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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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Karmilkar K, Norem RF. Amelanotic Malignant Melanoma: A Case Report. Cureus 2023; 15:e41665. [PMID: 37575793 PMCID: PMC10412465 DOI: 10.7759/cureus.41665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Amelanotic malignant melanoma (AMM) is a skin cancer that arises from mutated melanocytes that lack pigmentation. AMM represents 2-8% of all malignant melanomas. This rare subtype is difficult to diagnose clinically as it mimics other benign skin lesions. AMM can occur in any part of the body with various presentations and has a predilection for male gender and fair skin tones. We present a case report of a 62-year-old Caucasian male with AMM of the right lower extremity. The patient presented with a painless nodule on his right lower extremity that rapidly increased in size for seven months with no signs of malignancy, such as fever, night sweats, fatigue, bruising, weight loss, or headache. Simultaneously, the patient presented with right inguinal lymphadenopathy and pitting edema of the right lower extremity. The patient had a previous medical history of basal and squamous cell carcinoma and psoriasis with no personal or family history of melanoma. The mass was excised and sent to a pathologist along with a right inguinal sentinel lymph node biopsy. The final pathology report revealed an ulcerated AMM on the right lower extremity and a positive node for melanoma with a metastatic deposit. The patient underwent adjuvant immunotherapy resulting in the clearance of the cancer cells. This report highlights the importance of early diagnosis, appropriate surgical management, and adjuvant therapy to improve the prognosis of this rare melanoma subtype.
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Affiliation(s)
- Kunal Karmilkar
- Anatomy, Edward Via College of Osteopathic Medicine, Louisiana Campus, Monroe, USA
| | - Richard F Norem
- General Surgery, Rapides Regional Medical Center, Louisiana, USA
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Bladen JC, Malhotra R, Litwin A. Long-term outcomes of margin-controlled excision for eyelid melanoma. Eye (Lond) 2023; 37:1009-1013. [PMID: 36828958 PMCID: PMC10049999 DOI: 10.1038/s41433-023-02428-9] [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: 02/27/2022] [Revised: 01/13/2023] [Accepted: 01/25/2023] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVES To provide evidence for long-term outcomes for margin-controlled excision of eyelid melanoma. METHODS Retrospective single-centre observational case series of patients treated for eyelid melanoma between 2007 and 2016, with a minimum of 5-year follow-up. Tumour excision involved rush-paraffin en face horizontal sections and delayed repair (Slow Mohs; SM). RESULTS Twenty-two cases were seen with a survival of 91% (two deaths from nodular and lentigo maligna melanoma) and seven with melanoma in situ (MIS). Invasive melanoma includes eight lentigo maligna melanoma, four nodular, two amelanotic and one desmoplastic. Mean Breslow thickness was 6 mm for invasive (range 0.5-26). Mean excision margin for MIS was 3 mm (range 2-5 mm) and for invasive was 5 mm (range 2-10). Further excisions were performed in nine (41%); two went on to recur. Local recurrence was 36%; six invasive (27%) at a mean of 24 months (range 1.5-5 years) and two for MIS at a mean of 15 months (range 1-1.5 years). Imaging occurred for suspected advanced disease. Sentinel node biopsy was not performed. Advanced melanoma therapy was performed in two cases. No vitamin D testing occurred. CONCLUSIONS Survival rates are in line with 90% overall survival in the UK. Prescriptive excision margins are not applicable in the periocular region and margin-controlled excision with a delayed repair is recommended, but patients need to know further excision may be needed to obtain clearance. Evidence recommending vitamin D therapy needs to be put into clinical practice. In addition, upstaging of MIS occurred advocating excision rather than observation of MIS. More studies are needed to determine the best management of eyelid melanoma.
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Affiliation(s)
- John C Bladen
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK
| | - Raman Malhotra
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK
| | - Andre Litwin
- Corneoplastic department, Queen Victoria Hospital, East Grinstead, UK.
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4
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Tababa E, Teulings HE, Bhawan J. Differences Between Recommended Surgical Margins and Measured Histological Margins in Malignant Melanoma In Situ and Malignant Melanomas. Am J Dermatopathol 2021; 43:881-886. [PMID: 33534209 DOI: 10.1097/dad.0000000000001914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Wide local excision (WLE) using appropriate surgical margins is the standard surgical management for malignant melanoma in situ (MMIS) and primary cutaneous malignant melanoma (MM). The actual width of the histologic margins is frequently not assessed, whereas narrow histologic margins are associated with an increase in local melanoma recurrence. Our objective was to analyze the actual measured histological margins of WLE specimens of MMIS and MM cases and compare them with their recommended surgical margins. A retrospective study of formalin fixed specimens of MMIS and invasive MM treated with WLE from a large university-affiliated dermatopathology laboratory was conducted. Among a total of 164 MMIS and 128 MM cases, 14 MMIS (8.5%) and 7 MM (5.9%) had positive lateral margins. The median histologic margin for MMIS, after a 15% tissue shrinkage adjusted, was 2.7 mm [1.3-3.9] for LM type and 3.9 mm [2.3-5.6] for non-LM type, in contrast to the recommended 5-mm margin. In 96 MM of T1 type (≤1.0 mm), the median adjusted histologic margin was 6.7 mm [3.5-9.1] in contrast to the recommended 10-mm margin. These results show that measured and adjusted median histologic margins in WLE specimens in both MMIS and MM of T1 type were significantly narrower than the recommended surgical margins, regardless of anatomic location. These differences are concerning, whether they reflect clinicians' intentional or unintentional deviation from recommended guidelines.
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Affiliation(s)
- Erin Tababa
- Department of Dermatology, Dermatopathology Section, Boston University School of Medicine, Boston, MA
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5
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Krausz AE, Higgins HW, Etzkorn J, Sobanko J, Shin T, Giordano C, McMurray SL, Golda N, Maher IA, Leitenberger JJ, Bar A, Nijhawan RI, Srivastava D, Brewer JD, Baum CL, Holmes TE, Goldman GD, Bordeaux J, Carroll B, Macarthur K, Miller CJ. Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma. Dermatol Surg 2021; 47:1539-1544. [PMID: 34743123 DOI: 10.1097/dss.0000000000003268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. OBJECTIVE To define variations in published techniques for MMS for melanoma. METHODS AND MATERIALS A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS. RESULTS Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma. CONCLUSION Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.
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Affiliation(s)
- Aimee E Krausz
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - H William Higgins
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy Etzkorn
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Sobanko
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thuzar Shin
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cerrene Giordano
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stacy L McMurray
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Golda
- Department of Dermatology, University of Missouri School of Medicine, Columbus, Missouri
| | - Ian A Maher
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - Justin J Leitenberger
- Department of Dermatology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Anna Bar
- Department of Dermatology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Divya Srivastava
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Todd E Holmes
- Division of Dermatology, University of Vermont Medical Center, Burlington, Vermont
| | - Glenn D Goldman
- Division of Dermatology, University of Vermont Medical Center, Burlington, Vermont
| | - Jeremy Bordeaux
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Bryan Carroll
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kelly Macarthur
- Divison of Dermatology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Christopher J Miller
- Penn Dermatology Oncology Center, University of Pennsylvania, Philadelphia, Pennsylvania
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“Personalized Excision” of Malignant Melanoma—Need for a Paradigm Shift in the Beginning Era of Personalized Medicine. Am J Dermatopathol 2019; 41:884-896. [DOI: 10.1097/dad.0000000000001450] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Lo MC, Heaton MJ, Snelling A, Moncrieff MD. Reconstructive burden and financial implications of wider excision margins for invasive primary cutaneous melanoma. J Plast Reconstr Aesthet Surg 2019; 73:313-318. [PMID: 31680028 DOI: 10.1016/j.bjps.2019.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND For invasive primary cutaneous melanoma, wider excision is advocated to reduce local recurrence risk and improve patient outcomes. Excision detail is controversial, especially in intermediate- and high-risk primary melanoma (AJCC pT2-pT4). Guidance varies from sizes 1 to 3 cm (translating into large defects of 2-6 cm). The aim of this study was to determine the reconstructive and resource burden of wider excision margins (EMs). METHODS Data analysis from our prospective database (2008-2017) included 1184 patients (563F:621 M) with cutaneous melanoma (pT1b-pT4b). Procedure tariff data were sourced from our financial services department. RESULTS Two hundred twenty-nine patients had a narrower EM (1 cm) and 995 (80.7%) had a wider EM (2-3 cm). Reconstructive requirement significantly increased with a wider EM collectively (11.3% vs 29.3%, odds ratio (OR) = 3.2; p < 0.0001), in the extremities (15.2% vs 42.0%; p < 0.0001), and in the head and neck (H&N) (23.5 % vs 64.7%; p < 0.0001). Reconstruction significantly increased hospitalisation rates (26.6% vs 63.0%, OR = 4.7; p < 0.0001) collectively, in the H&N (26.8 % vs 53.9%), and in the upper (18.9 % vs 42.3%) and lower extremities (34.8% vs 77.3%). Narrower EMs significantly reduced hospitalisation rates in the upper and lower extremities (7.1% vs 28.5%; p = 0.004, 37.9% vs 58.5%; p = 0.005, respectively). Overall procedure cost significantly increased by £180 (mean, p < 0.0001) and £346 (median, p = 0.0004) per patient when reconstruction was required. CONCLUSIONS Our data suggest substantial impact of wider EM on patients, which more than doubled in the functionally and cosmetically sensitive extremities and the H&N region. Reconstructions add significant financial and healthcare service burden. Without randomised controlled trial (RCT) evidence demonstrating increased efficacy of wider EM, narrower EM is advocated whilst awaiting future planned RCT results specifically investigating on this.
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Affiliation(s)
- Michelle Chin Lo
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital, Norwich NR4 7UY, UK.
| | - Martin J Heaton
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital, Norwich NR4 7UY, UK
| | - Andrew Snelling
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital, Norwich NR4 7UY, UK
| | - Marc Ds Moncrieff
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital, Norwich NR4 7UY, UK; Norwich Medical School, University of East Anglia, UK
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8
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Summarize the changes to the American Joint Committee on Cancer Eighth Edition Melanoma Staging System. 2. List advances in genetic, molecular, and histopathologic melanoma diagnosis and prognostication. 3. Recommend sentinel lymph node biopsy and appropriate surgical margins based on individualized patient needs. 4. Recognize the currently available treatments for in-transit metastasis and advanced melanoma. 5. Describe current and future therapies for melanoma with distant visceral or brain metastases. SUMMARY Strides in melanoma surveillance, detection, and treatment continue to be made. The American Joint Committee on Cancer Eighth Edition Cancer Staging System has improved risk stratification of patients, introduced new staging categories, and resulted in stage migration of patients with improved outcomes. This review summarizes melanoma advances of the recent years with an emphasis on the surgical advances, including techniques and utility of sentinel node biopsy, controversies in melanoma margin selection, and the survival impact of time-to-treatment metrics. Once a disease manageable only with surgery, a therapeutic paradigm shift has given a more promising outlook to melanoma patients at any stage. Indeed, a myriad of novel, survival-improving immunotherapies have been introduced for metastatic melanoma and more recently in the high-risk adjuvant setting.
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Friedman EB, Dodds TJ, Lo S, Ferguson PM, Beck M, Saw RPM, Stretch JR, Lee KK, Nieweg OE, Spillane AJ, Scolyer RA, Thompson JF. Correlation Between Surgical and Histologic Margins in Melanoma Wide Excision Specimens. Ann Surg Oncol 2018; 26:25-32. [DOI: 10.1245/s10434-018-6858-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Indexed: 11/18/2022]
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10
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Bittar JM, Bittar PG, Wan MT, Kovell RC, Guzzo TJ, Shin TM, Etzkorn JR, Sobanko JF, Miller CJ. Systematic Review of Surgical Treatment and Outcomes After Local Surgery of Primary Cutaneous Melanomas of the Penis and Scrotum. Dermatol Surg 2018; 44:1159-1169. [PMID: 29985865 DOI: 10.1097/dss.0000000000001579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Few data exist to guide surgical management and counseling about local recurrence after surgery of primary male genital melanoma. OBJECTIVE To compile all available data on local recurrence rates after surgery of primary cutaneous melanoma of the penis and scrotum. MATERIALS AND METHODS A systematic review of PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Excerpta Medica database (EMBASE), and Web of Science identified all surgically treated penile and scrotal melanomas that reported local recurrence status and follow-up time. RESULTS One hundred twenty-seven melanomas from 74 manuscripts were included. Eighty-six percent of melanomas were located on the penis, and 14% were located on the scrotum. Average follow-up time was 35.7 months. Scrotal melanomas were predominantly treated with organ-sparing surgeries (16/18, 88.9%), whereas penile melanomas were treated more often with amputation (61/109, 56.0%). Overall, local recurrence rate was 15.7% (20/127). Local recurrence rates for penile cases were 18.8% (9/48) after organ-sparing surgery versus 13.1% (8/61) for amputative surgery. Local recurrence rates were 66.7% (4/6) after positive surgical margins versus 10.2% (5/49) after negative surgical margins. CONCLUSION Local recurrence rates are high after both organ-sparing and amputative surgery of primary cutaneous melanoma of the penis and scrotum. There is a need to standardize reporting for this rare tumor, as more complete data are necessary to develop consensus guidelines for surgical management of male genital melanoma.
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Affiliation(s)
- Julie M Bittar
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Peter G Bittar
- Duke University School of Medicine, Durham, North Carolina
| | - Marilyn T Wan
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Kovell
- Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J Guzzo
- Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thuzar M Shin
- 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
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Abstract
OPINION STATEMENT Melanoma is one of the most aggressive malignant skin tumors and its incidence has been increasing worldwide in recent decades. Among the four subtypes, acral lentiginous melanoma (ALM) shows the highest incidence in Asian countries, whereas ALM comprises only 1% of all melanomas in white populations. Early clinical diagnosis of ALM is essential, but early ALM lesions are often difficult to diagnose because the pigmentation of the lesions sometimes follows the skin marking of the palms and soles, resulting in an asymmetrical appearance and an irregular border in both ALM and benign melanocytic nevus. To overcome this difficulty, dermoscopy was introduced, and determination of the patterns by this method is essential for accurate clinical diagnosis of ALM. Although recent clinical trials have demonstrated that immune checkpoint inhibitors and BRAF/MEK inhibitors showed significantly improved overall survival of patients with advanced melanoma, ALM may be less susceptible to immune checkpoint inhibitors because of the poor immune response to the tumor. Therefore, strategies for enhancing the immune response to the tumor cells may be required when we apply immune checkpoint inhibitors in advanced ALM. In this context, imiquimod, dacarbazine, or interferon are possible therapies that may enhance the effectiveness of the immune checkpoint inhibitors. In addition to being known to have poor immunogenicity, ALM is also known to have infrequent BRAF mutation. Therefore, the majority of ALM patients may not benefit from therapy with BRAF/MEK inhibitors. However, some ALMs have mutations such as KIT and NRAS mutations, and therefore, targeted therapies may improve the survival of ALM patients in the future.
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Affiliation(s)
- Yoshiyuki Nakamura
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yasuhiro Fujisawa
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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12
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Foxton GC, Elliott TG, Litterick KA. Treating melanoma in situ
and lentigo maligna with Mohs micrographic surgery in Australia. Australas J Dermatol 2018; 60:33-37. [DOI: 10.1111/ajd.12845] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Glen C Foxton
- South Perth Specialist Skin Cancer Centre; Perth Western Australia Australia
| | - Timothy G Elliott
- South Perth Specialist Skin Cancer Centre; Perth Western Australia Australia
| | - Kelly A Litterick
- South Perth Specialist Skin Cancer Centre; Perth Western Australia Australia
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Beaulieu D, Fathi R, Srivastava D, Nijhawan RI. Current perspectives on Mohs micrographic surgery for melanoma. Clin Cosmet Investig Dermatol 2018; 11:309-320. [PMID: 29950878 PMCID: PMC6016488 DOI: 10.2147/ccid.s137513] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mohs micrographic surgery (MMS), a specialized surgical excision technique used primarily in the treatment of skin cancers, is tissue sparing and provides optimal margin control through evaluation of 100% of both the peripheral and deep margin. The use of MMS for the treatment of malignant melanoma (MM) and melanoma in situ (MIS) has been slow in gaining the same widespread acceptance that it has for keratinocyte carcinomas despite its cost-effectiveness and the growing body of evidence demonstrating similar or improved cure rates to standard wide local excision. However, modern advances in immunohistochemical staining have continued to greatly enhance the ability of Mohs surgeons to interpret MMS frozen sections of melanoma specimens – the primary concern of most opponents of MMS for melanoma. These advances, coupled with an increased recognition by professional organizations of the utility of MMS in treating MM and MIS, have led to a rise in the use of MMS for melanoma in recent years. Given the expanding role of MMS in the treatment of cutaneous melanoma, this manuscript will describe how MMS is performed, discuss the rationale and current evidence regarding the use of MMS for MM and MIS, review the immunohistochemical stains currently available for use in MMS, and consider special situations and future directions in this area of growing interest.
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Affiliation(s)
| | - Ramin Fathi
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Divya Srivastava
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Sladden MJ, Nieweg OE, Howle J, Coventry BJ, Thompson JF. Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma. Med J Aust 2018; 208:137-142. [PMID: 29438650 DOI: 10.5694/mja17.00278] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/11/2017] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Definitive management of primary cutaneous melanoma consists of surgical excision of the melanoma with the aim of curing the patient. The melanoma is widely excised together with a safety margin of surrounding skin and subcutaneous tissue, after the diagnosis and Breslow thickness have been established by histological assessment of the initial excision biopsy specimen. Sentinel lymph node biopsy should be discussed for melanomas ≥ 1 mm thickness (≥ 0.8 mm if other high risk features) in which case lymphoscintigraphy must be performed before wider excision of the primary melanoma site. The 2008 evidence-based clinical practice guidelines for the management of melanoma (http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/ClinicalPracticeGuidelines-ManagementofMelanoma.pdf) are currently being revised and updated in a staged process by a multidisciplinary working party established by Cancer Council Australia. The guidelines for definitive excision margins for primary melanomas have been revised as part of this process. Main recommendations: The recommendations for definitive wide local excision of primary cutaneous melanoma are: melanoma in situ: 5-10 mm margins invasive melanoma (pT1) ≤ 1.0 mm thick: 1 cm margins invasive melanoma (pT2) 1.01-2.00 mm thick: 1-2 cm margins invasive melanoma (pT3) 2.01-4.00 mm thick: 1-2 cm margins invasive melanoma (pT4) > 4.0 mm thick: 2 cm margins Changes in management as a result of the guideline: Based on currently available evidence, excision margins for invasive melanoma have been left unchanged compared with the 2008 guidelines. However, melanoma in situ should be excised with 5-10 mm margins, with the aim of achieving complete histological clearance. Minimum clearances from all margins should be assessed and stated. Consideration should be given to further excision if necessary; positive or close histological margins are unacceptable.
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15
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Pasquali S, Hadjinicolaou AV, Chiarion Sileni V, Rossi CR, Mocellin S. Systemic treatments for metastatic cutaneous melanoma. Cochrane Database Syst Rev 2018; 2:CD011123. [PMID: 29405038 PMCID: PMC6491081 DOI: 10.1002/14651858.cd011123.pub2] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognosis of people with metastatic cutaneous melanoma, a skin cancer, is generally poor. Recently, new classes of drugs (e.g. immune checkpoint inhibitors and small-molecule targeted drugs) have significantly improved patient prognosis, which has drastically changed the landscape of melanoma therapeutic management. This is an update of a Cochrane Review published in 2000. OBJECTIVES To assess the beneficial and harmful effects of systemic treatments for metastatic cutaneous melanoma. SEARCH METHODS We searched the following databases up to October 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers and the ASCO database in February 2017, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We considered RCTs of systemic therapies for people with unresectable lymph node metastasis and distant metastatic cutaneous melanoma compared to any other treatment. We checked the reference lists of selected articles to identify further references to relevant trials. DATA COLLECTION AND ANALYSIS Two review authors extracted data, and a third review author independently verified extracted data. We implemented a network meta-analysis approach to make indirect comparisons and rank treatments according to their effectiveness (as measured by the impact on survival) and harm (as measured by occurrence of high-grade toxicity). The same two review authors independently assessed the risk of bias of eligible studies according to Cochrane standards and assessed evidence quality based on the GRADE criteria. MAIN RESULTS We included 122 RCTs (28,561 participants). Of these, 83 RCTs, encompassing 21 different comparisons, were included in meta-analyses. Included participants were men and women with a mean age of 57.5 years who were recruited from hospital settings. Twenty-nine studies included people whose cancer had spread to their brains. Interventions were categorised into five groups: conventional chemotherapy (including single agent and polychemotherapy), biochemotherapy (combining chemotherapy with cytokines such as interleukin-2 and interferon-alpha), immune checkpoint inhibitors (such as anti-CTLA4 and anti-PD1 monoclonal antibodies), small-molecule targeted drugs used for melanomas with specific gene changes (such as BRAF inhibitors and MEK inhibitors), and other agents (such as anti-angiogenic drugs). Most interventions were compared with chemotherapy. In many cases, trials were sponsored by pharmaceutical companies producing the tested drug: this was especially true for new classes of drugs, such as immune checkpoint inhibitors and small-molecule targeted drugs.When compared to single agent chemotherapy, the combination of multiple chemotherapeutic agents (polychemotherapy) did not translate into significantly better survival (overall survival: HR 0.99, 95% CI 0.85 to 1.16, 6 studies, 594 participants; high-quality evidence; progression-free survival: HR 1.07, 95% CI 0.91 to 1.25, 5 studies, 398 participants; high-quality evidence. Those who received combined treatment are probably burdened by higher toxicity rates (RR 1.97, 95% CI 1.44 to 2.71, 3 studies, 390 participants; moderate-quality evidence). (We defined toxicity as the occurrence of grade 3 (G3) or higher adverse events according to the World Health Organization scale.)Compared to chemotherapy, biochemotherapy (chemotherapy combined with both interferon-alpha and interleukin-2) improved progression-free survival (HR 0.90, 95% CI 0.83 to 0.99, 6 studies, 964 participants; high-quality evidence), but did not significantly improve overall survival (HR 0.94, 95% CI 0.84 to 1.06, 7 studies, 1317 participants; high-quality evidence). Biochemotherapy had higher toxicity rates (RR 1.35, 95% CI 1.14 to 1.61, 2 studies, 631 participants; high-quality evidence).With regard to immune checkpoint inhibitors, anti-CTLA4 monoclonal antibodies plus chemotherapy probably increased the chance of progression-free survival compared to chemotherapy alone (HR 0.76, 95% CI 0.63 to 0.92, 1 study, 502 participants; moderate-quality evidence), but may not significantly improve overall survival (HR 0.81, 95% CI 0.65 to 1.01, 2 studies, 1157 participants; low-quality evidence). Compared to chemotherapy alone, anti-CTLA4 monoclonal antibodies is likely to be associated with higher toxicity rates (RR 1.69, 95% CI 1.19 to 2.42, 2 studies, 1142 participants; moderate-quality evidence).Compared to chemotherapy, anti-PD1 monoclonal antibodies (immune checkpoint inhibitors) improved overall survival (HR 0.42, 95% CI 0.37 to 0.48, 1 study, 418 participants; high-quality evidence) and probably improved progression-free survival (HR 0.49, 95% CI 0.39 to 0.61, 2 studies, 957 participants; moderate-quality evidence). Anti-PD1 monoclonal antibodies may also result in less toxicity than chemotherapy (RR 0.55, 95% CI 0.31 to 0.97, 3 studies, 1360 participants; low-quality evidence).Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival (HR 0.63, 95% CI 0.60 to 0.66, 1 study, 764 participants; high-quality evidence) and progression-free survival (HR 0.54, 95% CI 0.50 to 0.60, 2 studies, 1465 participants; high-quality evidence). Anti-PD1 monoclonal antibodies may result in better toxicity outcomes than anti-CTLA4 monoclonal antibodies (RR 0.70, 95% CI 0.54 to 0.91, 2 studies, 1465 participants; low-quality evidence).Compared to anti-CTLA4 monoclonal antibodies alone, the combination of anti-CTLA4 plus anti-PD1 monoclonal antibodies was associated with better progression-free survival (HR 0.40, 95% CI 0.35 to 0.46, 2 studies, 738 participants; high-quality evidence). There may be no significant difference in toxicity outcomes (RR 1.57, 95% CI 0.85 to 2.92, 2 studies, 764 participants; low-quality evidence) (no data for overall survival were available).The class of small-molecule targeted drugs, BRAF inhibitors (which are active exclusively against BRAF-mutated melanoma), performed better than chemotherapy in terms of overall survival (HR 0.40, 95% CI 0.28 to 0.57, 2 studies, 925 participants; high-quality evidence) and progression-free survival (HR 0.27, 95% CI 0.21 to 0.34, 2 studies, 925 participants; high-quality evidence), and there may be no significant difference in toxicity (RR 1.27, 95% CI 0.48 to 3.33, 2 studies, 408 participants; low-quality evidence).Compared to chemotherapy, MEK inhibitors (which are active exclusively against BRAF-mutated melanoma) may not significantly improve overall survival (HR 0.85, 95% CI 0.58 to 1.25, 3 studies, 496 participants; low-quality evidence), but they probably lead to better progression-free survival (HR 0.58, 95% CI 0.42 to 0.80, 3 studies, 496 participants; moderate-quality evidence). However, MEK inhibitors probably have higher toxicity rates (RR 1.61, 95% CI 1.08 to 2.41, 1 study, 91 participants; moderate-quality evidence).Compared to BRAF inhibitors, the combination of BRAF plus MEK inhibitors was associated with better overall survival (HR 0.70, 95% CI 0.59 to 0.82, 4 studies, 1784 participants; high-quality evidence). BRAF plus MEK inhibitors was also probably better in terms of progression-free survival (HR 0.56, 95% CI 0.44 to 0.71, 4 studies, 1784 participants; moderate-quality evidence), and there appears likely to be no significant difference in toxicity (RR 1.01, 95% CI 0.85 to 1.20, 4 studies, 1774 participants; moderate-quality evidence).Compared to chemotherapy, the combination of chemotherapy plus anti-angiogenic drugs was probably associated with better overall survival (HR 0.60, 95% CI 0.45 to 0.81; moderate-quality evidence) and progression-free survival (HR 0.69, 95% CI 0.52 to 0.92; moderate-quality evidence). There may be no difference in terms of toxicity (RR 0.68, 95% CI 0.09 to 5.32; low-quality evidence). All results for this comparison were based on 324 participants from 2 studies.Network meta-analysis focused on chemotherapy as the common comparator and currently approved treatments for which high- to moderate-quality evidence of efficacy (as represented by treatment effect on progression-free survival) was available (based on the above results) for: biochemotherapy (with both interferon-alpha and interleukin-2); anti-CTLA4 monoclonal antibodies; anti-PD1 monoclonal antibodies; anti-CTLA4 plus anti-PD1 monoclonal antibodies; BRAF inhibitors; MEK inhibitors, and BRAF plus MEK inhibitors. Analysis (which included 19 RCTs and 7632 participants) generated 21 indirect comparisons.The best evidence (moderate-quality evidence) for progression-free survival was found for the following indirect comparisons:• both combinations of immune checkpoint inhibitors (HR 0.30, 95% CI 0.17 to 0.51) and small-molecule targeted drugs (HR 0.17, 95% CI 0.11 to 0.26) probably improved progression-free survival compared to chemotherapy;• both BRAF inhibitors (HR 0.40, 95% CI 0.23 to 0.68) and combinations of small-molecule targeted drugs (HR 0.22, 95% CI 0.12 to 0.39) were probably associated with better progression-free survival compared to anti-CTLA4 monoclonal antibodies;• biochemotherapy (HR 2.81, 95% CI 1.76 to 4.51) probably lead to worse progression-free survival compared to BRAF inhibitors;• the combination of small-molecule targeted drugs probably improved progression-free survival (HR 0.38, 95% CI 0.21 to 0.68) compared to anti-PD1 monoclonal antibodies;• both biochemotherapy (HR 5.05, 95% CI 3.01 to 8.45) and MEK inhibitors (HR 3.16, 95% CI 1.77 to 5.65) were probably associated with worse progression-free survival compared to the combination of small-molecule targeted drugs; and• biochemotherapy was probably associated with worse progression-free survival (HR 2.81, 95% CI 1.54 to 5.11) compared to the combination of immune checkpoint inhibitors.The best evidence (moderate-quality evidence) for toxicity was found for the following indirect comparisons:• combination of immune checkpoint inhibitors (RR 3.49, 95% CI 2.12 to 5.77) probably increased toxicity compared to chemotherapy;• combination of immune checkpoint inhibitors probably increased toxicity (RR 2.50, 95% CI 1.20 to 5.20) compared to BRAF inhibitors;• the combination of immune checkpoint inhibitors probably increased toxicity (RR 3.83, 95% CI 2.59 to 5.68) compared to anti-PD1 monoclonal antibodies; and• biochemotherapy was probably associated with lower toxicity (RR 0.41, 95% CI 0.24 to 0.71) compared to the combination of immune checkpoint inhibitors.Network meta-analysis-based ranking suggested that the combination of BRAF plus MEK inhibitors is the most effective strategy in terms of progression-free survival, whereas anti-PD1 monoclonal antibodies are associated with the lowest toxicity.Overall, the risk of bias of the included trials can be considered as limited. When considering the 122 trials included in this review and the seven types of bias we assessed, we performed 854 evaluations only seven of which (< 1%) assigned high risk to six trials. AUTHORS' CONCLUSIONS We found high-quality evidence that many treatments offer better efficacy than chemotherapy, especially recently implemented treatments, such as small-molecule targeted drugs, which are used to treat melanoma with specific gene mutations. Compared with chemotherapy, biochemotherapy (in this case, chemotherapy combined with both interferon-alpha and interleukin-2) and BRAF inhibitors improved progression-free survival; BRAF inhibitors (for BRAF-mutated melanoma) and anti-PD1 monoclonal antibodies improved overall survival. However, there was no difference between polychemotherapy and monochemotherapy in terms of achieving progression-free survival and overall survival. Biochemotherapy did not significantly improve overall survival and has higher toxicity rates compared with chemotherapy.There was some evidence that combined treatments worked better than single treatments: anti-PD1 monoclonal antibodies, alone or with anti-CTLA4, improved progression-free survival compared with anti-CTLA4 monoclonal antibodies alone. Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival, and a combination of BRAF plus MEK inhibitors was associated with better overall survival for BRAF-mutated melanoma, compared to BRAF inhibitors alone.The combination of BRAF plus MEK inhibitors (which can only be administered to people with BRAF-mutated melanoma) appeared to be the most effective treatment (based on results for progression-free survival), whereas anti-PD1 monoclonal antibodies appeared to be the least toxic, and most acceptable, treatment.Evidence quality was reduced due to imprecision, between-study heterogeneity, and substandard reporting of trials. Future research should ensure that those diminishing influences are addressed. Clinical areas of future investigation should include the longer-term effect of new therapeutic agents (i.e. immune checkpoint inhibitors and targeted therapies) on overall survival, as well as the combination of drugs used in melanoma treatment; research should also investigate the potential influence of biomarkers.
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Affiliation(s)
- Sandro Pasquali
- Sarcoma Service, Fondazione IRCCS 'Istituto Nazionale Tumori', Via G. Venezian 1, Milano, Italy, 20133
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Varey AHR, Goumas C, Hong AM, Mann GJ, Fogarty GB, Stretch JR, Saw RPM, Spillane AJ, Shannon KF, Lee KJ, Quinn MJ, Thompson JF, Scolyer RA. Neurotropic melanoma: an analysis of the clinicopathological features, management strategies and survival outcomes for 671 patients treated at a tertiary referral center. Mod Pathol 2017; 30:1538-1550. [PMID: 28731051 DOI: 10.1038/modpathol.2017.76] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/18/2017] [Accepted: 05/20/2017] [Indexed: 11/08/2022]
Abstract
Neurotropic cutaneous melanoma is a rare melanoma subtype that invades nerves and is often associated with desmoplastic melanoma. Limited data suggest that it has a greater propensity to recur locally, but it is unknown whether its behavior differs from that of other melanoma subtypes, including desmoplastic melanoma. We investigated clinicopathological predictors of outcome in a cohort of 671 patients with neurotropic melanoma to develop evidence-based management recommendations. Patients with primary neurotropic melanoma diagnosed from 1985 to 2013 were identified from the Melanoma Institute Australia database, along with a control cohort of 718 non-neurotropic melanoma patients. Features predictive of sentinel lymph node status, recurrence, melanoma-specific survival and response to adjuvant radiotherapy were sought. Neither local recurrence (hazard ratio: 1.28 (0.73-2.25) P=0.39) nor melanoma-specific survival (hazard ratio: 0.79 (0.55-1.15) P=0.22) were significantly affected by the presence of neurotropism on multivariate analysis. However, there was a markedly reduced likelihood of sentinel node positivity (hazard ratio: 0.61 (0.41-0.89) P=0.01) in neurotropic melanoma patients. Surgical margins ≥8mm halved the recurrence risk compared with <2 mm margins (hazard ratio: 0.46 (0.31-0.68) P<0.001). Additionally, in neurotropic melanoma patients with <8 mm margins, adjuvant radiotherapy halved the recurrence risk (hazard ratio: 0.48 (0.27-0.87) P=0.02). This, the largest study of neurotropic melanoma reported to date, has demonstrated that the presence of neurotropism does not alter the risk of melanoma recurrence or survival but does reduce the likelihood of sentinel node positivity. For successful treatment of neurotropic melanoma, adequate excision margins are of paramount importance. However, when adequate margins cannot be achieved, adjuvant radiotherapy reduces the risk of recurrence.
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Affiliation(s)
- Alexander H R Varey
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Chris Goumas
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
| | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Graham J Mann
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
| | - Gerald B Fogarty
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kenneth J Lee
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Michael J Quinn
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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17
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Varey AHR, Madronio CM, Cust AE, Goumas C, Mann GJ, Armstrong BK, Scolyer RA, Curtin AM, Thompson JF. Poor Adherence to National Clinical Management Guidelines: A Population-Based, Cross-Sectional Study of the Surgical Management of Melanoma in New South Wales, Australia. Ann Surg Oncol 2017; 24:2080-2088. [PMID: 28547563 DOI: 10.1245/s10434-017-5890-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Standardization of the clinical management of melanoma through the formulation of national guidelines, based on interpretation of the existing evidence and consensus expert opinion, seeks to improve quality of care; however, adherence to national guidelines has not been well studied. METHODS A population-based, cross-sectional study of the clinical management of all patients with newly notified primary melanomas in the state of New South Wales, Australia, during 2006/2007 was conducted using cancer registry identification and questionnaires completed by treating physicians. RESULTS Surgical margin guidelines were adhered to in 35% of cases; 45% were over treated and 21% were undertreated. Factors independently associated with non-concordance on multivariate analysis were lower Breslow thickness, lower socio-economic status of the physician's practice location, older physician age, lower physician caseload, and physicians who biopsied the lesion and then referred for definitive management. Complications were not related to over- or under-treatment on multivariate analysis (p = 0.72). Sentinel lymph node biopsy was performed in 17% of patients with invasive melanoma, with the main determinant for selection being a Breslow thickness >0.75 mm. CONCLUSIONS The low level of concordance with national guidelines for surgical management of melanoma resulted in overtreatment of many patients. However, a fifth of patients were undertreated, which is likely to have resulted in increased locoregional recurrence rates. The better concordance achieved by physicians treating >30 melanomas per year suggests that a minimum caseload threshold for physicians treating melanoma patients would be desirable. High guideline concordance will ensure patients receive optimal care and minimize morbidity and health service costs.
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Affiliation(s)
- Alexander H R Varey
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Department of Plastic Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Christine M Madronio
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne E Cust
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Chris Goumas
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Graham J Mann
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Centre for Cancer Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Bruce K Armstrong
- Cancer Epidemiology and Prevention Research, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Austin M Curtin
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia. .,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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18
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Surgical excision margin for primary acral melanoma. J Surg Oncol 2016; 114:933-939. [DOI: 10.1002/jso.24442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 09/02/2016] [Indexed: 11/07/2022]
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Haydu LE, Stollman JT, Scolyer RA, Spillane AJ, Quinn MJ, Saw RPM, Shannon KF, Stretch JR, Bonenkamp JJ, Thompson JF. Minimum Safe Pathologic Excision Margins for Primary Cutaneous Melanomas (1-2 mm in Thickness): Analysis of 2131 Patients Treated at a Single Center. Ann Surg Oncol 2016; 23:1071-81. [PMID: 25956574 DOI: 10.1245/s10434-015-4575-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Indexed: 12/16/2023]
Abstract
OBJECTIVE This study was designed to determine the minimum safe pathologic excision margin for primary cutaneous melanomas 1.01-2.00-mm thick (T2) and to identify prognostic factors that influence survival in these patients. BACKGROUND Several studies have shown previously that "narrow" clinical excision margins (1-2 cm in vivo) are as safe as "wide" excision margins (4-5 cm) for management of primary T2 melanomas. However, pathologic margins are likely to be a better predictor of recurrence than clinical margins. METHODS Clinicopathologic and follow-up data for 2131 T2 melanoma patients treated at Melanoma Institute Australia between January 1992 and May 2012 were analyzed. RESULTS Of the 2131 patients, those who had a pathologic excision margin of <8 mm (equivalent to 1 cm in vivo) had poorer prognosis in terms of disease-free survival compared with the 8-16-mm group (equivalent to 1-2 cm in vivo; P = 0.044). When comparing 8-mm with 16-mm pathologic margins, no differences were observed in any of the survival outcomes. Only the deep margin proved to be an independent predictor of local and in-transit recurrence-free survival (P = 0.003) in all excision margin categories. Pathologic excision margins <8 mm were associated with worse regional node recurrence-free survival and distant recurrence-free survival compared with margins ≥8 mm (P = 0.049 and P = 0.045; respectively). However, these results failed to translate into a statistically significant difference in melanoma-specific survival. CONCLUSIONS The results of this study suggest that if a peripheral/radial pathologic excision margin for a T2 primary cutaneous melanoma is <8 mm consideration should be given to performing a wider excision.
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Affiliation(s)
- Lauren E Haydu
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Richard A Scolyer
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Quinn
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Johannes J Bonenkamp
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, NSW, Australia.
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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MacKenzie Ross AD, Haydu LE, Quinn MJ, Saw RPM, Shannon KF, Spillane AJ, Stretch JR, Scolyer RA, Thompson JF. The Association Between Excision Margins and Local Recurrence in 11,290 Thin (T1) Primary Cutaneous Melanomas: A Case-Control Study. Ann Surg Oncol 2016; 23:1082-9. [PMID: 26561405 DOI: 10.1245/s10434-015-4942-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Indexed: 12/16/2023]
Abstract
BACKGROUND At presentation, most primary cutaneous melanomas are "thin" (Breslow thickness ≤1 mm, designated T1 in the American Joint Committee on Cancer staging system) and local recurrence (LR) is rare. Most current management guidelines recommend 1 cm surgical excision margins for T1 melanomas, but evidence to support this recommendation is sparse. We sought to identify clinical and pathologic factors associated with LR in patients with T1 melanomas that might guide primary tumor management. METHODS From a large, prospectively collected, single-institution database, patients with primary cutaneous melanomas ≤1 mm thick diagnosed between 1970 and 2011 who developed LR were identified and matched with controls. Clinical and pathologic parameters were analyzed for their association with LR. RESULTS From 11,290 primary melanomas ≤1 mm thick, 176 (1.56 %) cases with LR were identified and 176 controls (without LR) were selected. LR occurred after a median time of 37 months (range 3-306 months) and was associated with narrower excision margins (hazard ratio = 0.95, 95 % confidence interval 0.92-0.98, p = 0.001), desmoplastic, acral, and lentigo maligna melanoma subtypes (p = 0.008), and melanomas composed predominantly of spindle cells (p = 0.005). However, Breslow thickness, Clark level, ulceration, mitotic rate, regression, and lymphovascular invasion were not. CONCLUSIONS LR was associated with <8 mm histologic excision margins (corresponding to <1 cm margins in vivo) and desmoplastic, acral, and lentigo maligna melanoma subtypes. This study provides evidence that a ≥1 cm clinical excision margin for thin (T1) primary melanomas reduces the risk of LR.
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Affiliation(s)
- Alastair D MacKenzie Ross
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Department of Plastic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lauren E Haydu
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Quinn
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, NSW, Australia.
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Wheatley K, Wilson JS, Gaunt P, Marsden JR. Surgical excision margins in primary cutaneous melanoma: A meta-analysis and Bayesian probability evaluation. Cancer Treat Rev 2016; 42:73-81. [PMID: 26563920 DOI: 10.1016/j.ctrv.2015.10.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/27/2015] [Accepted: 10/29/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgery is the only curative treatment for primary cutaneous melanoma, therefore it is important to determine excision margins that minimise risk of local recurrence, distant recurrence and death. METHODS MEDLINE, EMBASE and Cochrane CENTRAL were searched from 2009 to 2015. Inclusion criteria were: population/setting - patients with primary melanoma; comparison - narrow versus wide margins; outcomes - overall survival, melanoma-specific survival, recurrence-free survival, and loco-regional recurrence; design - randomized controlled trials (RCTs). Results were pooled using meta-analysis and data explored using likelihood Bayesian probability plots. RESULTS Six RCTs with 4233 patients were included. Narrow margins were defined as 1 or 2 cm of clinically normal skin around the melanoma; wide margins as 3, 4 or 5 cm. Hazard ratios (HR) were as follows (HR>1 indicates wide margin better): overall survival 1.09 (95% CI 0.98-1.22; p=0.1); melanoma-specific survival 1.17 (CI 1.03-1.34; p=0.02); recurrence-free survival 1.08 (CI 0.97-1.20; p=0.2); loco-regional recurrence 1.10 (CI 0.96-1.26; p=0.2), with no evidence of heterogeneity between trials for any end point or within subgroup analyses. There was an 94% probability that overall survival was worse with a narrow margin and a 43% probability that it was more than 10% worse in proportional terms (i.e. HR>1.1). Probabilities that narrow margins were worse were 99%, 92% and 92% for melanoma-specific survival, recurrence-free survival and loco-regional recurrence respectively. CONCLUSIONS Contrary to recommendations in several national guidelines that narrow margins are safe, this systematic review and meta-analysis provides evidence that a narrow margin may lead to a worse outcome than a wide margin.
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Affiliation(s)
- Keith Wheatley
- Cancer Research UK Clinical Trials Unit, Institute of Cancer & Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Jayne S Wilson
- Cancer Research UK Clinical Trials Unit, Institute of Cancer & Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Piers Gaunt
- Cancer Research UK Clinical Trials Unit, Institute of Cancer & Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Jerry R Marsden
- Skin Oncology Service, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
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Ross MI, Balch CM. Excision Margins of Melanoma Make a Difference: New Data Support an Old Paradigm. Ann Surg Oncol 2015; 23:1053-6. [PMID: 26561402 DOI: 10.1245/s10434-015-4950-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Merrick I Ross
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles M Balch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Teng J, Halbert T, McMurry TL, Levine PA, Christophel JJ. Histopathologic margin distance in survival in resection of cutaneous melanoma of the head and neck. Laryngoscope 2015; 125:1856-60. [PMID: 25891166 DOI: 10.1002/lary.25311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Treatment of cutaneous melanoma involves surgical excision with wide clinical margins. No guidelines regarding safe histopathologic margin distance exist. This study examines the impact of histopathologic margin, measured from closest cut edge of the specimen, on overall survival in resection of cutaneous melanoma of the head and neck. We hypothesize that close histopathologic margins (<2 mm) are associated with decreased survival. STUDY DESIGN Retrospective chart review. METHODS A total of 637 patients were treated for cutaneous melanoma of the head and neck between 2001 and 2011. Demographics, tumor characteristics, histopathologic margin distance (from a pathology database), and survival data from state health registries and health system clinical data repositories were used to create a dataset. Cox regression models and Kaplan-Meier curves were used to analyze data, adjusting for age, tumor location, ulceration, and depth of invasion (DOI). RESULTS When analyzing for overall survival, Cox multivariate regression analysis showed age (hazard ratio [HR] = 1.0-1.1), DOI (HR = 1.2-1.5), ulceration (HR = 1.3-3.8), and subsite (ear, HR = 1.0-3.9) were significant predictors of survival. Histopathologic margin distance was not significant for predicting survival. Three percent of histopathologic margins were <1 mm. CONCLUSIONS In a large dataset of head and neck cutaneous melanoma, known factors associated with overall survival (age, DOI, ulceration, subsite) proved significant, validating the dataset. Examining the effect of histopathologic margin distance on survival, while controlling for these factors, we failed to reject the null hypothesis. Margin distance as measured by histopathology does not affect survival. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- James Teng
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System (j.t., p.a.l., j.j.c.)
| | - Travis Halbert
- School of Medicine (t.h., t.l.m.), University of Virginia, Charlottesville, Virginia, U.S.A
| | - Timothy L McMurry
- School of Medicine (t.h., t.l.m.), University of Virginia, Charlottesville, Virginia, U.S.A
| | - Paul A Levine
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System (j.t., p.a.l., j.j.c.)
| | - J Jared Christophel
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System (j.t., p.a.l., j.j.c.)
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Pasquali S, Kefford R, Chiarion Sileni V, Nitti D, Rossi CR, Pilati P, Mocellin S. Systemic treatments for metastatic cutaneous melanoma. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011123] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sandro Pasquali
- Veneto Institute of Oncology - IRCCS; Surgical Oncology Unit; Via Gattamelata 64 Padova Italy 35128
| | - Richard Kefford
- The University of Sydney; Discipline of Medicine; Clinical Sciences Block, Westmead Hospital Westmead Australia 2145
| | - Vanna Chiarion Sileni
- Veneto Region Oncology Research Institute; Medical Oncology Unit 2; Via Gattamelata 64 Padova Italy 35128
| | - Donato Nitti
- University of Padova; Clinica Chirurgica II; Via Giustiniani 2 Padova Italy 35128
| | - Carlo Riccardo Rossi
- Veneto Institute of Oncology; Melanoma and Sarcomas Unit; Via Gattamelata 64 Padova Italy 35128
| | - Pierluigi Pilati
- University of Padova; Meta-Analysis Unit, Department of Surgery, Oncology and Gastroenterology; via Giustiniani 2 Padova Italy 35128
| | - Simone Mocellin
- University of Padova; Dept. Surgery Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
- IOV-IRCCS; Istituto Oncologico Veneto; Padova Italy 35100
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The Safety of and Indications for Immediate Reconstruction of Head and Neck Melanoma Defects. Ann Plast Surg 2014; 72 Suppl 1:S35-7. [DOI: 10.1097/sap.0000000000000166] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Chin-Lenn L, Murynka T, McKinnon JG, Arlette JP. Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision. Dermatol Surg 2013; 39:1637-45. [PMID: 24164702 DOI: 10.1111/dsu.12335] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Mohs micrographic surgery (MMS) is an accepted treatment for nonmelanoma skin cancer and has an evolving role in melanoma. OBJECTIVE To review oncologic outcomes of MMS and wide local excision (WLE) treatments for facial melanoma. METHODS AND MATERIALS A retrospective review of patients with invasive melanoma of the face between 1997 and 2007 identified from the Alberta Cancer Registry (Canada) was performed. Outcome measures were local recurrence (recurrence <2 cm from excision scar), distant recurrence (regional or systemic), and disease-specific survival. RESULTS One hundred fifty-one patients were available for analysis (60 MMS, 91 WLE). Median follow-up time was 48 months. The groups differed in tumor location and mitotic rate. Overall, there was no significant difference in 5-year local recurrence (7.9% WLE vs 6.2% MMS, p = .58), regional or systemic recurrence (18.8% vs 8.8%, p = 0.37) or disease-specific survival (82.8% vs 92.4%, p = .59). Breslow thickness was the only consistent predictor of local recurrence or other recurrence and disease-specific survival on multivariate analysis. Subset analysis of tumors with Breslow thickness less than 2 mm did not reveal any difference in outcomes. CONCLUSION Mohs micrographic surgery has oncologic outcomes of local recurrence, distant recurrence and overall survival similar to those of WLE for invasive facial melanoma.
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Affiliation(s)
- Laura Chin-Lenn
- Division of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
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Pasquali S, Haydu LE, Scolyer RA, Winstanley JB, Spillane AJ, Quinn MJ, Saw RPM, Shannon KF, Stretch JR, Thompson JF. The importance of adequate primary tumor excision margins and sentinel node biopsy in achieving optimal locoregional control for patients with thick primary melanomas. Ann Surg 2013; 258:152-7. [PMID: 23426339 DOI: 10.1097/sla.0b013e31828421e1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study sought to investigate the impact of histopathologically measured excision margins and SNB on local and locoregional disease control in patients with primary cutaneous melanomas more than 4 mm thick. BACKGROUND Most current guidelines recommend at least a 2-cm surgical margin (which corresponds to a 16-mm histopathologic margin). These guidelines are based on limited evidence, mostly obtained in patients who did not have an SNB. METHODS Histopathologic tumor excision margins for clinically lymph node-negative patients with melanomas more than 4 mm thick, treated at Melanoma Institute Australia (1992-2009), were determined. Clinicopathologic predictors of local and locoregional disease-free survival were investigated. RESULTS There were 632 patients eligible for the study; of these, 397 (62.8%) had an SNB. The median histopathologic excision margin was 15 mm (interquartile range, 11.0-19.5 mm). After a median follow-up of 37 months, local and locoregional recurrences were observed in 48 (7.6%) and 159 (25.2%) patients, respectively. Excision margin as a continuous variable was a significant predictor of local [hazard ratio (HR), 0.91; P < 0.001) and locoregional (HR, 0.97; P = 0.042) tumor control on multivariate analyses. Patients with histopathologic margins 16 mm or less had worse local disease-free survival (HR, 2.41; P = 0.01). Patients who did not have an SNB were at higher risk of locoregional recurrence (HR, 1.67; P = 0.003). CONCLUSIONS Histopathologically determined primary tumor excision margins more than 16 mm, corresponding to 2-cm surgical margins, were associated with better local control in patients with melanomas more than 4 mm thick. Patients achieved the best local and locoregional control when SNB was coupled with a more than 16-mm histologic excision margin.
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Grotz TE, Glorioso JM, Pockaj BA, Harmsen WS, Jakub JW. Preservation of the deep muscular fascia and locoregional control in melanoma. Surgery 2013; 153:535-41. [DOI: 10.1016/j.surg.2012.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 09/11/2012] [Indexed: 11/30/2022]
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Abstract
UNLABELLED Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and primary cutaneous melanoma (PCM) are the major forms of skin cancer. Surgical excision is one of the most frequently utilized treatment modalities for these tumors. METHODS literature review. RESULTS recommendations for lateral surgical excision margin (LEM) for BCCs is 4 mm for low-risk BCCs and Mohs surgery or resection with complete circumferential peripheral and deep margin assessment for high risk. Recommended LEM is 4-6 mm for low-risk SCCs and Mohs surgery or resection with complete circumferential peripheral and deep margin assessment for high risk BCCs. If SCC or BCC is >20 mm in area L with no other high-risk factors and can be repaired primarily, 10-mm clinical margins may be used. Recommended LEM is 5 mm for melanoma-in-situ; 1 cm for PCM <1 mm (Breslow); 1-2 cm for PCM 1.01-2 mm (Breslow); and, 2-3 cm for high-risk PCM >2.01 mm (Breslow). Tumor subtype-specific recommendations for histologic margins are offered which provide the greatest degree of certainty regarding the completeness of excision. CONCLUSION Recommendations can be made regarding appropriate surgical excision margins by classifying skin cancers as low-risk or high-risk based on histopathological and clinical factors. Ascertaining that histopathologic margins are free of tumor is not a perfect science and requires thoughtful sampling, grossing, and staining procedures.
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Christophel JJ, Johnson AK, McMurry TL, Park SS, Levine PA. Predicting positive margins in resection of cutaneous melanoma of the head and neck. Laryngoscope 2013; 123:683-8. [DOI: 10.1002/lary.23799] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 09/20/2012] [Accepted: 09/24/2012] [Indexed: 12/21/2022]
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Seth R, Khan AA, Pencavel T, Harrington KJ, Harris PA. Targeted gene delivery by free-tissue transfer in oncoplastic reconstruction. Lancet Oncol 2012; 13:e392-402. [DOI: 10.1016/s1470-2045(12)70235-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Robertson GAJ, Robertson BF, Senior M, Zetlitz E, Shoaib T. Adherence to guideline excision margins in head and neck melanoma: the influence on 5-year survival and loco-regional recurrence. EUROPEAN JOURNAL OF PLASTIC SURGERY 2012. [DOI: 10.1007/s00238-011-0668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Hui AM, Jacobson M, Markowitz O, Brooks NA, Siegel DM. Mohs Micrographic Surgery for the Treatment of Melanoma. Dermatol Clin 2012; 30:503-15. [DOI: 10.1016/j.det.2012.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Etzkorn JR, Cherpelis BS, Glass LF. Mohs surgery for melanoma: rationale, advances and possibilities. Expert Rev Anticancer Ther 2012; 11:1041-52. [PMID: 21806328 DOI: 10.1586/era.11.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mohs surgery (MS) is an effective technique for the removal of a variety of cutaneous neoplasms by virtue of its thorough assessment of margins. It has yet to become widely accepted for melanoma because recognizing melanocytes histologically in frozen section can be problematic. Recently, 'rapid' methods of immunohistochemistry have been developed that resolve this issue by staining the melanocytes in frozen section. In addition, some of the immunohistochemistry protocols that previously required up to 1 h now take 19 min or less. These technological enhancements for MS have removed some of the obstacles towards the acceptance of MS as a legitimate option for removal of melanomas, especially poorly demarcated lesions and lesions from the head and neck, the distal extremities and the genitalia. Experience thus far with MS for melanoma has shown lower recurrence rates and improved disease-specific survival compared with historical controls for standard excision, while at the same time minimizing the sacrifice of normal tissue.
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Affiliation(s)
- Jeremy R Etzkorn
- Department of Dermatology and Cutaneous Surgery, University of South Florida, School of Medicine, 12901 Bruce B Downs Blvd, DC 79 Tampa, FL 33612, USA
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35
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Ross MI, Gershenwald JE. Evidence-based treatment of early-stage melanoma. J Surg Oncol 2011; 104:341-53. [DOI: 10.1002/jso.21962] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Grotz TE, Markovic SN, Erickson LA, Harmsen WS, Huebner M, Farley DR, Pockaj BA, Donohue JH, Sim FH, Grant CS, Bagaria SP, Shives TC, Balch CM, Jakub JW. Mayo Clinic consensus recommendations for the depth of excision in primary cutaneous melanoma. Mayo Clin Proc 2011; 86:522-8. [PMID: 21628616 PMCID: PMC3104911 DOI: 10.4065/mcp.2011.0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Currently, no data from randomized controlled clinical trials are available to guide the depth of resection for intermediate-thickness primary cutaneous melanoma. Thus, we hypothesized that substantial variability exists in this aspect of surgical care. We have summarized the literature regarding depth of resection and report the results of our survey of surgeons who treat melanoma. Most of the 320 respondents resected down to, but did not include, the muscular fascia (extremity, 71%; trunk, 66%; and head and neck, 62%). However, significant variation exists. We identified variability in our own practice and have elected to standardize this common aspect of routine surgical care across our institution. In light of the lack of evidence to support resection of the deep muscular fascia, we have elected to preserve the muscular fascia as a matter of routine, except when a deep primary melanoma or thin subcutaneous tissue dictates otherwise.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - James W. Jakub
- Individual reprints of this article are not available. Address correspondence to James W. Jakub, MD, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Vermeeren L, van der Ent FWC, Sastrowijoto PSH, Hulsewé KWE. Thick Melanoma: Prognostic Value of Positive Sentinel Nodes. World J Surg 2009; 33:2464-8. [DOI: 10.1007/s00268-009-0159-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Erickson Foster J, Velasco JM, Hieken TJ. Adverse outcomes associated with noncompliance with melanoma treatment guidelines. Ann Surg Oncol 2008; 15:2395-402. [PMID: 18600380 DOI: 10.1245/s10434-008-0021-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 01/16/2023]
Abstract
BACKGROUND Clinical practice guidelines have been developed to improve melanoma patient care. However, it is unclear whether failure to comply with these standards (either excessive or inadequate treatment) increases morbidity or relapse rates. Therefore, we undertook this study to evaluate the effect of variance from National Comprehensive Cancer Network (NCCN) recommendations on postoperative complication rates and disease recurrence. METHODS We retrospectively reviewed our institutional cancer registry data on 327 clinically node-negative melanoma patients and assessed compliance with NCCN guidelines, complication rates, and outcome. Data were confirmed by chart, pathology report, and operative note review. Statistical analysis was performed by using the SAS statistical software package. RESULTS Postoperative complications were documented in 17% of patients and were 3.4-fold higher for patients treated in a margin-noncompliant fashion and 2.4-fold higher for patients treated in a lymph-node-noncompliant manner (P < 0.001 for both). After mean follow-up of 51 months, disease recurred in 58 patients (18%) at a mean of 33 months (range 4-93 months). Locoregional disease alone as the first site of relapse was seen in 24% of margin-noncompliant versus 6% of margin-compliant cases and in 33% of lymph-node-noncompliant versus 6% of lymph-node-compliant cases (P < 0.0001). CONCLUSION While there are valid reasons for variance from treatment algorithms, these data suggest that compliance with NCCN guidelines improves outcome and decreases morbidity in clinically node-negative melanoma patients.
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Affiliation(s)
- Jennifer Erickson Foster
- Department of Surgery, Rush North Shore Medical Center, 9669 North Kenton, Suite 204, Skokie, IL, 60076, USA
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Erickson JL, Velasco JM, Hieken TJ. Compliance with melanoma treatment guidelines in a community teaching hospital: time trends and other variables. Ann Surg Oncol 2008; 15:1211-7. [PMID: 18239975 DOI: 10.1245/s10434-007-9789-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 12/10/2007] [Accepted: 12/11/2007] [Indexed: 12/18/2022]
Abstract
BACKGROUND Variation in the surgical treatment of melanoma occurs despite efforts to standardize care. This may lead to morbidity, inaccurate staging, and poor outcomes, or it may be cost ineffective. The purpose of our study was to evaluate our institutional compliance with National Comprehensive Cancer Network (NCCN) melanoma treatment guidelines. METHODS We studied 252 clinically node-negative melanoma patients identified from our cancer registry. Treatment data were confirmed by individual review of pathology and operative reports. RESULTS Documented margins of excision conformed to NCCN guidelines in 87% of Tis-T1 tumors and 60% of T2-T4 tumors. Lymph node staging was performed in 11% of T1a, 64% of T1b, 74% of T2, 63% of T3, and 47% of T4 patients. Treatment by a surgical oncologist achieved margin and lymph node compliance in 95% and 92% of cases versus other practitioners in 38% and 67%, respectively (P < .0001). Documented compliance with margin guidelines improved from 46% to 73% for the years 1995 to 1999 versus 2000 to 2004 (P < .0001) and for lymph node staging and treatment from 74% to 84% (P = .04). Other factors associated with greater adherence to NCCN guidelines were patient age <80 years, upper extremity tumors, and thinner tumors (all P < .05). CONCLUSIONS Our data suggest that our compliance with NCCN melanoma treatment guidelines was suboptimal. Treatment directed by a surgical oncologist showed the highest rate of adherence to national standards. Further investigation is needed to determine the effect of this on patient outcomes and how best to provide high-quality care to the greatest number of melanoma patients.
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Affiliation(s)
- Jennifer L Erickson
- Department of Surgery, Rush North Shore Medical Center, 9669 North Kenton, Suite 204, Skokie, Illinois 60076, USA
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Karim RZ, Van Den Berg KS, Colman MH, McCarthy SW, Thompson JF, Scolyer RA. The advantage of using a synoptic pathology report format for cutaneous melanoma. Histopathology 2007; 52:130-8. [DOI: 10.1111/j.1365-2559.2007.02921.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Griffiths RW, Suvarna SK, Stone J. Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper? J Plast Reconstr Aesthet Surg 2006; 60:41-7. [PMID: 17126265 DOI: 10.1016/j.bjps.2006.06.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 06/09/2006] [Accepted: 06/16/2006] [Indexed: 11/16/2022]
Abstract
An analysis of peripheral and deep margins of histological clearance around 1539 consecutive basal cell carcinomas excised by conventional surgery showed that 81 lesions (5.3%) were incompletely excised peripherally; 36 lesions (2.3%) were incompletely excised deeply; 13 lesions (0.8%) were incompletely excised peripherally and deeply. Nine hundred and ninety-six lesions (65%) were excised with a peripheral histological clearance margin<5mm (0.1-4.9mm), whereas 1303 lesions (85%) were excised with a deep histological clearance margin<5mm (0.1-4.9mm). Four hundred and eight lesions (27%) had a peripheral histological clearance margin of 5.0-9.9mm, whereas 170 lesions (11%) had a deep histological margin of 5.0-9.9mm. Peripheral histological clearance margins exceeded 10mm in 41 lesions (3%) and deep histological margins exceeded 10mm in 17 lesions (1%). Thus 30% of peripheral histological margins were 5mm or more but only 12% of deep histological margins were 5mm or more. Despite a relative sparing of deep tissue, incomplete excision in depth affected only 36 lesions compared with 81 incomplete peripheral excisions. Peripheral histological clearance was <5mm (0.1-4.9mm) for 55% of temple lesions, 50% of scalp lesions and 43% for limb lesions. In the cosmetically sensitive areas of peri-orbital region, nose, cheek, lip, neck and chin more than 70% of lesions were excised with a peripheral histological margin<5mm. This study of conventional surgical excision of basal cell carcinomas with an incomplete excision rate of 8% has shown that 65% of lesions were excised with <5mm histological clearance peripherally and 85% with <5mm deep clearance. These figures for 'normal tissue sacrifice' are not excessive when compared with those of 'tissue sparing' Mohs' micrographic surgery in which the operator may take a margin of several millimetres of normal tissue in the initial 'slice', or in the subsequent 'safety margin' beyond the eventual tumour free plane. However, peripheral margins did exceed 5mm in more than 30% of lesions of scalp, temple and forehead, and for these sites where even with loupe magnification the tumour edge could be difficult to define, either frozen section control or Mohs' technique, might with benefit be more often used in order to minimise normal tissue sacrifice.
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Affiliation(s)
- R W Griffiths
- Department of Reconstructive Plastic Surgery, Northern General Hospital, Sheffield Teaching Hospitals Trust, Herries Road, Sheffield S5 7AU, UK.
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Heenan PJ. Histopathologic excision margin affects local recurrence rate: Analysis of 2681 patients with melanoma < or = 2 mm thick. Ann Surg 2006; 243:569; author reply 569-570. [PMID: 16552212 PMCID: PMC1448958 DOI: 10.1097/01.sla.0000209150.32978.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clausen SP, Brady MS. Surgical margins in patients with cutaneous melanoma--assessing the adequacy of excision. Melanoma Res 2006; 15:539-42. [PMID: 16314740 DOI: 10.1097/00008390-200512000-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Appropriate margins of excision for melanoma have been well defined on the basis of prospective clinical trials. Various factors may result in a discrepancy between the intended clinical margin and the pathologic margin ex vivo, however, making it difficult to determine whether adequate excision margins have been obtained. We reviewed the clinical and pathologic margins in 220 patients evaluated at our institution for localized primary cutaneous melanoma between 1995 and 1997. We calculated the percentage difference between the intended clinical margins (C) and the measured pathologic margin (P). We then divided this number by the intended clinical margin to determine the percentage margin discrepancy. We asked whether the margin discrepancy varied as a function of the Breslow depth or anatomic site of the primary lesion, age or sex of the patient, or surgeon performing the excision. Student's t-test was used to determine whether the differences observed between the groups were significant. Pathologic margins were narrower than clinical margins in 59% (129/220) of specimens, equal in 12% (27/220) and wider in 29% (64/220). The median difference between the two measurements was 10% for the group. There was no significant impact of tumor or patient features on margin discrepancy. Margin discrepancy varied by surgeon, but this was not statistically significant. It can be concluded that, in most cases, the discrepancy between the pathologic and clinical margin of a wide excision specimen approximates to 10%. Larger differences should alert the clinician to the possibility of inadequate excision margins.
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Benvenuto-Andrade C, Oseitutu A, Agero AL, Marghoob AA. Cutaneous melanoma: surveillance of patients for recurrence and new primary melanomas. Dermatol Ther 2005; 18:423-35. [PMID: 16297018 DOI: 10.1111/j.1529-8019.2005.00049.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The increasing incidence and overall survival of patients diagnosed with melanoma of the skin are leading to an ever-increasing population of individuals with a personal history of melanoma. These patients are at risk for developing local, regional, or distant recurrence and are also at greater risk than the general population for developing a new primary melanoma. This article presents the rational for implementing surveillance strategies for patients with a history of melanoma.
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