Multiple studies have shown a 5-mm surgical margin to be inadequate for excision of melanoma in situ. Some have suggested that a wider margin is needed only for the lentigo maligna subtype.
To ...compare subclinical extension of lentigo maligna with that of melanoma in situ. The secondary objective was to investigate the effect of other factors on extent of subclinical extension.
A prospectively collected series of noninvasive melanomas was studied. Original pathology reports were used to identify lentigo maligna and compare data for that subtype with data for the remaining melanomas in situ.
A total of 1506 lentigo maligna cases and 829 melanomas in situ were included. To obtain a 97% clearance rate, both lentigo maligna and melanoma in situ required a 12-mm margin on the head and neck and a 9-mm margin on the trunk and extremities. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6-mm margin (P = .12). Local recurrence was identified in 0.26% (5 facial, 1 scalp, and 1 acral), with a mean follow-up time of 5.7 years.
Margins less than 6 mm were not studied. The use of lentigo maligna diagnosis was not used by all dermatopathologists consistently. The degree of surrounding photodamage was not assessed.
Subclinical extension of lentigo maligna and melanoma in situ are similar. Standard surgical excision of all melanoma in situ subtypes, including lentigo maligna, should include at least 9 mm of normal-appearing skin, which is similar to the amount recommended for early invasive melanoma. Lesions on the head and neck or those with a diameter greater than 1 cm may require even wider margins and are best treated with Mohs micrographic surgery. The perception that lentigo maligna has wider subclinical extension may be related to its frequent location on the head and neck, where photodamage can camouflage the clinical border.
The efficacy of Mohs micrographic surgery (MMS) in treating cutaneous squamous cell carcinoma has been demonstrated. The cost effectiveness of MMS has rarely been studied to support the perceived ...higher cost.
Perform a cost-effectiveness analysis to determine whether MMS is cost effective over wide local excision (WLE) for Brigham and Women's Hospital tumor stage T2a cutaneous squamous cell carcinoma over a 5-year period.
A Markov model with a 5-year time horizon was created using variables from published data. Costs in United States dollars and quality-adjusted life-years (QALY) were calculated.
MMS was $333.83 less expensive ($4365.57 95% CI, $3664.68-$6901.66 vs $4699.41 95% CI, $3782.94-$10,019.31) than WLE. MMS gained 2.22 weeks of perfect health (3.776 QALY 95% CI, 3.774-3.777 for MMS and 3.733 QALY 95% CI, 3.728-3.777) over 5 years. The incremental cost-effectiveness ratio was -$7,822.19. MMS had a 99.9% probability of being more cost effective than WLE. Annualized savings of choosing MMS over WLE would be $200 million and over 25,000 QALY. MMS could cost 3.1 times its current rate and remain cost effective.
Relied on data from external retrospective sources.
MMS is less costly and more effective than WLE and should be strongly considered for stage T2a cSCC, given improvements in costs and QALY.
Extramammary Paget disease is an intraepidermal adenocarcinoma, most often limited to the epidermis, with typical cases affecting genital skin. When limited to the epidermis, primary extramammary ...Paget disease is not life-threatening, but invasive disease may portend a poor prognosis. Surgical excision remains the mainstay of treatment of extramammary Paget disease, and Mohs micrographic surgery is the surgical treatment of choice. Alternative treatments include topical 5-fluorouracil and imiquimod, photodynamic therapy, laser vaporization, chemotherapy, and radiation therapy but data are limited. Implementation of cytokeratin 7 immunostain has increased the ability to detect extramammary Paget disease on frozen section.
Surgical margins for melanoma in situ Kunishige, Joy H., MD; Brodland, David G., MD; Zitelli, John A., MD
Journal of the American Academy of Dermatology,
03/2012, Letnik:
66, Številka:
3
Journal Article
Recenzirano
Background A controversy in the treatment of melanoma in situ is the required width of surgical margin. The currently accepted 5-mm margin is based on a 1992 consensus opinion, despite data since ...then showing this is inadequate. Objective We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ. Methods A prospectively collected series of 1072 patients with 1120 melanoma in situs was studied. All lesions were excised by Mohs micrographic surgery with frozen-section examination of the margin. The minimal surgical margin was 6 mm, and the total margin was calculated by adding an additional 3 mm for each subsequent stage required. The minimum surgical margin that would successfully remove 97% of all tumors was calculated. Local recurrence was also tabulated. Results In all, 86% of melanoma in situs were successfully excised with a 6-mm margin; 9 mm removed 98.9% of melanoma in situs. The superiority of 9-mm to 6-mm margins was significant ( P < .001). Gender, location, and diameter did not affect results. Recurrence rate for this set of patients treated with Mohs micrographic surgery was 0.3% (n = 3). Limitations Margins less than 6 mm were not studied. This is a referral center for melanoma in situ and 10% of tumors were previously treated before presentation to our clinic. Conclusion The frequently recommended 5-mm margin for melanoma is inadequate. Standard surgical excision of melanoma in situ should include 9 mm of normal-appearing skin, similar to that recommended for early invasive melanoma.
The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world.
The purpose of this article is to expose the ...value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines.
This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery.
The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma.
Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression.
Background Evaluation of the entire surgical margin results in high rates of complete excision, low local recurrence rates, and maximal tissue conservation. Although well recognized for melanoma of ...the head and neck, few studies have focused exclusively on the trunk and proximal extremities. Objective We sought to evaluate the efficacy of Mohs micrographic surgery for melanoma in situ (MIS) of the trunk and proximal extremities, and determine adequate excision margins for MIS when total margin evaluation is not used. Methods Long-term outcomes in 882 cases of MIS treated with Mohs micrographic surgery were analyzed and compared with historical controls. Rates of complete excision were determined for increasing surgical margin intervals. Results One local recurrence occurred in our cohort (0.1%). Only 83% of MIS were excised with a 6-mm margin. Margins of 9 mm were needed to excise 97% of MIS, statistically equivalent to thin melanomas. Limitations We used a nonrandomized, single-institution, retrospective design. Conclusion Mohs micrographic surgery may cure the 17% of MIS that exceed traditional excision margins of 5 mm and is a valuable option for these patients. Surgical margins of at least 0.9 cm should be considered for MIS of the trunk and extremities when total margin evaluation is not used.
Single-institution studies show that frozen section Mohs micrographic surgery (MMS) is an effective treatment modality for cutaneous melanoma, but no multi-institutional studies have been published.
...To characterize the use of MMS in the treatment of melanoma at 3 academic and 8 private practices throughout the United States, to recommend excision margins when 100% histologic margin evaluation is not used, and to compare actual costs of tumor removal with MMS vs standard surgical excision.
Prospective, multicenter, cohort study of 562 melanomas treated with MMS with melanoma antigen recognized by T cells 1 immunostaining.
Primary trunk and extremity melanomas (noninvasive and invasive melanoma) achieved histologically negative margins in 97% of tumors with 10-mm margins, whereas 12-mm margins were necessary to achieve histologically negative margins in 97% of head and neck melanomas. Overall average cost per tumor treated was $1328.46.
Nonrandomized and noncontrolled study.
MMS with melanoma antigen recognized by T cells 1 immunostaining safely provides tissue conservation and same-day reconstruction of histologically verified tumor-free margins in a convenient, single-day procedure. When comprehensive margin evaluation is not used, initial surgical margins of at least 10 mm for primary trunk/extremity and 12 mm for head/neck melanomas should be used to achieve histologically negative margins 97% of the time.
The ear is a complex and intricate feature of the human face in which reconstruction after oncologic excision is predicated on the complete removal of skin cancer. Reconstructive strategies are based ...on an understanding of the hierarchy of aesthetic concerns for the ear.
Review of the reconstructive strategies for reconstruction of the ear.
The 2 most important characteristics of the ear are its symmetrical projection from the head and the smooth curvature of the helix. With this in mind, the reconstructive plan must begin from the "inside out" with assessment of the cartilaginous frameworks followed by the cutaneous defect.
A reconstructive strategy that takes into account the hierarchy of aesthetic concerns for defects of the ear will optimize cosmesis, function, and patient's satisfaction.
Outcomes for patients with cutaneous squamous cell carcinoma (CSCC) treated with Mohs micrographic surgery (MS) in the United States have never been prospectively defined. Risk factors as they relate ...to outcomes are primarily derived from single-institution, retrospective data without regard for treatment modality. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital T staging systems have not been prospectively validated.
To prospectively quantify outcomes by T stage and verify historically high-risk features as they pertain to outcomes in MS-treated CSCC.
A 5-year, prospective, multicenter analysis of patients undergoing MS for invasive CSCC was conducted.
The study enrolled 647 patients with 745 tumors. The 5-year local recurrence (LR)-free survival, nodal metastasis (NM)-free survival, and disease-specific survival were 99.3%, 99.2%, and 99.4%, respectively. Both staging systems were predictive of NM, disease-specific death, and all-cause death; neither was predictive of LR. Although Breslow depth was statistically associated with LR, NM, and disease-specific death, incidental perineural invasion was not.
The Brigham and Women's Hospital and the American Joint Committee on Cancer Staging Manual, Eighth Edition T staging systems were published after study enrollment, therefore T stages were retrospectively applied using the prospectively collected data.
MS is a highly effective treatment for CSCC and may mitigate factors typically considered high risk. Uniform reporting of Breslow depth should be considered in CSCC. The American Joint Committee on Cancer Staging Manual, Eighth Edition, and the Brigham and Women's Hospital staging system are useful prognosticators but are not predictive of LR after MS.
Microscopic evaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few ...studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximal portion of the extremities.
To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival.
Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes.
True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75 months and were not associated with tumor depth. The rate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values.
We used a nonrandomized, single institution, retrospective design.
Mohs micrographic surgery of primary cutaneous invasive melanoma on the trunk and proximal portion of the extremities resulted in local control of 99.86% of tumors and an overall disease-specific death rate superior to that of wide local excision.
