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Scott Kitchener
- Griffith School of Medicine Southport Queensland Australia
- Clifton Health Services Clifton Queensland Australia
| | | | - Keegan Hunter
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Lynsey Cochrane
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Stephanie Gederts
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Tim Sy
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Brianna Watts
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Adrienne Murray
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | | | - Swaha Bose
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - Alexander Do
- Griffith Rural Summer Scholar, Griffith Health Toowoomba Queensland Australia
| | - John Hall
- Downs Rural Medicine Oakey Queensland Australia
| | - Andrew Reedy
- Millmerran Medical Practice Millmerran Queensland Australia
| | - Lynton Hudson
- Condamine Medical Centre Warwick Queensland Australia
| | - Matthew Masel
- Goodniwindi Medical Centre Goondiwindi Queensland Australia
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Kimlin MG, Youlden DR, Brodie AM, DiSipio T, Youl P, Nair-Shalliker V, Baade PD. Risk of Second Primary Cancer in Survivors of In Situ Melanoma. J Invest Dermatol 2019; 139:842-847. [PMID: 30423330 DOI: 10.1016/j.jid.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 11/04/2018] [Indexed: 01/12/2023]
Abstract
Survivors of invasive melanoma have an increased risk of developing second primary cancers; however, similar risks associated with in situ melanoma have not been established. We evaluated 39,872 survivors of first primary in situ melanoma diagnosed from 1982 through 2012 in Queensland, Australia. Relative risk of second nonmelanoma primary cancers was estimated from standardized incidence ratios with 95% confidence intervals. A total of 4,823 (12%) in situ melanoma survivors developed a second primary cancer. A small increased risk (6%) compared with the general population was found. In those younger than 50 years, risk was increased by 14% for all cancers combined. In situ melanoma survivors had significantly increased risks of developing lip, thyroid, pancreatic, and brain cancers and decreased risks of head and neck, and lung cancers. Male in situ melanoma survivors had a significantly increased risk of prostate cancer; female survivors had an increased risk of thyroid cancer and lymphoid leukemia. Findings indicate that in situ melanoma may predict the diagnosis of certain second primary cancers. This altered risk may be due to biological, behavioral, or genetic factors or increased medical surveillance, and it requires further investigation, particularly among people younger than 50 years.
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Affiliation(s)
- Michael G Kimlin
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia; Cancer Council Queensland, Spring Hill, Queensland, Australia.
| | - Danny R Youlden
- Cancer Council Queensland, Spring Hill, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Alison M Brodie
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Tracey DiSipio
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Philippa Youl
- University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Visalini Nair-Shalliker
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia; The University of Sydney, Sydney, Australia
| | - Peter D Baade
- Cancer Council Queensland, Spring Hill, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia; School of Mathematical Sciences, Queensland University of Technology, Queensland, Australia
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25
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Thomas NE, Edmiston SN, Tsai YS, Parker JS, Googe PB, Busam KJ, Scott GA, Zedek DC, Parrish EA, Hao H, Slater NA, Pearlstein MV, Frank JS, Kuan PF, Ollila DW, Conway K. Utility of TERT Promoter Mutations for Cutaneous Primary Melanoma Diagnosis. Am J Dermatopathol 2019; 41:264-272. [PMID: 30211730 PMCID: PMC6411457 DOI: 10.1097/dad.0000000000001259] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Telomerase reverse transcriptase (TERT) promoter mutations are commonly found in malignant melanomas but rare in melanocytic nevi. To assess its potential diagnostic utility for the distinction of melanoma from nevus, we determined the TERT promoter mutation status of 86 primary melanomas, 72 melanocytic nevi, and 40 diagnostically problematic melanocytic proliferations. Of the 86 melanomas, 67 (77.9%) were TERT-positive, defined as harboring a hotspot TERT promoter mutation at positions -124C>T, -124_125CC>TT, -138_139CC>TT, or -146C>T. Of the 72 nevi, only 1 (1.4%) was TERT-positive. Of the 40 diagnostically uncertain melanocytic proliferations, 2 (5.0%) were TERT-positive. TERT positivity as a test for melanoma versus nevus had an accuracy of 87.3% [95% confidence interval (CI), 81.1-92.1], a sensitivity of 77.9% (95% CI, 68.9-85.4), a specificity of 98.6% (95% CI, 95.8-100), a positive predictive value of 98.5% (95% CI, 95.6-100), and a negative predictive value of 78.9% (95% CI, 72.6-85.4). Our results indicate that hotspot TERT promoter mutation status may be a useful ancillary parameter for the diagnosis of melanoma. In particular, the high specificity of these mutations for melanoma indicates the presence of a TERT promoter mutation in a melanocytic neoplasm associated with diagnostic controversy, or uncertainty should increase concern for a melanoma.
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Affiliation(s)
- Nancy E. Thomas
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sharon N. Edmiston
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yihsuan S. Tsai
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Joel S. Parker
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Genetics, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Paul B. Googe
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Klaus J. Busam
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, NY, USA
| | - Glynis A. Scott
- Department of Dermatology, University of Rochester School of Medicine, Rochester, NY
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Daniel C. Zedek
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Eloise A. Parrish
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Honglin Hao
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Nathaniel A. Slater
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Michelle V. Pearlstein
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jill S. Frank
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Pei Fen Kuan
- Department of Applied Mathematics and Statistics, State University of New York, Stony Brook, NY
| | - David W. Ollila
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Kathleen Conway
- Department of Dermatology, School of Medicine, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC
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Robinson M, Curchin C, McMeniman E. Reflectance confocal microscopy margin mapping and monitoring of an amelanotic melanoma in situ of the ear. Australas J Dermatol 2018; 60:231-233. [PMID: 30592021 DOI: 10.1111/ajd.12986] [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: 10/08/2018] [Accepted: 12/01/2018] [Indexed: 11/28/2022]
Abstract
In situ amelanotic melanoma represents a diagnostic and therapeutic challenge for clinicians. Poor demarcation of these lesions often results in repeated therapeutic intervention until appropriate clearance has been achieved. Reflectance confocal microscopy (RCM) is a noninvasive bedside imaging modality which allows real-time visualisation, to a near-histological level, of the epidermis and reticular dermis. We present a case of an amelanotic melanoma in situ in which reflectance confocal microscopy margin mapping allowed for demarcation of the melanocytic proliferation and targeted therapeutic intervention with topical imiquimod. Reflectance confocal microscopy was further utilised for noninvasive assessment of therapeutic response.
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Affiliation(s)
- Mitchell Robinson
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Claudia Curchin
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Erin McMeniman
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
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Adler NR, Kelly JW, Guitera P, Menzies SW, Chamberlain AJ, Fishburn P, Button-Sloan AE, Heal C, Soyer HP, Thompson JF. Methods of melanoma detection and of skin monitoring for individuals at high risk of melanoma: new Australian clinical practice. Med J Aust 2018; 210:41-47. [PMID: 30636296 DOI: 10.5694/mja2.12033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The evidence-based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma-related mortality. MAIN RECOMMENDATIONS Clinicians who perform skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy. The use of short term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual melanocytic lesions of concern. The use of long term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual or multiple melanocytic lesions for routine surveillance of high risk patients. The use of total body photography should be considered in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi. There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma. MANAGEMENT OVERVIEW Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.
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Affiliation(s)
- Nikki R Adler
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC
| | - John W Kelly
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC.,Armadale Dermatology, Melbourne, VIC
| | - Pascale Guitera
- Melanoma Institute Australia, Sydney, NSW.,University of Sydney, Sydney, NSW.,Royal Prince Alfred Hospital, Sydney, NSW
| | - Scott W Menzies
- Sydney Melanoma Diagnostic Centre, University of Sydney, Sydney, NSW
| | - Alex J Chamberlain
- Victorian Melanoma Service, Alfred Health, Melbourne, VIC.,Glenferrie Dermatology, Melbourne, VIC
| | | | | | | | - H Peter Soyer
- Dermatology Research Centre, Diamantina Institute, University of Queensland, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
| | - John F Thompson
- Melanoma Institute Australia, Sydney, NSW.,University of Sydney, Sydney, NSW
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Huang CY, Lin YS, Kang BH, Chang KP, Chi CC, Lin MY, Su HH, Chang TS, Lee HP, Lee CC. Log margin-to-thickness ratio improves disease-specific survival prediction in oral cancer: A single cancer centre database. Clin Otolaryngol 2018; 44:63-69. [DOI: 10.1111/coa.13237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/15/2018] [Accepted: 10/02/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Chien-Yu Huang
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Yaoh-Shiang Lin
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- School of Medicine; National Defense Medical Center; Taipei Taiwan
- Department of Otolaryngology, Head and Neck Surgery; Tri-Service General Hospital; Taipei Taiwan
| | - Bor-Hwang Kang
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- School of Medicine; National Defense Medical Center; Taipei Taiwan
- Department of Otolaryngology, Head and Neck Surgery; Tri-Service General Hospital; Taipei Taiwan
| | - Kuo-Ping Chang
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- School of Medicine; National Defense Medical Center; Taipei Taiwan
- Department of Otolaryngology, Head and Neck Surgery; Tri-Service General Hospital; Taipei Taiwan
| | - Chao-Chuan Chi
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Ming-Yee Lin
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Hsing-Hao Su
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Ting-Shou Chang
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- School of Medicine; National Defense Medical Center; Taipei Taiwan
- Department of Otolaryngology, Head and Neck Surgery; Tri-Service General Hospital; Taipei Taiwan
| | - Huai-Pao Lee
- Department of Pathology and Laboratory Medicine; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Ching-Chih Lee
- Department of Otolaryngology, Head and Neck Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- School of Medicine; National Defense Medical Center; Taipei Taiwan
- Department of Otolaryngology, Head and Neck Surgery; Tri-Service General Hospital; Taipei Taiwan
- Institute of Hospital and Health Care Administration; National Yang-Ming University; Taipei Taiwan
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