Excision Of Melanoma Research Articles

The Potential Efficacy of β-Blockers on Melanoma Survival: A Narrative Review

Melanoma is a common tumor accounting for around 3–5% of all cutaneous malignancies with worldwide increasing incidence. It is still associated with significant mortality despite the breakthrough of new innovative therapies within the last decade. A wide variety of treatment modalities is currently used for the management of melanoma, ranging from surgical excision of primary melanoma to adju-vant and palliative treatment with target molecules, including BRAF and MEK inhibitors, and immune checkpoint inhibitors. β-blockers have recently demonstrated in preclinical and clinical studies to reduce recurrence and to correlate with better overall survival in meta-static melanoma as an additional supportive treatment option, owing to their anti-tumor potential. Further investigation regarding their efficacy and safety profile is needed, since there are only few studies in the literature on this topic. Our aim is to evaluate the role and current status of β-blockers in melanoma management. The literature research includes peer-reviewed articles (clinical trials or scien-tific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included. J Drugs Dermatol. 20(4):380-383. doi:10.36849/JDD.5673

Clinical and Histopathological Features of Corneal Primary Acquired Melanosis and Melanoma

Aim: The aim of this study is to describe the clinical and pathologic features of corneal primary acquired melanosis (PAM) and melanoma. Methods: We describe 3 cases in total: two cases of corneal melanomas and 1 case of corneal PAM. The eyes were processed routinely for histopathological examination. Clinical histories, treatments, and outcomes were reviewed. Results: Corneal melanomas arose from recurrence of conjunctival melanoma or conjunctival PAM at the limbus. One patient had a recurrence after excision of a limbal melanoma, another had a de novo corneal melanoma, and the last patient had corneal PAM in the setting of conjunctival PAM with atypia. All lesions were excised with adjuvant alcohol debridement and cryotherapy with no recurrence ranging from 1 week to 8 years. Conclusions: Corneal melanomas arise at the limbus from corneal PAM or conjunctival atypia. They can appear after excisional removal of a conjunctival melanoma. Surgical excision with alcohol debridement and adjuvant cryotherapy is successful.

Impact of the time interval between primary melanoma excision and sentinel node biopsy: A systematic review and meta-analysis

Obtaining a sentinel lymph node biopsy (SLNB) specimen is a standard staging procedure in the management of cutaneous melanoma. However, there is no consensus on the safe time interval between the primary melanoma biopsy procedure and the SLNB procedure. We evaluated the association between time from biopsy to SLNB and patients' outcomes for melanoma. We performed this systematic review and meta-analysis based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six retrospective studies were included. Nine thousand seven hundred five patients were identified, of which 4383 underwent a SNLB procedure at a time interval defined as early and 4574 at an interval defined as late. A combined hazard ratio of 1.25 (95% confidence interval [CI] 0.92-1.68) was determined, and there was high heterogeneity (I2=83%; P=.002) of the SLNB time interval on melanoma-specific survival. The combined HR for disease-free survival was 1.05 (95% CI 0.95-1.15), with low heterogeneity (I2=9%; P=.36). Regarding overall survival, a combined HR of 1.25 (95% CI 0.92-1.70) was found, with low heterogeneity (I2=37%; P=.2). There is heterogeneity between some studies. There are no significant differences in patient outcome between a short interval versus a long interval between the primary biopsy procedure and obtaining a SNLB specimen.

Surgical Excision of Perirectal Melanoma in the Horse. 3 Cases

Equine melanoma is one of the most common skin neoplasms encountered in equine practice. Surgical excision of melanocytic tumors is a viable treatment option and is considered to be locally curative. In the literature, information regarding surgical removal and long-term outcome of perirectal melanomas is limited. A total of three cases were included in this report, all presented with large perirectal melanomas, infiltrating the retroperitoneal musculature, leading to extra-luminal obstruction of the rectum. Horses were showing signs of dyschezia and tenesmus, secondary to rectal fecal impaction. Rectal palpation and transrectal ultrasonography aided in assessing the depth and size of the masses, as well as tumor invasion into the rectal wall. Tumor biopsy by fine needle aspiration was used to confirm the diagnosis. All horses underwent surgical excision of the masses to permanently alleviate clinical signs. In one horse, complete incision and reconstruction of the rectal wall was necessary in order to excise the whole tumor. Although surgery was successful in all three horses, one of them had to be euthanized 5 days after surgery, as clinical signs persisted. The aim of this report was to extensively describe the surgical approach, pre-operative considerations and postsurgical complications associated with surgical excision of perirectal melanoma in the horse.

Cost-Effectiveness of Mohs Micrographic Surgery Versus Standard Surgical Excision for Invasive Melanoma of the Trunk and Extremity

Cost-Effectiveness of Mohs Micrographic Surgery Versus Standard Surgical Excision for Invasive Melanoma of the Trunk and Extremity

Influence of plastic surgery for melanoma on progression-free survival in patients with skin melanoma according to the degree of tumor lymphoid infiltration

The aim of the study was to analyze the effect of plastic methods for closing the defect after excision of primary skin melanoma according to the degree of lymphoid infiltration of the tumor.
 Material and methods. Patients with primary skin melanoma (SM) treated in 2013 (n = 337) were studied; these patients were randomized into 2 groups using the method of blind selection to the main (n = 182). In these groups, the tumor removal operation in patients ended with plastic tissue defect and the group comparisons (n = 155) (after removal of the tumor, simple linear wound closure was performed).
 Results. It was found that pronounced lymphoid tumor infiltration in patients with primary skin melanoma as a predictor of a favorable prognosis (in terms of the occurrence of locoregional recurrence) is realized in patients with plastic defect replacement significantly 2 times more often than in patients without plastic surgery in the period from 12 to 60 months of observation.
 Discussion. The dependence of the occurrence of locoregional relapses in patients on lymphoid infiltration of the tumor and the performance of plastic surgery was revealed. In general, all patients who underwent plastic surgery have an advantage in terms of the occurrence of locoregional relapses in the long term for a period of up to 5 years by 12.5%. In patients with severe lymphoid infiltration and plastic surgery, locoregional relapses occur almost 2 times less often than in patients without plastic surgery, starting from a follow-up period of 1236 months by 20.6% (22.9% and 43.5%, respectively; p = 0.008), and in the period from 36 to 60 months of observation by 24.7% (25.3% and 50.0%, respectively; p = 0.002).
 Conclusion. The use of plastic techniques for closing a wound defect in patients with skin melanoma with pronounced lymphoid tumor infiltration reduces the risk of gross scarring and halves the risk of locoregional metastasis as compared to linear suturing of the postoperative defect.

3D wide-field multispectral photoacoustic imaging of human melanomas in vivo: a pilot study.

The Breslow depth is an important parameter to determine the excision margin and prognosis of melanoma. However, it is difficult to accurately determine the actual Breslow depth before surgery using the existing ocular micrometer and biopsy technique. To evaluate the use of 3D wide-field multispectral photoacoustic imaging to non-invasively measure depth and outline the boundary of melanomas for optimal surgical margin selection. Six melanoma patients were examined in vivo using the 3D multispectral photoacoustic imaging system. For five cases of melanomas (one in situ, three nodular, and one acral lentiginous type melanoma), the spectrally unmixed photoacoustic depths were calculated and compared against histopathological depths. Spectrally unmixed photoacoustic depths and histopathological depths match well within a mean absolute error of 0.36mm. In particular, the measured minimum and maximum depths in the in situ and nodular type of melanoma were 0.6 and 9.1mm, respectively. In the 3D photoacoustic image of one metastatic melanoma, feeding vessels were visualized in the melanoma, suggesting the neovascularization around the tumour. The 3D multispectral photoacoustic imaging not only provides well-measured depth and sizes of various types of melanomas, it also visualizes the metastatic type of melanoma. Obtaining accurate depth and boundary information of melanoma before surgery would play a useful role in the complete excision of melanoma during surgery.

Dermatologic surgery during the COVID-19 pandemic: Experience of a large academic center

Dermatologic surgery during the COVID-19 pandemic: Experience of a large academic center

13943 Factors influencing rates of complete excision of basal cell carcinomas and melanomas

Skin cancer, composed of both melanoma and nonmelanoma skin cancer (NMSC), can be treated with myriad modalities, including surgical excision. The primary end point for surgical excision of melanoma-in-situs (MIS) and NMSC is tumor clearance rate, determined postoperatively by the presence of tumor-free resection margins in the excised sample. This study explored which factors impacted the success of a MIS or NMSC excision. We conducted a retrospective study of 5800 standard excisions of MIS and basal cell carcinomas (BCC) performed by dermatologists, general surgeons, otolaryngologists, and plastic surgeons from 13 different Kaiser Permanente centers.

1101P Near real-time intraoperative melanoma diagnosis using deep neural networks

Intraoperative diagnosis is essential for providing safe and effective care during staged melanoma resections. The existing workflow for intraoperative diagnosis based on H&E staining of processed tissue is time-, resource-, and labor-intensive. Moreover, interpretation of intraoperative histologic images is dependent on a pathology workforce that is contracting and unevenly distributed across the centers where melanoma excisions are performed worldwide.

Surgical Reconstruction following Wide Local Excision of Malignant Melanoma of the Scalp.

Background:Scalp reconstruction in cases of melanoma excision can be challenging due to specific functional and aesthetic outcome requirements. Reconstructive techniques reported in the literature were reviewed to establish whether a surgical algorithm for the management of melanoma of the scalp may be deduced.Methods:A literature search was conducted to evaluate reconstructive strategies after melanoma wide local excision of the scalp according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Inclusion criteria were English language, diagnosis of melanoma of the scalp, and the presence of the following data: characteristics of the residual defect (width and depth), type of reconstruction, follow-up, and surgical outcome.Results:Six hundred twenty-five records were identified after excluding the duplicates; 48 full-text articles were assessed for eligibility, and 17 records were selected for inclusion. A total of 39 patients were included in the review. The majority of patients (n = 20) underwent skin grafting subsequent to dermal regeneration template positioning. Local flaps (n = 10), free flaps (n = 7), skin grafting alone (n = 1), and dermal regeneration template positioning alone (n = 1) were less frequent.Conclusions:Numerous reconstructive strategies for the scalp are described in the literature. Melanoma patients present a greater variability in terms of general health conditions and social needs that must be taken into account while choosing the most suitable procedure.

MELALIB15 : étude observationnelle rétrospective de 383 mélanomes dépistés par des dermatologues libéraux

Early detection of melanoma constitutes a major challenge and is a common reason for dermatological consultations. There is no recent data on melanomas diagnosed in the private medical sector in France, nor on the circumstances of diagnosis. This was a retrospective observational study on records collating data on all new consecutive cases of melanoma diagnosed between January 2015 and June 2018, in the private sector only, by volunteer dermatologists belonging to the association for continuing medical education, "Dermatologie Paris XV". A data collection sheet was prepared on which to record information about the dermatologist, the patient, the main complaint, the characteristics of the melanoma, and the initial treatment given, using the computerized list provided by our dermatopathology offices. The study involved 383 cases of melanoma, 37% in situ and 63% invasive, which consisted chiefly of superficial spreading melanoma. The median age of the cohort was 61years and patients were predominantly female (58%). Follow-up of high-risk patients and complete routine examination (in those consulting for another reason) resulted in direct detection by a dermatologist of 202of the 383melanomas (52.7%); these melanomas had a lower median Breslow index than the rest of the cohort and were thin in the main. When patients consulted for a suspect lesion (139cases), the lesion had been identified mostly by either the patient or by a relative (61% of cases). The decision to consult was made chiefly by the patients themselves, and the Breslow index was thicker. An initial consultation for nevus screening resulted in diagnosis of 42melanomas, i.e. only 11% of the cohort. Dermoscopy was performed by 92% of the dermatologists participating in the study. Melanoma excision was performed in the office by the practitioner in 75% of cases, and management was validated at multidisciplinary meetings in 65% of cases. In terms of French primary care, dermatologists in private practice play a key role in ensuring early detection and initial management of melanoma.

Leser-Trélat sign as a rare manifestation of cutaneous melanoma.

Leser-Trélat Sign (LTS) is a rare paraneoplastic syndrome characterized by the sudden eruption of multiple seborrheic keratoses in patients with internal malignancy, commonly localized in the gastrointestinal tract. We report an 80-year-old female patient showing a rapid increase in the number and size of seborrheic keratosis associated with the diagnosis of a cutaneous nodular melanoma (Breslow thickness: 4.5 mm) located on the right flank. After the excision of melanoma, subsequent staging procedures resulted negative, moreover no evidence of melanoma recurrence and no changes of the seborrheic keratoses was detected after a follow-up of 52 months. Although the association between melanoma and Leser Trelat sign is rare, an accurate skin examination with the aid of dermatoscopy searching for undiagnosed skin cancers, should be suggested in patient with sudden eruption of keratosis seborrheic to early diagnose and treat a possible melanoma.

Anxiety and depression after diagnosis of high-risk primary cutaneous melanoma: a 4-year longitudinal study.

To quantify the prevalence of anxiety or depression (overall; melanoma-related) among people with high-risk primary melanoma, their related use of mental health services and medications, and factors associated with persistent new-onset symptoms across 4years post-diagnosis. A longitudinal study of 675 patients newly diagnosed with tumor-stage 1b-4b melanoma. Participants completed the Hospital Anxiety and Depression Scale and answered questions about fear of cancer recurrence, use of medication, and support, serially over 4years. We identified anxiety and depression trajectories with group-based trajectories models and factors associated with persistent symptoms with logistic regression. At diagnosis, 93 participants (14%) had melanoma-related anxiety or depression, and 136 (20%) were affected by anxiety and/or depression unrelated to melanoma. After 6months, no more than 27 (5%) reported melanoma-related anxiety or depression at any time, while the point prevalence of anxiety and depression unrelated to melanoma was unchanged (16-21%) among the disease-free. Of 272 participants reporting clinical symptoms of any cause, 34% were taking medication and/or seeing a psychologist or psychiatrist. Of the participants, 11% (n = 59) had new-onset symptoms that persisted; these participants were more likely aged < 70. Melanoma-related anxiety or depression quickly resolves in high-risk primary melanoma patients after melanoma excision, while prevalence of anxiety or depression from other sources remains constant among the disease-free. However, one-in-ten develop new anxiety or depression symptoms (one-in-twenty melanoma-related) that persist. Chronic stress has been linked to melanoma progression. Survivors with anxiety and depression should be treated early to improve patient and, potentially, disease outcomes.

Reconstruction of Medial Malleolar Defect Using Posterior Tibial Artery Perforator Based Deep Fascial Flap after Malignant Melanoma Ablation

The soft tissue structure near the medial malleolus is an area where the bone is covered only with thin skin and subcutaneous tissue without structures like ligaments or tendons. In addition to the above anatomical features, wearing normal footwear should be considered when reconstructing the soft tissues in these areas. Therefore, it may be desirable to restore the original thickness of the soft tissue when performing a reconstruction. The authors reconstructed defects on the medial malleolus of a 50-year-old woman, after wide excision of a malignant melanoma, using only a deep fascial flap based on the posterior tibial artery-based perforator. This technique is thought to be a good option for reconstructing soft tissue defects in this area.

Machine learning models to predict the response to anti-cancer therapy in metastatic melanoma patients.

e14071 Background: Machine learning methods are new artificial intelligence tools with promising applications in healthcare. We developed and validated 4 machine learning models to predict the response to immunotherapy and targeted therapy in stage IIIc or IV melanoma patients. Methods: This work was conducted on data from 10 centers participating in the French network for Research and Clinical Investigation on Melanoma (RIC-Mel), launched in 2012. Thus, 935 patients, corresponding to 1978 systemic treatments have been extracted from RIC-Mel database. The following data were considered: age, sex, Breslow, melanoma type, ulceration, spontaneous regression, mitotic index, number of invaded lymph nodes, extracapsular extension, mutational status, melanoma stage, number of metastasis sites, lines of treatments, and time between first melanoma excision and metastatic relapse. Treatment response: complete response, partial response, stable disease, defined as class 1 and progressive disease as class 2. We split this cohort/database into a training set (80%) and test set (20%). The algorithm performances were evaluated on the test set by the percentage of treatments correctly classified in class 1 or 2. Four machine learning algorithms (linear model, random forest, XGBoost and LightGBM) were compared in terms of performance and interpretation for both types of treatments. Results: The accuracies of the best models for immunotherapy (LightGBM) and targeted therapy (random forest) were respectively 66% and 65%. The most significant variables for building the models were respectively: stage (IIIc or IV), response to previous treatments lines, age, number of metastasis sites and time between first melanoma excision and metastatic relapse. Conclusions: We present here the first machine learning models to predict the response to immunotherapy and targeted therapy in stage IIIc or IV melanoma patients. The most predictive variables are coherent with the literature. Future development will include data from 18FDG-PET/CT imaging and other predictive markers recently identified, as circulating DNA to improve the models performance.

SAT-239 Combination of Immune Check Point Inhibitors Causing Hypopituitarism

Introduction: Immune Check Point inhibitors (ICI) have been associated with immune related adverse events including a wide array of Endocrinopathies particularly when a combination of ICIs is used. We present a case of Hypopituitarism secondary to CTLA-4 inhibitor Iplimumab and PD-1 inhibitor Pembrulizumab in a patient with Vulvar Melanoma.Case Description: 49-year-old female with past medical history of Type 2 Diabetes and Vulvar Melanoma presented with nausea, vomiting and fatigue. The patient had surgical excision of Vulvular Melanoma and had been on chemotherapy with Pembrolizumab and Ipilimumab for 1 month. She was found to be hypotensive in the ER, but blood pressure improved after fluid resuscitation. Her blood sugar levels were 76 MG/DL. She denied using any insulin in the last 24 hours. AM Cortisol was <1 UG/ML. TSH was 0.205 UIU/ML with free T4 at 0.74 NG/DL. FSH was 2.5 MIU/ML. LH was 0.5 MIU/ML. Prolactin was 90.2 NG/ML. ACTH was less than 9 PG/ML. MRI of the brain showed mildly enlarged pituitary gland with suprasellar extension, measuring 10.5 mm in craniocaudal height and normal homogeneous enhancement. A diagnosis of Hypopituitarism secondary Ipilimumab and Pembrolizumab was made. She was started on steroids and thyroid replacement. The patient’s symptoms resolved, and she was discharged home in a stable condition with outpatient Endocrinology follow up.Discussion: Immune checkpoint inhibitors (ICI) includes PD1(Programmed cell death receptor 1) inhibitors like Pembrolizumab and CTLA-4 (Cytotoxic T Lymphocyte Antigen-4) inhibitors like Ipilimumab. CTLA-4 inhibitors have more frequently been associated with Hypophysitis leading to particularly ACTH and TSH deficiencies and causing secondary adrenal insufficiency and secondary hypothyroidism. Posterior Pituitary involvement is less common. MRI usually shows mild to moderate enlargement of the pituitary gland. ICI therapy usually does not need to be stopped. Patients commonly require long term glucocorticoid and thyroid replacement.

Late Metastases from a Thin Primary Cutaneous Malignant Melanoma

Cutaneous malignant melanoma is the third most common type of skin cancer, and its incidence has been rising. Its mortality rate is considerable, due to an aggressive phenotype and great ability of dissemination, mainly in the first years of follow- -up. Late recurrences, those presenting more than 10 years after diagnosis, are rare. The main prognostic factor of cutaneous malignant melanoma is tumor thickness, which also guides management. Thin tumors often have a good prognosis. We report a case of a 66-year-old woman with a history of excision of a thin primary cutaneous malignant melanoma of the dorsum, presenting 16 years later with an unexpected, rapidly progressing and lethal recurrence.

Comparison of staged excision and Mohs micrographic surgery with and without MART-1 immunostains for surgical treatment of melanoma of the head, neck, and special sites: A retrospective cohort study

To the Editor: As the incidence of melanoma in situ (MIS)/invasive melanoma (IM) of the head, neck, and special sites (HNS) has increased in the last decade, so has the use of comprehensive margin assessment (CMA) techniques, including Mohs micrographic surgery (MMS), with an added trend of increased use of immunohistochemistry special stains such as MART-1. 1 Lee M.P. Sobanko J.F. Shin T.M. et al. Evolution of excisional surgery practices for melanoma in the United States. JAMA Dermatol. 2019; 155: 1244-1251 Crossref Scopus (10) Google Scholar This is not surprising considering that more recent studies show improved local recurrence and overall survival outcomes with MMS compared to wide local excision, along with a distinct advantage in areas of cosmetic and functional importance. 2 Sharma A.N. Foulad D.P. Doan L. Lee P.K. Mesinkovska N.A. Mohs surgery for the treatment of lentigo maligna and lentigo maligna melanoma—a systematic review. J Dermatolog Treat. 2020; ([E-pub ahead of print]): 1-7https://doi.org/10.1080/09546634.2019.1690624 Crossref PubMed Scopus (6) Google Scholar , 3 Demer A.D. Vance K.K. Cheraghi N. Reich H.C. Lee P.K. Benefit of Mohs micrographic surgery over wide local excision for melanoma of the head and neck: a rational approach to treatment. Dermatol Surg. 2019; 45: 381-389 Crossref PubMed Scopus (7) Google Scholar , 4 Cheraghlou S. Christensen S.R. Agogo G.O. Girardi M. Comparison of survival after Mohs micrographic surgery vs wide margin excision for early-stage invasive melanoma. JAMA Dermatol. 2019; 155: 1252-1259 Crossref Scopus (12) Google Scholar , 5 Hanson J. Demer A. Liszewski W. Forman N. Maher I. Improved overall survival of melanoma of the head and neck treated with Mohs micrographic surgery versus wide local excision. J Am Acad Dermatol. 2020; 82: 149-155 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar This study evaluates additional outcome measures of CMA surgical approaches for treatment of MIS/IM.

Management of conjunctival melanoma with local excision and adjuvant brachytherapy.

To evaluate the management of conjunctival melanoma with local excision and adjuvant brachytherapy. Data of all patients who received local excision and adjuvant brachytherapy for conjunctival melanoma between 1999 and 2016 in a Dutch national referral centre were reviewed. A protocol with Sr-90 was used until 2012, a protocol with Ru-106 was used hereafter. Local recurrence, metastasis, survival, visual acuity and treatment complications were assessed. A total of 58 patients was identified: 32 patients were treated with Sr-90 and 26 with Ru-106. Mean follow-up time was 97.3 months (143.1 months after Sr-90, and 40.2 months after Ru-106). All lesions were epibulbar, the median tumour thickness was 0.9 mm. Local recurrence occurred in 13/58 cases (22%), with a 5-year recurrence rate of 21%. Local recurrence occurred equally often in both protocols, with 5-year recurrence rates of 19% (Sr-90) versus 23% (Ru-106) (p = 0.68). Metastasis developed in 3/58 cases (5%), with 2 cases after Sr-90, and 1 after Ru-106 (p = 1.00). The most reported complications were pain (29%), dry eyes (21%), symblepharon (9%), ptosis (12%) and cataract (9%). No severe corneal or scleral complications were observed. Median visual acuity was 1.00 pre-surgery, at the end of follow-up this was 1.00(Sr-90) and 0.95 (Ru-106). Local excision with adjuvant brachytherapy provides good tumour control with excellent visual outcome and mild side effects in patients with limited conjunctival melanoma. Results after Sr-90 or Ru-106 were comparable; a choice for either treatment may be based on experience of the clinician and availability of materials.