Surgery For Melanoma Research Articles

Productivity in relation to organization of a surgical department: a retrospective observational study

BackgroundResponsible and efficient resource utilization are important factors in healthcare. The aim of this study was to investigate how total case time differs between two differently organized surgical departments.MethodsThis is a retrospective observational study of a cohort of patients undergoing elective surgery for breast cancer or malignant melanoma in a university hospital setting in Sweden. All patients were operated on by the same set of surgeons but in two different surgical departments: a general surgery (GS) and a cardiothoracic (CT) surgery department. Patients were selected to the two departments from a waiting list in the order of referral for surgery. The effect of being operated on at the CT department compared to the GS department was estimated by linear regression.ResultsThe final study cohort comprised 349 patients in the GS department and 177 patients in the CT department. Both groups were similar regarding surgical procedures, American Society of Anesthesiologists’ score, body mass index, age, sex, and the skill level of the operating surgeon. These covariates were included in the linear regression model. The total case time, defined by the Procedural Time Glossary as room set-up start to room clean-up finish, was significantly shorter for the patients who underwent a surgical procedure at the CT department compared to the GS department, even after adjusting for the background characteristics of the patients and surgeon. After adjusting for the selected covariates, the average difference in total case time between the two departments was − 30.67 min (p = 0.001).ConclusionsA significantly shorter total case time was measured for operations in the CT department. Plausible explanations may be more beneficial organizational factors, such as staffing ratio, skill mix in the operating room team, and working behavioral aspects regarding resource utilization.

Fluorescence Imaging Using Methylene Blue Sentinel Lymph Node Biopsy in Melanoma.

Fluorescence imaging of sentinel node biopsy in melanoma is a novel method. Both indocyanine green (ICG) and methylene blue (MB) have fluorescent properties. The aim of this study was to present, for the first time in a clinical series of patients, the possible usage of MB as a fluorescent dye for sentinel node biopsy during surgery for melanoma. Twenty patients with skin melanoma, who were candidates for sentinel node biopsy were enrolled in our study. All patients underwent simultaneous use of standard nanocolloid and blue dye. Transcutaneous visualization of the sentinel node, visualization of lymphatic channels as well as sentinel node fluorescent visualization were all measured. We also performed calculations of Signal to Background ratios (SBR). In 15% (3/20) of patients, the fluorescent sentinel node was visible through the skin. The median SBR for the sentinel node visualization by fluorescence was 3.15 (range, 2.7-3.5). Lymphatic channels were visible in lymphatic tissue via fluorescence before visualization by the naked eye in 4 patients (20%). The median SBR ratio was 3.69 (range, 2.7-4.2). Sentinel nodes were visible by fluorescence in 13 cases (65%). The median SBR ratio was 2.49 (range, 1.5-5.7). No factors were found to be associated with fluorescent MB visualization of a sentinel node during biopsy. This is the first clinical study presenting the usefulness of fluorescent sentinel node biopsy in melanoma patients using MB as a fluorophore. Further studies are necessary to provide methods for its' clinical implementation.

Consideraciones prácticas sobre incisiones/extirpaciones óptimas en cirugía dermatológica con énfasis en la orientación de las incisiones y la cirugía del melanoma cutáneo primario

Dermatologic surgery has 2main objectives: 1) to guarantee surgical radicality; and 2) to achieve optimal aesthetic and functional results. These 2paradigms and their hierarchy must be considered when performing surgical procedures on the skin. Even the easiest intervention, the elliptical excision, presents some features that should be known to achieve such goals. One of these features is the incision orientation.The optimal incisions orientation is still matter of debate, especially because studies that compare the outcomes of performing incisions in different directions are lacking. However, some anatomical, clinical, and histological observations may point out why incising the skin in one orientation is better than another.Knowing the theory behind skin incisions/excisions become of outmost importance when dealing with primary cutaneous melanoma surgery. Especially if the melanocytic lesion is suspected to be an invasive melanoma and a sentinel lymph node biopsy will be required.

Mohs Micrographic Surgery for Melanoma: A Convincing Treatment Modality.

Mohs micrographic surgery (MMS) is the gold standard for treating keratinocyte carcinomas in specific locations or due to other tumor-specific factors, given its comprehensive margin assessment, tissue sparing, and high cure rate. The use of MMS for treating invasive melanoma with intraoperative immunostains is still a subject of debate. Herein, a literature review supports the following recommendations. In cosmetically or functionally demanding sites such as head, neck, hands, feet, and pretibial leg, we recommend MMS for MMIS and all thin melanomas measuring <0.8 mm Breslow depth. Additionally, on the head and neck, all superficial spreading and lentigo maligna melanoma (LMM) histologic subtypes <0.8 mm Breslow depth should be treated with MMS. We recommend using melanoma antigen recognized by T cells 1 (MART-1) immunostain intraoperatively given its high sensitivity. However, microphthalmia transcription factor (MITF) and Sry-related HMG-Box gene 10 (SOX10) are useful adjuncts for difficult cases.

Operative Complications of Posterior Uveal Melanoma Surgery.

Operative Complications of Posterior Uveal Melanoma Surgery.

Treatment of Excision Wound of Melanoma In Situ of the Trunk and Extremities with Zinc Chloride Solution

The majority of physicians treating melanoma in situ recommend a 5mm to 1cm margin with excision into the subcutaneous tissue extending between the superficial and the deep fat. There is always the potential for an unrecognized invasive component in a melanoma in situ, making aqueous zinc chloride solution an ideal agent to treat the excision wound of a melanoma in situ of the trunk and extremities. Zinc chloride solution penetrates deeply and widely, killing and fixing tissue when applied to the excision wound, facilitating the excision by allowing for a simple saucerized excision with a narrower and thinner margin while ensuring the treatment of any possible unrecognized invasive components. Zinc chloride has been used in a paste since 1835 to treat skin cancers and melanoma but unlike pastes zinc chloride in solution is recognized by the U.S. Food &amp; Drug Administration as a generally safe substance (Code of Federal Regulations Title 21 [Part 182]). The solution penetrates as deeply and widely and effectively as in the paste which Mohs described to be an inactive vehicle for the active ingredient, zinc chloride solution. Mohs reported a large significant survival benefit (p=0.003) for invasive melanoma using surgery combined with zinc chloride over conventional melanoma surgery. Zinc chloride solution without the paste is a new medicine effective as a surgical adjuvant in the treatment of the excision wound of a melanoma in situ of the trunk and extremities. Zinc chloride can be used as a surgical adjuvant for any melanoma, but melanoma in situ of the trunk and extremities is the logical starting point for a physician interested in using this adjuvant in the treatment of melanoma. Zinc chloride is very powerful and potentially scarring and should be used on the excision wound of a previously histologically diagnosed melanoma only.

Curative Intent Surgery of Oral Malignant Melanoma and Regional Lymph Node Biopsy Assessment in 25 Dogs: 2006-2017.

Medical records were searched for dogs that had received curative intent surgery for oral malignant melanoma and ipsilateral excisional regional lymph node biopsy. Twenty-seven dogs were operated on and 25 dogs of these dogs met the inclusion criteria of signalment, post-excision margin status, presence of metastasis for each biopsied lymphocentrum, survival time post-excision, presence of recurrence or metastasis at follow-up or at death/euthanasia, location of the primary tumor, and any postoperative adjuvant treatment. These 25 dogs had complete tumor excision with tumor-free margins and 19 (76%) had postoperative adjuvant therapy. Median survival time after excision for the dogs in this study was 335.5 days. Results of this study support previous work that documents prolonged survival time following complete excision of oral malignant melanoma with tumor-free surgical margins in dogs. Additionally, 4 dogs (16%) had histologically confirmed regional lymph node metastasis at the time of definitive surgery.

Commentary on Systematic Review of Technical Variations for "Mohs Micrographic Surgery for Melanoma".

Commentary on Systematic Review of Technical Variations for "Mohs Micrographic Surgery for Melanoma".

Melanoma Surgery in the Emerging Era of Effective Neoadjuvant Therapy

Melanoma Surgery in the Emerging Era of Effective Neoadjuvant Therapy

Outcomes of radical surgical resections for nonmetastatic anorectal melanomas: Experience from a tertiary care centre.

The outcome of radical surgery in nonmetastatic anorectal melanoma (AM) patients is studied infrequently. Here, we aimed to explore the stage-wise outcomes and the impact of radical resections in these patients. In this single-centre retrospective study, data of 154 eligible patients were recorded and analysed. Data were obtained from November 2010 to September 2019 with follow-up until November 2020. Overall survival (OS) and disease-free survival (DFS) was calculated by Kaplan Meir method and univariate analysis of prognostic factors by Cox regression. Of 154 patients, 110 were metastatic (stage III) and 44 were nonmetastatic (stage I:22, stage II:22) and underwent curative resections. Median follow-up was 48months (14-119months). A total of 39 patients underwenttotal mesorectal excisions (TME) and five transanal excision (TAE) were performed. Seven patients underwent extended resections. Stage I and II patients had 3- and 5-year OS of 40% and 36%; and DFS of 45% and 33.2%, respectively. Median OS and DFS were 31 and 24months, respectively. Stage II (node-positive) patients had better median OS compared to stage III (21 vs. 4months; p=0.000), and 54.5% patients had recurrences, most commonly both systemic and nodal (45.83%). Median OS of patients without recurrence was 34months. In this large surgical series of AMs, outcome in stage I and II patients was significantly better than stage III and patients with stage II disease can have acceptable oncological outcomes. Radical surgical resections with or without lymphadenectomy could be considered in these patients. The role of adjuvant systemic therapy and radiation needs to be explored as part of multimodality treatment.

Impact of adjuvant therapies following surgery for anal melanoma

BackgroundAnal melanoma is rare. Surgery is standard of care for non-metastatic disease. There are limited data supporting adjuvant therapy. We sought to examine the impact of adjuvant radiation, chemotherapy and immunotherapy on survival. MethodsThe National Cancer Database was queried. Factors associated with overall survival were examined by Kaplan-Meier and Cox proportional hazards analyses. Patients were grouped by treatment regimen. Results450 patients had complete treatment data: surgery alone (63.8%), surgery + radiation (14.9%), surgery + chemotherapy (7.6%), surgery + immunotherapy (9.6%) and non-surgical treatment (4.2%). Median survival was 27.2 months. Node-positive patients had worse survival than node-negative (22.4 vs. 36.8 months; p = 0.0002). Non-surgical treatment yielded worse survival than any surgery-inclusive regimen (10.4 vs. 27.8 months; p = 0.0002). No adjuvant modality conferred a survival advantage. By multivariate analysis, increasing age (HR/1 year = 1.02, p = 0.012) and node positivity (HR = 2.10, p = 0.0002) negatively impacted survival. ConclusionAdjuvant therapy for non-metastatic anal melanoma does not appear to influence survival.

Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma.

Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. To define variations in published techniques for MMS for melanoma. 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. 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. 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.

1337 A Regional Review of The Epidemiology and Pathological Characteristics of Malignant Melanoma in Northern Ireland (NI), And Correlation with Socio-Economic Status

Abstract Introduction The incidence of cutaneous malignant melanoma is increasing. Internationally, there is evidence of an association between melanoma incidence and higher socioeconomic status (SES). This study aims to assess the characteristics of patients with melanoma in NI, and correlate to SES. Method Retrospective review of electronic records for patients undergoing surgery for melanoma at the Northern Ireland Plastic Surgery Unit from August 2015 to March 2020. Patients were identified from theatre records and a prospectively collected sentinel lymph node database. The NI Multiple Deprivation Measure 2017 was used to measure SES. Results 440 patients were included (F = 54%, M = 46%). Mean age=63 (M = 67, F = 59). Mean Breslow Depth (BD) = 2.61mm (Range 0.17 – 27mm). Females had significantly thinner tumours at presentation (mean BD 2.16mm. vs 3.1mm in males, p = 0.001). In males the commonest sites were head and neck (36%) and back (23%). In females, the commonest sites were lower limb (42%) and upper limb (23%). There was a positive correlation between higher SES and increased incidence of melanoma (correlation coefficient (CC) 0.922), but this did not correlate with an increase in Breslow depth (CC -0.020). Conclusions This study provides important information on melanoma in NI, including gender and site variances. Females were more commonly affected and were a mean of 8 years younger than males at diagnosis but presented with significantly thinner tumours. Unlike the rest of the UK, the commonest site in males was the head and neck. Higher SES was related to higher incidence of melanoma but with presentation at an earlier stage of disease.

Broad-Spectrum Antibiotic Use and Disease Progression in Early-Stage Melanoma Patients: A Retrospective Cohort Study.

Simple SummaryWe conducted a retrospective cohort study to evaluate the association between broad-spectrum antibiotic use and disease progression in early-stage melanoma patients who underwent surgery. We used healthcare claims data (2008–2018) and identified individuals with melanoma diagnosis and surgery within 90 days of diagnosis. We studied the relationship between melanoma progression (a proxy measure created using cancer therapies, surgery, and metastasis) within 2 years of melanoma surgery and antibiotic use in three time windows separately: (i) 3 months prior to surgery, (ii) 1 month after surgery, and (iii) 3 months after surgery. We found that prescriptions for antibiotics in 3 months prior to surgery were not associated with melanoma progression; in contrast, antibiotic use in post-1- and post-3-months windows was associated with reduced risk of progression. Our study is exploratory and limited to early-stage melanoma patients with surgery.Animal studies and a few clinical studies have reported mixed findings on the association between antibiotics and cancer incidence. Antibiotics may inhibit tumor cell growth, but could also alter the gut-microbiome-modulated immune system and increase the risk of cancer. Studies that assess how antibiotics affect the progression of cancer are limited. We evaluated the association between broad-spectrum antibiotic use and melanoma progression. We conducted a retrospective cohort study using IQVIA PharMetrics® Plus data (2008–2018). We identified patients with malignant melanoma who underwent wide local excision or Mohs micrographic surgery within 90 days of first diagnosis. Surgery date was the index date. Patients were excluded if they had any other cancer diagnosis or autoimmune disorders in 1 year before the index date (“baseline”). Exposure to broad-spectrum antibiotics was identified in three time windows using three cohorts: 3 months prior to the index date, 1 month after the index date, and 3 months after the index date. The covariates were patients’ demographic and clinical characteristics identified in the 1-year baseline period. The patients were followed from the index date until cancer progression, loss of enrollment, or the end of 2 years after the index date. Progression was defined as: (i) any hospice care after surgery, (ii) a new round of treatment for melanoma (surgery, chemotherapy, immunotherapy, targeted therapy, or radiotherapy) 180 days after prior treatment, or (iii) a metastasis diagnosis or a diagnosis of a new nonmelanoma primary cancer at least 180 days after first melanoma diagnosis or prior treatment. A high-dimensional propensity score approach with inverse weighting was used to adjust for the patients’ baseline differences. Cox proportional hazard regression was used for estimating the association. The final samples included 3930, 3831, and 3587 patients (mean age: 56 years). Exposure to antibiotics was 16% in the prior-3-months, 22% in the post-1-month, and 22% in the post-3-months. In the pre-3-months analysis, 9% of the exposed group and 9% of the unexposed group had progressed. Antibiotic use was not associated with melanoma progression (HR: 0.81; 95% CI: 0.57–1.14). However, antibiotic use in subsequent 1 month and subsequent 3 months was associated with 31% reduction (HR: 0.69; 95% CI: 0.51–0.92) and 32% reduction (HR: 0.68; 95% CI: 0.51–0.91) in progression, respectively. In this cohort of patients with likely early-stage melanoma cancer, antibiotic use in 1 month and 3 months after melanoma surgery was associated with a lower risk of melanoma progression. Future studies are warranted to validate the findings.

General anaesthesia versus other types of anaesthesia in patients undergoing surgery for treatment of cutaneous melanoma: a systematic review and meta-analysis.

General and local anaesthetics alter tumour behaviour in experimental models. Objectives: To investigate the relationship between general anaesthesia and recurrence or survival in patients who received surgery for malignant melanoma. A meta-analysis was performed based on a comprehensive literature search. Controlled and observational studies of patients undergoing surgery for melanoma under general anaesthesia, compared with other types of anaesthesia, were included. The primary outcomes were overall survival and disease-free survival. The secondary outcomes included cancer-specific survival, cost analysis, and adverse events. Risk of bias was assessed. Individual study information was summarized. The meta-analysis was performed using a random-effects model. The GRADE approach was used to summarise the certainty of evidence. Eight studies were included (n = 5,832). The use of general anaesthesia was not associated with any statistical difference in overall survival (p = 0.087; 1 NRS; n= 104; very low certainty of evidence) or disease-free survival (HR: 1.266; 95%CI: 0.904-1.773; p = 0.169; 1 NRS; n = 281; very low certainty of evidence). However, general anaesthesia was associated with worse melanoma-specific survival (HR: 1.46; 95%CI: 1.22-1.68: p < 0.00001; 3 NRS; n = 4654; low certainty of evidence). Three studies reported increased intraoperative costs associated with the use of general anaesthesia (3 NRT; n = 513; very low certainty of evidence). No study adequately reported other primary or secondary outcomes. General anaesthesia may reduce melanoma-specific survival in patients undergoing surgery for treatment of cutaneous melanoma. We are uncertain whether general anaesthesia impacts the other reported outcomes.

Functional assessment of cancer therapy questionnaire for melanoma in the Serbian population: A factor analytic approach

The aim of this study was to examine the psychometric properties of the Functional Assessment Cancer Therapy—Melanoma (FACT-M) questionnaire in the Serbian language. The FACT-M was translated into Serbian using the standard methodology after obtaining the licence from the Functional Assessment of Chronic Illness Therapy (FACIT) translation project team. This version of FACT-M was distributed to a cohort of consecutive patients with histologically confirmed high-risk skin melanoma treated at the tertiary referral center. To examine construct validity of the FACT-M in Serbian, we performed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The FACT-General (FACT-G) did not fit the original 4-domain structure. Instead, we accepted a 7-domain structure which, aside from physical, emotional, social and functional well-being, had domains of ‘friends’ support’, ‘illness acceptance’ and ‘fear of death’. Melanoma scale (MS) and Melanoma surgery scale (MSS) did not fit the original one-dimensional structure. The MS was observed to have 4 domains: ‘pain’, ‘skin problems’, ‘abdominal metastases’ and ‘other problems’. The MSS was observed to have 2 domains: ‘having symptoms’ and ‘no symptoms’. It is suggested that the FACT-M questionnaire is analyzed using the newly extracted domains to examine quality of life of people with high-risk melanoma in Serbia.

Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision

Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.

The saga of lymph node surgery in malignant melanoma: a history repeating itself in gynecologic oncology.

In view of the high morbidity to complete lymphadenectomy, the sentinel node procedure is currently being investigated in different cancers with the aim of reducing morbidity and of achieving oncological outcomes similar to complete lymphadenectomy. In this review, a parallel will be drawn between the evolutions of the place of lymph node surgery in the management of melanoma and gynecologic cancers. Currently, in the case of cutaneous melanoma, the indications of lymph node surgery are becoming increasingly rare. In contrast with the scarce available evidence in gynecologic cancer, this trend is supported by multicenter randomized studies with a large number of patients for cutaneous melanoma. The second difference is the demonstrated therapeutic benefit of immunotherapies and targeted therapies in cutaneous melanoma, which are less significant in gynecological cancers for which the mainstay of treatment is surgery. According to this review, it seems that in gynecologic oncology, we could in the next decades follow the same pathway currently taken in the management of lymph nodes in malignant melanoma.

Association of Treatment Facility Characteristics With Overall Survival After Mohs Micrographic Surgery for T1a-T2a Invasive Melanoma

Early-stage melanoma, among the most common cancers in the US, is typically treated with wide local excision. However, recent advances in immunohistochemistry have led to an increasing number of these cases being excised via Mohs micrographic surgery (MMS). Although studies of resections for other cancers have reported that facility-level factors are associated with patient outcomes, it is not yet established how these factors may affect outcomes for patients treated with Mohs micrographic surgery. To evaluate the association of treatment center academic affiliation and case volume with long-term patient survival after MMS for T1a-T2a invasive melanoma. In a retrospective cohort study, 4062 adults with nonmetastatic, T1a-T2a melanoma diagnosed from 2004 to 2014 and treated with MMS in the National Cancer Database (NCDB) were identified. The NCDB includes all reportable cases from Commission on Cancer-accredited facilities and is estimated to capture approximately 50% of all incident melanomas in the US. Multivariable survival analyses were conducted using Cox proportional hazards models. Data analysis was conducted from February 27 to August 18, 2020. Treatment facility characteristics. Overall survival. The study population included 4062 patients (2213 [54.5%] men; median [SD] age, 60 [16.3] years) treated at 462 centers. Sixty-two centers were top decile-volume facilities (TDVFs), which treated 1757 patients (61.9%). Most TDVFs were academic institutions (37 of 62 [59.7%]). On multivariable analysis, treatment at an academic center was associated with a nearly 30% reduction in hazard of death (hazard ratio, 0.730; 95% CI, 0.596-0.895). In a separate analysis, treatment at TDVFs was also associated with improved survival (hazard ratio, 0.795; 95% CI, 0.648-0.977). In this cohort study, treatment of patients with T1a-T2a invasive melanoma excised with MMS at academic and top decile-volume (≥8 cases per year) facilities was associated with improved long-term survival compared with those excised by MMS at nonacademic and low-volume facilities. Identification and protocolization of the practices of these facilities may help to reduce survival differences between centers.

Mohs Micrographic Surgery for Melanoma—Do Outcomes Vary Among Treatment Facilities?

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue