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Huynh J, Leiter U, Garbe C, Shiderova G, Walter V, Eigentler T, Scheu A, Häfner HM, Schnabl SM. Sentinel lymph node biopsy for lentigo maligna melanoma under local anaesthesia. J Eur Acad Dermatol Venereol 2024; 38:84-92. [PMID: 37611257 DOI: 10.1111/jdv.19456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Lentigo maligna melanoma is mainly localized in the head and neck region in elderly patients. Due to its slow horizontal growth, it has a good prognosis compared to other melanoma subtypes, but specific data are rare. OBJECTIVES The aim of this study was to investigate sentinel lymph node biopsy in lentigo maligna melanoma under local anaesthesia and to discuss the benefit. METHODS Investigation of patients with lentigo maligna melanoma and tumour thickness ≥1 mm treated at the Department of Dermatology, University Medical Centre Tuebingen, between January 2008 and October 2019. RESULTS In total, 204 patients (126 SLNB, 78 non-SLNB) with a median age of 75.7 years (SLNB: 73.3 years, non-SLNB: 79.7 years) could be included. Sixteen of 126 (12.7%) sentinel lymph nodes were positive. Five-year overall survival was 87.9% (88.5% SLNB; 87.4% non-SLNB) and 5-year distant metastasis-free survival was 85.8% (85.4% SLNB; 86.7% non-SLNB). There was no significant difference for distant metastasis-free survival (p = 0.861) and overall survival (p = 0.247) between patients with and without sentinel lymph node biopsy. CONCLUSIONS Sentinel lymph node biopsy in lentigo maligna melanoma under local anaesthesia is a safe and simple method, even in very old patients. However, LMM has a very good 5-year overall survival. In high-risk patients with high tumour thickness and/or ulceration, adjuvant immunotherapy can now be offered without the need to perform this procedure.
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Affiliation(s)
- Julia Huynh
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Leiter
- Department of Dermatology, University of Tuebingen, Tübingen, Germany
| | - Claus Garbe
- Department of Dermatology, University of Tuebingen, Tübingen, Germany
| | - Galina Shiderova
- Department of Dermatology, University of Tuebingen, Tübingen, Germany
| | - Vincent Walter
- Department of Dermatology, University of Tuebingen, Tübingen, Germany
| | - Thomas Eigentler
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Scheu
- Department of Dermatology, University of Tuebingen, Tübingen, Germany
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Civantos F, Helmen ZM, Bradley PJ, Coca-Pelaz A, De Bree R, Guntinas-Lichius O, Kowalski LP, López F, Mäkitie AA, Rinaldo A, Robbins KT, Rodrigo JP, Takes RP, Ferlito A. Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck. Cancers (Basel) 2023; 15:4201. [PMID: 37686478 PMCID: PMC10486745 DOI: 10.3390/cancers15174201] [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: 06/21/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.
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Affiliation(s)
- Francisco Civantos
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (F.C.); (Z.M.H.)
| | - Zachary M. Helmen
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (F.C.); (Z.M.H.)
| | - Patrick J. Bradley
- Department of Otorhinolaryngology-Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham NG7 2UH, UK
| | - Andrés Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, 33011 Oviedo, Spain; (A.C.-P.); (F.L.)
| | - Remco De Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Orlando Guntinas-Lichius
- Department of Otorhinolaryngology, Institute of Phoniatry/Pedaudiology, Jena University Hospital, 07747 Jena, Germany
| | - Luiz P. Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Sao Paolo 01509-900, Brazil
- Head and Neck Surgery Department, University of São Paulo Medical School, Sao Paulo 05403-000, Brazil
| | - Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, 33011 Oviedo, Spain; (A.C.-P.); (F.L.)
| | - Antti A. Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, FI-00029 HUS Helsinki, Finland;
| | | | - K. Thomas Robbins
- Department of Otolaryngology Head and Neck Surgery, School of Medicine, Southern Illinois University Carbondale, Carbondale, IL 62901, USA
| | - Juan P. Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, University of Oviedo, ISPA, IUOPA, CIBERONC, 33011 Oviedo, Spain; (A.C.-P.); (F.L.)
| | - Robert P. Takes
- Department of Otorhinolaryngology-Head and Neck Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy
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Pasha T, Arain Z, Buscombe J, Aloj L, Durrani A, Patel A, Roshan A. Association of Complex Lymphatic Drainage in Head and Neck Cutaneous Melanoma With Sentinel Lymph Node Biopsy Outcomes: A Cohort Study and Literature Review. JAMA Otolaryngol Head Neck Surg 2023; 149:416-423. [PMID: 36892824 PMCID: PMC9999281 DOI: 10.1001/jamaoto.2023.0076] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/18/2023] [Indexed: 03/10/2023]
Abstract
Importance Although sentinel lymph node biopsy (SLNB) is a vital staging tool, its application in head and neck melanoma (HNM) is complicated by a higher false-negative rate (FNR) compared with other regions. This may be due to the complex lymphatic drainage in the head and neck. Objective To compare the accuracy, prognostic value, and long-term outcomes of SLNB in HNM with melanoma from the trunk and limb, focusing on the lymphatic drainage pattern. Design, Setting, and Participants This cohort observational study at a single UK University cancer center included all patients with primary cutaneous melanoma undergoing SLNB between 2010 to 2020. Data analysis was conducted during December 2022. Exposures Primary cutaneous melanoma undergoing SLNB between 2010 to 2020. Main Outcomes and Measures This cohort study compared the FNR (defined as the ratio between false-negative results and the sum of false-negative and true-positive results) and false omission rate (defined as the ratio between false-negative results and the sum of false-negative and true-negative results) for SLNB stratified by 3 body regions (HNM, limb, and trunk). Kaplan-Meier survival analysis was used to compare recurrence-free survival (RFS) and melanoma-specific survival (MSS). Comparative analysis of detected lymph nodes on lymphoscintigraphy (LSG) and SLNB was performed by quantifying lymphatic drainage patterns by number of nodes and lymph node basins. Multivariable Cox proportional hazards regression identified independent risk factors. Results Overall, 1080 patients were included (552 [51.1%] men, 528 [48.9%] women; median age at diagnosis 59.8 years), with a median (IQR) follow-up 4.8 (IQR, 2.7-7.2) years. Head and neck melanoma had a higher median age at diagnosis (66.2 years) and higher Breslow thickness (2.2 mm). The FNR was highest in HNM (34.5% vs 14.8% trunk or 10.4% limb, respectively). Similarly, the false omission rate was 7.8% in HNM compared with 5.7% trunk or 3.0% limbs. The MSS was no different (HR, 0.81; 95% CI, 0.43-1.53), but RFS was lower in HNM (HR, 0.55; 95% CI, 0.36-0.85). On LSG, patients with HNM had the highest proportion of multiple hotspots (28.6% with ≥3 hotspots vs 23.2% trunk and 7.2% limbs). The RFS was lower for patients with HNM with 3 or more affected lymph nodes found on LSG than those with fewer than 3 affected lymph nodes (HR, 0.37; 95% CI, 0.18-0.77). Cox regression analysis showed head and neck location to be an independent risk factor for RFS (HR, 1.60; 95% CI, 1.01-2.50), but not for MSS (HR, 0.80; 95% CI, 0.35-1.71). Conclusions and Relevance This cohort study found higher rates of complex lymphatic drainage, FNR, and regional recurrence in HNM compared with other body sites on long-term follow-up. We advocate considering surveillance imaging for HNM for high-risk melanomas irrespective of sentinel lymph node status.
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Affiliation(s)
- Terouz Pasha
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Zohaib Arain
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - John Buscombe
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Luigi Aloj
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Amer Durrani
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Animesh Patel
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Amit Roshan
- Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
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Bittar PG, Bittar JM, Etzkorn JR, Brewer JD, Aizman L, Shin TM, Sobanko JF, Higgins HW, Giordano CN, Cohen JV, Pride R, Wan MT, Leitenberger JJ, Bar AA, Aasi S, Bordeaux JS, Miller CJ. Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision. J Am Acad Dermatol 2021; 85:681-692. [PMID: 33961921 DOI: 10.1016/j.jaad.2021.04.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. OBJECTIVE To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. METHODS A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. RESULTS Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). LIMITATIONS Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. CONCLUSION Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.
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Affiliation(s)
- Peter G Bittar
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Julie M Bittar
- Section of Dermatology, Rush University Medical Center, Chicago, Illinois
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Leora Aizman
- George Washington University School of Medicine, Washington, DC
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold W Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justine V Cohen
- Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee Pride
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Marilyn T Wan
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anna A Bar
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Sumaira Aasi
- Department of Dermatology, Stanford Medicine, Stanford, California
| | | | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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MacArthur KM, Baumann BC, Sobanko JF, Etzkorn JR, Shin TM, Higgins HW, Giordano CN, McMurray SL, Krausz A, Newman JG, Rajasekaran K, Cannady SB, Brody RM, Karakousis GC, Miura JT, Cohen JV, Amaravadi RK, Mitchell TC, Schuchter LM, Miller CJ. Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery. Cancer 2021; 127:3591-3598. [PMID: 34292585 DOI: 10.1002/cncr.33651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/30/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen-section MART-1 immunohistochemical stains (MMS-IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS-IHC. METHODS This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS-IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes. RESULTS In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a-T4b) were treated with MMS-IHC. The median patient age was 69 years (range, 25-101 years). Ninety-two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB-eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB-eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%). CONCLUSIONS Combining SLNB and MMS-IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS-IHC.
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Affiliation(s)
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University, St Louis, Missouri
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - H William Higgins
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Cerrene N Giordano
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Stacy L McMurray
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Aimee Krausz
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Robert M Brody
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Justine V Cohen
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ravi K Amaravadi
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Tara C Mitchell
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Lynn M Schuchter
- Division of Hematology Oncology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Zhang Y, Liu C, Wang Z, Zhu G, Zhang Y, Xu Y, Xu X. Sentinel lymph node biopsy in head and neck cutaneous melanomas: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24284. [PMID: 33592872 PMCID: PMC7870248 DOI: 10.1097/md.0000000000024284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/02/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Head and neck melanomas (HNMs) behave differently from cutaneous melanomas in other sites, and the efficacy of sentinel lymph node biopsy (SLNB) for patients with HNMs remains controversial. METHODS Studies on prognosis following SLNB were included. The prognostic role of SLNB and other potential predictors were analyzed using pooled relative risk (RR) or hazard ratio (HR). RESULTS Pooled statistics showed that SLNB improved overall survival of HNMs patients (HR = 0.845; 95% CI: 0.725-0.986; P = .032). The positive status of SN was proved as a risk factor of poor prognosis in HNMs (HR = 3.416; 95% CI: 1.939-6.021; P < .001). SLNB did not have significant correlation with lower recurrences (RR = .794; 95% CI: 0.607-1.038; P = .091). CONCLUSIONS SLNB is associated with better overall survival and the SN status is a promising risk factor of poor prognosis for HNMs patients.
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Affiliation(s)
- Yingyi Zhang
- Department of Aesthetic Plastic and Burn Surgery
| | - Chuanqi Liu
- Department of Aesthetic Plastic and Burn Surgery
| | | | - Guonian Zhu
- Research Core Facility, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yange Zhang
- Department of Aesthetic Plastic and Burn Surgery
| | | | - Xuewen Xu
- Department of Aesthetic Plastic and Burn Surgery
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Invasive Melanoma and Melanoma in Situ Treated With Modified Mohs Micrographic Surgery With En Face Permanent Sectioning: A 10-Year Retrospective Review. Dermatol Surg 2021; 46:1004-1013. [PMID: 31714384 DOI: 10.1097/dss.0000000000002246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Successful surgical treatment of cutaneous melanoma is dependent on margin control. OBJECTIVE To determine efficacy of modified Mohs micrographic surgery (mMMS) with en face permanent margins in management of invasive melanoma (IM) and melanoma in situ (MIS). METHODS A retrospective cohort study evaluating local recurrence, 5-year recurrence-free survival, and 5-year melanoma-specific survival. Overall, 657 melanomas (128 IM and 529 MIS) from 631 patients were treated using mMMS during a 10-year period. Follow-up information was obtained from medical records and telephone encounters. RESULTS The median follow-up time was 5.18 years. Most melanomas were located on the head and neck 93.6% (615/657). Margins required for clearance were 0.77 ± 0.44 cm (mean ± SD). Local recurrence was identified in 1.98% (13/657) of melanomas with no local recurrences in IM. Five-year local recurrence-free and melanoma-specific survival rates were estimated to be 96.9% (95% confidence interval [CI]: 94.6%-98.2%) and 99.0% (95% CI: 97.7%-99.6%). There were 5 melanoma-related deaths. CONCLUSION Modified Mohs micrographic surgery is an effective treatment of melanoma as evidenced by low local recurrence rates and high melanoma-specific survival.
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Burnett ME, Brodland DG, Zitelli JA. Long-term outcomes of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities. J Am Acad Dermatol 2020; 84:661-668. [PMID: 32763327 DOI: 10.1016/j.jaad.2020.07.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/22/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Microscopic evaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximal portion of the extremities. OBJECTIVE To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival. METHODS Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes. RESULTS True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75 months and were not associated with tumor depth. The rate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values. LIMITATIONS We used a nonrandomized, single institution, retrospective design. CONCLUSIONS Mohs micrographic surgery of primary cutaneous invasive melanoma on the trunk and proximal portion of the extremities resulted in local control of 99.86% of tumors and an overall disease-specific death rate superior to that of wide local excision.
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Affiliation(s)
- Mark E Burnett
- Zitelli & Brodland, PC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - David G Brodland
- Zitelli & Brodland, PC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John A Zitelli
- Zitelli & Brodland, PC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Bachar G, Tzelnick S, Amiti N, Gutman H. Patterns of failure in patients with cutaneous head and neck melanoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:914-917. [PMID: 31952929 DOI: 10.1016/j.ejso.2019.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/01/2019] [Accepted: 12/20/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The incidence of head and neck melanoma is increasing. Various factors influence prognosis. OBJECTIVE We sought to investigate the subgroup of patients with head and neck melanoma who fail primary treatment and to define the patterns of failure. METHODS The database of a tertiary medical center was reviewed for patients diagnosed and surgically treated for cutaneous head and neck melanoma in 1995-2014. Regional disease failure was defined as disease confirmed in positive SLNB at first assessment or at recurrence. RESULTS The cohort included 141 patients followed for a median duration of 6.8 years (range 1-20 years). Median tumor thickness was 2.1 mm (range 0.5-12 mm). Ulceration was documented in 38 patients (26.9%). Sentinel lymph node biopsy (SLNB) was positive in 18 patients (12.8%). Total disease failure rate was 32.6% with similar rates of regional (n = 26, 18.4%) and distal (n = 22, 15.6%) failure. Most patients (86.3%) with systemic recurrence had a negative SNLB as did 6/26 patients (23%) with regional failure. Forty-three patients (30.4%) died during follow-up, half of them (23 patients, 16.3%) of melanoma. On multivariate analysis, Breslow thickness was the only significant predictor of outcome. CONCLUSIONS The pattern of treatment failure in patients with head and neck melanoma relate predominantly to Breslow thickness. The high false-negative rate of SNLB and the relatively high rate of systemic failures in patients with negative SNLB indicate a low predictive value of this procedure. Efforts to detect systemic disease during follow-up need to be intensified.
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Affiliation(s)
- Gideon Bachar
- Department of Otolaryngology, Head and Neck Surgery, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Sharon Tzelnick
- Department of Otolaryngology, Head and Neck Surgery, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Nimrod Amiti
- Department of Otolaryngology, Head and Neck Surgery, Beilinson Hospital, Petach Tikva, Israel.
| | - Haim Gutman
- Surgical Oncology Unit, Department of Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
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10
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Outcomes for Invasive Melanomas Treated With Mohs Micrographic Surgery: A Retrospective Cohort Study. Dermatol Surg 2019; 45:223-228. [DOI: 10.1097/dss.0000000000001658] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fix W, Etzkorn JR, Shin TM, Howe N, Bhatt M, Sobanko JF, Miller CJ. Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more commonly than basal cell carcinoma and squamous cell carcinoma: A comparison of indications for microscopic margin control prior to reconstruction in 13,664 tumors. J Am Acad Dermatol 2018; 85:409-418. [PMID: 30458206 DOI: 10.1016/j.jaad.2018.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND On the basis of high-local recurrence risk features and tissue-rearranging reconstruction, consensus guidelines recommend microscopic margin control for keratinocyte carcinomas (KCs) but not for cutaneous melanoma. OBJECTIVE To compare high-local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC with those for melanoma. METHODS Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery. RESULTS A total of 12,189 KCs (8743 basal cell carcinomas and 3343 squamous cell carcinomas) and 1475 melanomas (1065 melanomas in situ and 410 invasive melanomas) were identified from a prospectively updated Mohs micrographic surgery database. Compared with KCs, melanomas were significantly more likely to have high-local recurrence risk features, including larger preoperative size (2.10 cm vs 1.30 cm [P < .0001]), recurrent status (5.08% vs 3.91% [P = .031]), and subclinical spread (31.73% vs 26.52% [P < .0001]). Tissue-rearranging reconstruction was significantly more common for melanoma than for KCs (44.68% vs 33.02% [P < .0001]; odds ratio, 1.98 [P < .0001]). LIMITATIONS This was a retrospective study, and it did not compare outcomes with those of other treatment methods, such as slow Mohs or conventional excision. CONCLUSION Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more frequently than KCs do.
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Affiliation(s)
- William Fix
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Nicole Howe
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Mehul Bhatt
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania Health System, Philadelphia.
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The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas. J Am Acad Dermatol 2018; 85:442-452. [PMID: 30447316 DOI: 10.1016/j.jaad.2018.11.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 01/01/2023]
Abstract
Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.
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Etzkorn JR, Tuttle SD, Lim I, Feit EM, Sobanko JF, Shin TM, Neal DE, Miller CJ. Patients prioritize local recurrence risk over other attributes for surgical treatment of facial melanomas-Results of a stated preference survey and choice-based conjoint analysis. J Am Acad Dermatol 2018; 79:210-219.e3. [PMID: 29505861 DOI: 10.1016/j.jaad.2018.02.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/21/2017] [Accepted: 02/23/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical treatment options for facial melanomas include conventional excision with postoperative margin assessment, Mohs micrographic surgery (MMS) with immunostains (MMS-I), and slow MMS. Patient preferences for these surgical options have not been studied. OBJECTIVES To evaluate patient preferences for surgical treatment of facial melanoma and to determine how patients value the relative importance of different surgical attributes. METHODS Participants completed a 2-part study consisting of a stated preference survey and a choice-based conjoint analysis experiment. RESULTS Patients overwhelmingly (94.3%) rated local recurrence risk as very important and ranked it as the most important attribute of surgical treatment for facial melanoma. Via choice-based conjoint analysis, patients ranked the following surgical attributes from highest to lowest in importance: local recurrence rate, out-of-pocket cost, chance of second surgical visit, timing of reconstruction, travel time, and time in office for the procedure. Consistent with their prioritization of low local recurrence rates, more than 73% of respondents selected MMS-I or slow MMS as their preferred treatment option for a facial melanoma. LIMITATIONS Data were obtained from a single health system. CONCLUSION Patients prefer surgical treatment options that minimize risk for local recurrence. Logistics for travel and treatment have less influence on patient preferences. Most survey participants chose MMS-I to maximize local cure and convenience of care.
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Affiliation(s)
- Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Scott D Tuttle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ilya Lim
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Elea M Feit
- Lebow College of Business, Drexel University, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thuzar M Shin
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donald E Neal
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Miller CJ, Shin TM, Sobanko JF, Sharkey JM, Grunyk JW, Elenitsas R, Chu EY, Capell BC, Ming ME, Etzkorn JR. Risk factors for positive or equivocal margins after wide local excision of 1345 cutaneous melanomas. J Am Acad Dermatol 2017; 77:333-340.e1. [DOI: 10.1016/j.jaad.2017.03.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 03/13/2017] [Accepted: 03/19/2017] [Indexed: 12/23/2022]
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15
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Etzkorn JR, Sharkey JM, Grunyk JW, Shin TM, Sobanko JF, Miller CJ. Frequency of and risk factors for tumor upstaging after wide local excision of primary cutaneous melanoma. J Am Acad Dermatol 2017; 77:341-348. [DOI: 10.1016/j.jaad.2017.03.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 03/12/2017] [Accepted: 03/16/2017] [Indexed: 12/23/2022]
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Mohs Micrographic Surgery Using MART-1 Immunostain in the Treatment of Invasive Melanoma and Melanoma In Situ. Dermatol Surg 2017; 42:733-44. [PMID: 27158886 DOI: 10.1097/dss.0000000000000725] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) with melanoma antigen recognized by T-cell (MART-1) immunostaining is an effective treatment of cutaneous melanoma. OBJECTIVE To determine the efficacy of MMS with MART-1 immunostain in the management of invasive and in situ melanoma. METHODS AND MATERIALS A retrospective cohort study evaluated 2,114 melanomas in 1,982 patients excised using MMS and MART-1 immunostain. The margins required for excision were calculated based on Breslow thickness, location, and size. Survival and local recurrence rates were calculated and compared with those of historical controls. RESULTS The mean follow-up period was 3.73 years. Local recurrence was identified in 0.49% (7/1,419) of primary melanomas. Approximately 82% of melanomas were excised with ≤6-mm margins. The surgical margin was significantly related to tumor location and size but not to Breslow thickness. The five-year Kaplan-Meier local recurrence and disease-specific survival rates were 0.59 ± 0.30 and 98.53 ± 0.42, respectively. Mohs micrographic surgery with MART-1 immunostain achieved lower local recurrence rates and equivalent or higher Kaplan-Meier survival rates than conventional wide local excision. CONCLUSION Mohs micrographic surgery with MART-1 immunostain is an effective treatment of melanoma as evidenced by low local recurrence rates. It offers the advantage of more tissue-conserving margins than those recommended for conventional excision.
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17
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Risk Factors Predicting Positive Margins at Primary Wide Local Excision of Cutaneous Melanoma. Dermatol Surg 2017; 42:646-52. [PMID: 27082057 DOI: 10.1097/dss.0000000000000702] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A small percentage of patients will have positive histological margins after primary wide local excision (WLE) of cutaneous melanoma (CM). Risk factors that predict marginal involvement at WLE remain unclear. OBJECTIVE To identify risk factors associated with positive margins after WLE of CM. MATERIALS AND METHODS A retrospective review of patients treated at a single institution for CM with sentinel lymph node biopsy from 1997 to 2011 was conducted. RESULTS Positive margins occurred in 6% of patients. Patients with positive margins were older (72.4 vs 60.7, p < .001), had thicker tumors (3.6 vs 1.9 mm, p < .001), and often involved the head and neck region (p < .001). Patients with positive margins at WLE had positive margins on initial biopsy (p = .012) and a higher rate of a melanoma in situ component on initial biopsy (24% vs 11%, p = .02). The 5-year local recurrence rate was significantly different between those with positive and negative margins at WLE (16.0% vs 6.9%; p = .047). CONCLUSION Positive margins after WLE are uncommon. When a patient has multiple risk factors for positive margins at WLE, histologically clear margins should be obtained through mapped serial excision or Mohs micrographic surgery.
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18
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Shin TM, Shaikh WR, Etzkorn JR, Sobanko JF, Margolis DJ, Gelfand JM, Chu EY, Elenitsas R, Miller CJ. Clinical and pathologic factors associated with subclinical spread of invasive melanoma. J Am Acad Dermatol 2017; 76:714-721. [PMID: 28139264 DOI: 10.1016/j.jaad.2016.11.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/23/2016] [Accepted: 11/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Indications to treat invasive melanoma with Mohs micrographic surgery (MMS) or analogous techniques with exhaustive microscopic margin assessment have not been defined. OBJECTIVE Identify clinical and histologic factors associated with subclinical spread of invasive melanoma. METHODS This retrospective, cross-sectional study evaluated 216 invasive melanomas treated with MMS and melanoma antigen recognized by T cells 1 immunostaining. Logistic regression models were used to correlate clinicopathologic risk factors with subclinical spread and construct a count prediction model. RESULTS Risk factors associated with subclinical spread by multivariate analysis included tumor localization on the head and neck (OR 3.28, 95% confidence interval [CI] 1.16-9.32), history of previous treatment (OR 4.18, 95% CI 1.42-12.32), age ≥65 (OR 4.45, 95% CI 1.29-15.39), and ≥1 mitoses/mm2 (OR 2.63, 95% CI 1.01-6.83). Tumor thickness and histologic subtype were not associated with subclinical spread. The probability of subclinical spread increased per number of risk factors, ranging from 9.22% (95% CI 2.57%-15.86%) with 1 factor to 80.32% (95% CI 68.13%-92.51%) with 5 factors. LIMITATIONS This study was conducted at a single academic institution with a small study population using a retrospective study design that was subject to potential referral bias. CONCLUSION Clinical and histologic factors identify invasive melanomas that are at increased risk for subclinical spread and might benefit from MMS or analogous techniques prior to reconstruction.
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Affiliation(s)
- Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Waqas R Shaikh
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Margolis
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel M Gelfand
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Y Chu
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosalie Elenitsas
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Roy JM, Whitfield RJ, Gill PG. Review of the role of sentinel node biopsy in cutaneous head and neck melanoma. ANZ J Surg 2015; 86:348-55. [DOI: 10.1111/ans.13286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Jennifer M. Roy
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
- Department of Surgery; Flinders Medical Centre; Adelaide South Australia Australia
| | - Robert J. Whitfield
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
| | - P. Grantley Gill
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
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20
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Etzkorn JR, Sobanko JF, Elenitsas R, Newman JG, Goldbach H, Shin TM, Miller CJ. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol 2015; 72:840-50. [PMID: 25774012 DOI: 10.1016/j.jaad.2015.01.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/20/2014] [Accepted: 01/07/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Various methods of tissue processing have been used to treat melanoma with Mohs micrographic surgery (MMS). OBJECTIVE We describe a method of treating melanoma with MMS that combines breadloaf frozen sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation, allowing detection of upstaging and comprehensive pathologic margin assessment before reconstruction. METHODS We conducted a retrospective cohort study evaluating for local recurrence and upstaging in 614 invasive or in situ melanomas in 577 patients treated with this MMS tissue processing methodology using frozen sections with melanoma antigen recognized by T cells 1 (MART-1) immunostaining. Follow-up was available in 597 melanomas in 563 patients. RESULTS Local recurrence was identified in 0.34% (2/597) lesions with a mean follow-up time of 1026 days (2.8 years). Upstaging occurred in 34 of 614 lesions (5.5%), of which 97% (33/34) were detected by the Mohs surgeon before reconstruction. LIMITATIONS Limitations include retrospective study, intermediate follow-up time, and that the recurrence status of 39.6% of patients was self-reported. CONCLUSION Treating melanoma with MMS that combines breadloaf sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation permits identification of upstaging and consideration of sentinel lymph node biopsy before definitive reconstruction and achieves low local recurrence rates compared with conventional excision.
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Affiliation(s)
| | - Joseph F Sobanko
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Rosalie Elenitsas
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jason G Newman
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | | | - Thuzar M Shin
- University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Al Ghazal P, Gutzmer R, Satzger I, Starz H, Bader C, Thoms KM, Mitteldorf C, Schön MP, Kapp A, Bertsch HP, Kretschmer L. Lower prevalence of lymphatic metastasis and poorer survival of the sentinel node-negative patients limit the prognostic value of sentinel node biopsy for head or neck melanomas. Melanoma Res 2014; 24:158-64. [PMID: 24346168 DOI: 10.1097/cmr.0000000000000042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Head or neck location of primary cutaneous melanomas has been described as an adverse prognostic factor, but this has to be reassessed after the introduction of sentinel lymph node (SLN) excision (SLNE). Descriptive statistics, Kaplan-Meier estimates and Cox proportional hazard models were used to study retrospectively a population of 2302 consecutive melanoma patients from three German melanoma centres undergoing SLNE. Approximately 10% of the patients (N=237) had a primary melanoma located at the head or neck (HNM). In both the SLN-positive and SLN-negative subpopulation, patients with HNM were significantly older, more frequently men and had thicker primaries compared with patients with tumours in other locations. The proportion of positive SLNs was lower in HNM compared with other locations of the primary (20 vs. 26%, P=0.048). The false-negative rate was higher in HNM (17.5 vs. 8.4%, P=0.05). In patients with HNM, the SLN status was a significant factor for recurrence-free survival but not for overall survival. SLN-negative HNM patients had a significantly worse overall survival than the SLN negatives with primaries at other sites, whereas the prognosis of the SLN-positive patients was similar in both groups. The prevalence of lymph node metastases after SLNE is lower in patients with HNM compared with other melanoma locations. As a result, the prognostic information provided by the SLN for HNM seems less important. Decision making for SLNE in HNM should be carefully balanced considering the potential morbidity of the procedure.
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Affiliation(s)
- Philipp Al Ghazal
- aDepartment of Dermatology and Allergy, Hannover Medical School, Skin Cancer Center Hannover, Hannove bDepartment of Dermatology and Allergology, Klinikum Augsburg, Augsburg cDepartment of Dermatology, Venereology and Allergology, Georg August University, Göttingen dDepartment of Dermatology, Venereology and Allergology, Klinikum Hildesheim GmbH, Hildesheim, Germany
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Gurney B, Newlands C. Management of regional metastatic disease in head and neck cutaneous malignancy. 1. Cutaneous squamous cell carcinoma. Br J Oral Maxillofac Surg 2014; 52:294-300. [PMID: 24559975 DOI: 10.1016/j.bjoms.2014.01.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 01/24/2014] [Indexed: 12/11/2022]
Abstract
This overview is the first of 2 articles on the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. In this paper we discuss cutaneous squamous cell carcinoma (SCC) and review the latest evidence for management of the regional nodes.
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Affiliation(s)
- Ben Gurney
- Royal Surrey County Hospital, United Kingdom
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23
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Erman AB, Collar RM, Griffith KA, Lowe L, Sabel MS, Bichakjian CK, Wong SL, McLean SA, Rees RS, Johnson TM, Bradford CR. Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma. Cancer 2011; 118:1040-7. [PMID: 21773971 DOI: 10.1002/cncr.26288] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/25/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has emerged as a widely used staging procedure for cutaneous melanoma. However, debate remains around the accuracy and prognostic implications of SLNB for cutaneous melanoma arising in the head and neck, as previous reports have demonstrated inferior results to those in nonhead and neck regions. Through the largest single-institution series of head and neck melanoma patients, the authors set out to demonstrate that SLNB accuracy and prognostic value in the head and neck region are comparable to other sites. METHODS A prospectively collected database was queried for cutaneous head and neck melanoma patients who underwent SLNB at the University of Michigan between 1997 and 2007. Primary endpoints included SLNB result, time to recurrence, site of recurrence, and date and cause of death. Multivariate models were constructed for analyses. RESULTS Three hundred fifty-three patients were identified. A sentinel lymph node was identified in 352 of 353 patients (99.7%). Sixty-nine of the 353 (19.6%) patients had a positive SLNB. Seventeen of 68 patients (25%) undergoing completion lymphadenectomy after a positive SLNB result had at least 1 additional positive nonsentinel lymph node. Patients with local control and a negative SLNB failed regionally in 4.2% of cases. Multivariate analysis revealed positive SLNB status to be the most prognostic clinicopathologic predictor of poor outcome; hazard ratio was 4.23 for SLNB status and recurrence-free survival (P < .0001) and 3.33 for overall survival (P < .0001). CONCLUSIONS SLNB is accurate and its results are of prognostic importance for head and neck melanoma patients.
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Affiliation(s)
- Audrey B Erman
- Department of Otolaryngology Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan 48109-5312, USA
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Miller MW, Vetto JT, Monroe MM, Weerasinghe R, Andersen PE, Gross ND. False-Negative Sentinel Lymph Node Biopsy in Head and Neck Melanoma. Otolaryngol Head Neck Surg 2011; 145:606-11. [DOI: 10.1177/0194599811411878] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. The results of sentinel lymph node biopsy (SLNB) can be useful for staging and deciding on adjuvant treatment for patients with head and neck melanoma. False-negative SLNB can result in treatment delay. This study aimed to evaluate the characteristics and outcome of patients with false-negative SLNB in cutaneous melanoma of the head and neck. Study Design. Longitudinal cohort study using a prospective institutional tumor registry. Setting. Academic health center. Subjects and Methods. Data from 153 patients who underwent SLNB for melanoma of the head and neck were analyzed. False-negative biopsy was defined as recurrence of tumor in a previously identified negative nodal basin. Statistical analysis was performed on registry data. Results. Positive sentinel lymph nodes were identified in 19 (12.4%) patients. False-negative SLNB was noted in 9 (5.9%) patients, with a false-negative SLNB rate of 32.1%. Using multivariate regression analysis, only examination of a single sentinel lymph node was a significant predictor of false-negative SLNB ( P = .01). The mean treatment delay for the false-negative SLNB group was 470 days compared with 23 days in the positive SLNB group ( P < .001). The 2-year overall survival of patients with false-negative SLNB was 75% compared with 84% and 98% in positive and negative SLNB groups, respectively ( P = .02). Conclusions. False-negative SLNB is more likely to occur when a single sentinel lymph node is harvested. There is significant treatment delay in patients with false-negative SLNB. False-negative SLNB is associated with poor outcome in patients with melanoma of the head and neck.
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Affiliation(s)
- Matthew W. Miller
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - John T. Vetto
- Department of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - Marcus M. Monroe
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Roshanthi Weerasinghe
- Department of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter E. Andersen
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Neil D. Gross
- Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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de Rosa N, Lyman GH, Silbermins D, Valsecchi ME, Pruitt SK, Tyler DM, Lee WT. Sentinel Node Biopsy for Head and Neck Melanoma. Otolaryngol Head Neck Surg 2011; 145:375-82. [DOI: 10.1177/0194599811408554] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. This systematic review was conducted to examine the test performance of sentinel node biopsy in head and neck melanoma, including the identification rate and false-negative rate. Data Sources. PubMed, EMBASE, ASCO, and SSO database searches were conducted to identify studies fulfilling the following inclusion criteria: sentinel node biopsy was performed, lesions were located on the head and neck, and recurrence data for both metastatic and nonmetastatic patients were reported. Review Methods. Dual-blind data extraction was conducted. Primary outcomes included identification rate and test performance based on completion neck dissection or nodal recurrence. Results. A total of 3442 patients from 32 studies published between 1990 and 2009 were reviewed. Seventy-eight percent of studies were retrospective and 22% were prospective. Trials varied from 9 to 755 patients (median 55). Mean Breslow depth was 2.53 mm. Median sentinel node biopsy identification rate was 95.2%. More than 1 basin was reported in 33.1% of patients. A median of 2.56 sentinel nodes per patient were excised. Sentinel node biopsy was positive in 15% of patients. Subsequent completion neck dissection was performed in almost all of these patients and revealed additional positive nodes in 13.67%. Median follow-up was 31 months. Across all studies, predictive value positive for nodal recurrence was 13.1% and posttest probability negative was 5%. Median false-negative rate for nodal recurrence was 20.4%. Conclusion. Sentinel node biopsy of head and neck melanoma is associated with an increased false-negative rate compared with studies of non–head and neck lesions. Positive sentinel node status is highly predictive of recurrence.
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Affiliation(s)
| | - Gary H. Lyman
- Duke University, Durham, North Carolina, USA
- Duke Comprehensive Cancer Center, Durham, North Carolina, USA
| | | | | | - Scott K. Pruitt
- Duke University, Durham, North Carolina, USA
- VA Medical Center, Durham, North Carolina, USA
| | - Douglas M. Tyler
- Duke University, Durham, North Carolina, USA
- VA Medical Center, Durham, North Carolina, USA
| | - Walter T. Lee
- Duke University, Durham, North Carolina, USA
- VA Medical Center, Durham, North Carolina, USA
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Chambers AJ, Murynka T, Arlette JP, McKinnon JG. Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution. J Surg Oncol 2011; 103:426-30. [PMID: 21400528 DOI: 10.1002/jso.21846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 11/29/2010] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face. METHODS Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded. RESULTS Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%). CONCLUSIONS Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.
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Affiliation(s)
- Anthony J Chambers
- Department of Surgery, Division of Surgical Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, Alberta, Canada
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Valsecchi ME, Silbermins D, de Rosa N, Wong SL, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma: a meta-analysis. J Clin Oncol 2011; 29:1479-87. [PMID: 21383281 DOI: 10.1200/jco.2010.33.1884] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To perform a meta-analysis of all published studies of sentinel lymph node (SLN) biopsy for staging patients with melanoma. METHODS Published literature in all languages between 1990 and 2009 was critically appraised. Primary outcomes evaluated included the proportion successfully mapped (PSM) and test performance including false-negative rate (FNR), post-test probability negative (PTPN), and positive predictive value in the same nodal basin recurrence. RESULTS A total of 71 studies including 25,240 patients met full eligibility criteria. The average PSM was 98.1% (95% CI, 97.3% to 98.6%) and increased with the year of publication, female sex, ulceration, age, and the quality score of the studies. The FNR ranged from 0.0% to 34.0%, averaging 12.5% overall (95% CI, 11% to 14.2%). FNR increased with the length of follow-up (P = .002) but decreased with greater PSM (P = .001). PTPN averaged 3.4% (95% CI, 3.0% to 3.8%), which also increased in studies with longer follow-up, younger age, female sex, deeper Breslow thickness, and with tumor ulceration while decreasing with greater PSM (P < .001). Approximately 20% of the patients with a positive SLN had additional lymph nodes in the complete lymph node dissection and 7.5% of the patients with positive SLN developed recurrence in the same nodal basin which was greater in studies that also reported higher FNR (P = .01). CONCLUSION The estimated risk of nodal recurrence after a negative SLN biopsy was ≤ 5% supporting the use of this technology for staging patients with melanoma.
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Koskivuo IO, Kinnunen IA, Suominen EA, Talve LA, Vihinen PP, Grénman RA. Head and neck cutaneous melanoma: a retrospective observational study on 146 patients. Acta Oncol 2009; 48:460-7. [PMID: 18843562 DOI: 10.1080/02841860802404356] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Sentinel node biopsy (SNB) is a novel staging technique in cutaneous melanoma, but it is more challenging in the head and neck (H&N) than in the trunk and extremities. The aim of this study was to investigate the utility of SNB in patients with clinical stage I-II H&N cutaneous melanoma, with emphasis on disease outcome. PATIENTS AND METHODS Twenty five patients with H&N melanoma of >1.0 mm in Breslow depth underwent SNB and were compared to 121 historic H&N melanoma patients, who had either undergone routine prophylactic neck dissection or had been observed without any invasive nodal staging. RESULTS Sixteen percent of the SNB patients were sentinel-positive and there have been no false-negative cases. In the Kaplan-Meier analysis, there were no significant differences between the study groups in melanoma-specific overall survival. Among the entire cohort, melanoma-specific overall survival rate was 67.1% at 5 years and 61.9% at 10 years. Predictive factors for worsen survival were nodal micrometastases, male sex, scalp location, thick primary lesion and ulceration. DISCUSSION SNB is a reliable and mini-invasive approach for the nodal staging of H&N cutaneous melanoma. Traditional neck dissection is recommended only for therapeutic purposes in clinically node-positive or sentinel-positive patients.
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