Wide Local Excision Of Melanoma Research Articles

Respecting the Art of Medicine: Wide Local Excision of Melanoma Within a Tattoo Sleeve.

Respecting the Art of Medicine: Wide Local Excision of Melanoma Within a Tattoo Sleeve.

Management of complications after skin surgery relevant for melanoma in the trunk and extremities during the COVID-19 pandemic: a case series report

BackgroundPatients with melanoma have been found to be at greater risk of adverse outcomes including mortality after contacting COVID-19. Management of postsurgical complications presented additional challenges by potentially increasing exposure to COVID-19 through repeated inpatient admissions to hospital during the pandemic. We report four cases for which skin flaps, lymph ligation, and split-thickness skin graft (STSG) were successfully used in the treatment of complications in the trunk and extremities after wide local excision (WLE). This study details the operative experience in management of postsurgical complications for melanoma in the trunk and extremities during a 6-month period at the height of the COVID-19 pandemic.Case presentationWe present 4 cases detailing management of complications that occurred after wide local excisions performed for melanoma during Feb. to Oct. 2020. Case 1: A 90-year-old man who experienced wound dehiscence and necrosis on the shoulder after non-radical excision for an aggressive melanoma and underwent the side-to-side closure after ellipse formed WLE with modified tangent-to-circle method. Case 2: An 80-year-old man who had undergone excision for melanoma in his left upper arm and histopathology did not show radically. Two weeks after the excision, he underwent a WLE and direct reconstruction with double rotation skin flap. Case 3: A 55-year-old man that experienced a large wound dehiscence on his back due to WLE. He underwent an advanced double skin flap operation. Case 4: A 36-year-old woman who had a lymphorrhea and graft necrosis after WLE and STSG on the right lower leg. A combination of micro lymph ligation and re-STSG was performed. One month after the operation, all wounds had healed. There was no clinical evidence of tumor recurrence after 8 months post procedure.ConclusionsSevere complications (e.g., large wound dehiscence, necrosis, or lymphorrhea) following wide local excision of melanoma are infrequent but must be swiftly and appropriately managed, especially during the COVID-19 pandemic to decrease the likelihood of COVID-19 infection and impaired oncology outcomes from delaying systemic cancer therapy due to the complications in primary interventions.

Variation in the practice of wide local excision for melanoma in Ireland and the UK: a questionnaire survey.

Wide local excision (WLE) is standard practice in the management of melanoma, but no national or international guidelines exist regarding its technique. To assess variation in the practice of WLE and to explore the effect of clinicians' specialty and grade on such variation. This was an international, anonymized, cross-sectional study. An online questionnaire was distributed to the Irish Association of Dermatologists, British Association of Dermatologists, British Association of Plastic and Reconstructive and Aesthetic Surgeons, Melanoma Focus and BioGenoMEL members. Of 128 respondents, 57% were dermatologists and 38% plastic surgeons. Most (80%) were consultants. Almost all clinicians learned their technique from colleagues (99%) 'on the job', although 21% also used textbooks or other media as part of WLE training. There was significant variation in planning and performing WLE: 59% considered margins already achieved, 71% marked margins with the skin relaxed. For 1 cm WLE, 84% delineated 1 cm from the edge of the scar; with a greater proportion of plastic surgeons than dermatologists marking from the centre of the scar (P < 0.05). Most followed a longitudinal/oblique axis on the limbs for WLE (81%). Only 40% sent 'dog ears' for histology. Most (70%) incised through the marked line, 27% incised outside it. Most (79%) excised to deep fascia, 18% to the next biological margin. This study demonstrates significant variation among clinicians performing WLE, an essential component of melanoma management. We postulate that this could have an impact on patient outcomes. A consensus statement should be developed, to achieve more consistency in the practice of WLE.

1285 Mohs micrographic surgery demonstrates slight survival benefit over wide local excision of melanoma in situ in the head and neck

1285 Mohs micrographic surgery demonstrates slight survival benefit over wide local excision of melanoma in situ in the head and neck

Local Recurrence of Melanoma Is Higher After Wide Local Excision Versus Mohs Micrographic Surgery or Staged Excision: A Systematic Review and Meta-analysis.

Complete removal of melanoma is a primary goal of excision, and local recurrence is one measure to evaluate the efficacy of surgical technique. To compare published local recurrence rates for melanoma treated with Mohs micrographic surgery (MMS) or staged excision versus wide local excision (WLE). Search of 6 databases identified comparative and noncomparative studies that reported local recurrence rates after MMS, staged excision, or WLE for melanoma. Random-effects meta-analysis was used to estimate odds ratios and 95% confidence interval (CI) from comparative studies and event rates from noncomparative studies. Of the 71 studies included (16,575 patients), 12 were comparative studies (2,683 patients) and 56 were noncomparative studies (13,698 patients). Comparative studies showed increased recurrence after WLE compared with MMS or staged excision (odds ratio [OR], 2.5; 95% CI, 1.4-4.6) and compared with MMS alone (OR, 3.3; 95% CI, 1.8-5.9). Pooled data from comparative and noncomparative studies showed a local recurrence rate of 7% after WLE (95% CI, 5%-11%), 3% after staged excision (95% CI, 2%-4%), and less than 1% after MMS (95% CI, 0%-1%). Statistical heterogeneity was moderate to high. Local recurrence of melanoma is significantly lower after MMS (<1%) and staged excision (3%) compared with WLE (7%).

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.

Outcomes of Cartilage-Sparing Wide Local Excision for Primary Melanoma of the External Ear.

ObjectiveTo describe outcomes after cartilage-sparing wide local excision for primary melanoma of the external ear.Study DesignRetrospective analysis of patients undergoing external ear melanoma excision using a cartilage-sparing approach at a university-based tertiary care center between 2010 and 2018.SettingUniversity-based tertiary care center.Subject and MethodsChart review was performed for all patients over age 18 who were treated for melanoma of the external ear at Massachusetts Eye and Ear between 2010 and 2018. Patients with melanoma in situ or with melanomas in noncartilaginous areas of the ear (eg, lobule) were excluded.ResultsA total of 8 patients underwent cartilage-sparing excision. Sentinel lymph node biopsy was performed in 7 patients, with positive lymph nodes in 1 of 7 cases. Positive margins and local recurrence occurred in 1 of 8 (12.5%) patients during a mean (SD) follow-up time of 22.5 (15.1) months (SE, 5.3 months). No distant metastasis or death was observed.ConclusionCartilage-sparing wide local excision for melanoma of the external ear is a surgical approach that enables surgeons to follow guideline-recommended oncologic excision margins but has the added benefit of improved postoperative aesthetic outcomes as well as reconstructive options through preservation of the auricular cartilage framework.

Distal perforator-only propeller (D-POP) anterolateral thigh flap for reconstructions around the knee: 4-year experience

Soft tissue reconstruction around the knee is challenging from a functional and aesthetic perspective. While locoregional options remain limited, free flaps produce additional scarring and longer hospitalization. We describe the most distal "D-perforator" of ALT-axis and present our 4-year experience with a distal perforator-only propeller anterolateral thigh (D-POP ALT) flap for reconstruction around the knee. Seventeen patients (7 males, 10 females, mean age 57 years), had distal perforator-only propeller (D-POP) ALT flap reconstruction of defects following the wide local excision of melanoma around the knee joint between May 2014 and December 2018. The most distal perforator in the line between spina illiaca anterior superior (SIAS) and the upper lateral border of patella was identified and marked with audible-Doppler and perforator-only propeller ALT (POP-ALT) flap, which was designed around it. Perforators were dissected intramuscularly or intraseptally to allow adequate flap mobilization, but no division of main pedicle was ever performed to ensure anterograde blood supply. Flaps were rotated into defects while all donor-sites were closed directly. The largest flap measured 25×6cm. The perforator was found between 4 and 9cm proximal to the upper lateral border of patella in all cases. It was found to be septal in 10 cases and intramuscular in 7 cases. Healing was uneventful in all cases, and patients were ambulatory immediately postoperatively. All patients were discharged on postoperative day 1. Excellent long-term outcomes were observed on follow-up by the senior author. In our experience, this technique is simple, reliable, and versatile. Thin and pliable flaps can be safely raised based on the most distal (D-POP) ALT perforator. In addition, sizeable flaps can be performed while still preserving the main ALT pedicle, if free flap is required for the same patient in the future.

Benefit of Mohs Micrographic Surgery Over Wide Local Excision for Melanoma of the Head and Neck: A Rational Approach to Treatment.

There are limited published data comparing wide local excision (WLE) with Mohs micrographic surgery (MMS) for the treatment of melanoma. To describe a novel treatment algorithm for the surgical management of head and neck melanoma and compare rates of local recurrence for tumors treated with either MMS using immunohistochemistry or WLE. A 10-year retrospective chart review including all in situ and invasive melanomas of the head and neck treated at one institution from January 2004 to June 2013. Among 388 patients with melanoma, MMS was associated with decreased rates of local recurrence (p = .0012). However, patient and tumor characteristics varied significantly, and WLE subgroup was largely composed of higher stage and risk tumors. Subgroup analysis found that patients with in situ or thin invasive tumors (<0.8 mm) treated with MMS had improved local recurrence outcomes (p = .0049), despite more frequent tumor location on high risk anatomic sites (e.g., central face). In addition, MMS was associated with a favorable delay in time to local recurrence among in situ tumors (HR = 31.8; p = .0148). These findings further support the use of MMS for treatment of melanoma of the head and neck and help to validate our proposed clinical decision tree.

Modified earlobe reconstruction technique following wide local excision of melanoma that facilitates sentinel lymph node biopsy

The earlobe represents an important element in the aesthetic appearance of the entire ear. Reconstruction of the earlobe is challenging. The authors present a reconstructive option following wide excision of melanoma of the earlobe that facilitates sentinel lymph node biopsy from the neck without further incision. We report satisfactory results obtained using this technique for immediate earlobe reconstruction. We present two cases of malignant melanoma of the earlobe. Both cases were treated with a 1-cm wide local excision of melanoma scar of the ear lobe and reconstruction with double opposing local transposition flaps and sentinel lymph node biopsy (SLNB) of the neck via the skin flap incisions without further need for incision extension. This is a technique for earlobe reconstruction that provides satisfactory results that can be performed in a single stage procedure simultaneously allowing access for sentinel lymph node biopsy from the cervical, pre- and post-auricular lymph node basins. We feel this technique is an option to be considered when treating melanoma of the earlobe requiring SLNB. Level of Evidence: Level V, therapeutic study.

The Impact of Education and Prescribing Guidelines on Opioid Prescribing for Breast and Melanoma Procedures.

Excessive opioid prescribing is common in surgical oncology, with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines, and then evaluating the impact of this intervention. In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time-series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills. During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (p = 0.03), equivalent to 13 tablets of oxycodone 5mg. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42%, or 12 tablets of oxycodone 5mg (p = 0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, p = 0.8), or lumpectomy/breast biopsy (4% vs. 5%, p = 0.7). Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas.

BackgroundAfter wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas.MethodsBetween January 2011 and September 2016, demographic, operative, pathologic, and outcome data were prospectively collected on 60 patients who underwent wide local excision of melanoma followed by immediate flap reconstruction. Flaps were of either rhomboid or keystone type. Chi-square analysis was used to compare relationships between factors.ResultsAll procedures were done by the senior author and as outpatient surgery. No patient required a surgical drain unless they were undergoing concomitant radical regional node dissection. Flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line) occurred in 16/61 patients (26 %). No patient had flap loss. The risk of flap morbidity was significantly higher if the primary tumor was on the distal extremity—10 of 24 patients (42 %), all with keystone flaps—than if it was on the trunk or the proximal extremity (6/37 patients, 16 %), p = 0.04. There were no margins positive for either invasive or in situ melanoma in the entire cohort.ConclusionsSimple transposition flaps can successfully cover large defects after melanoma excision without the need for skin grafting. Keystone flaps in the distal extremity are more prone to separation, but this is minor and does not result in flap loss. There is minimal risk of a positive margin requiring flap takedown and a second re-excision.

Melanoma of the ear: results of a cartilage-sparing approach to resection

Melanoma of the ear is often treated by composite resection of the skin and cartilage and, occasionally, by total auriculectomy. This review analyzes the oncologic, functional, and esthetic results of cartilage-sparing wide local excision for melanoma of the ear. This retrospective study reviewed patients with ear melanoma treated between 1997 and 2002. All patients were treated with cartilage-sparing wide local excision, and ears were reconstructed with skin grafts and/or local flaps. The majority of patients were men (16/18 patients) who ranged in age from 42 to 82years. The most common sites of occurrence were the helical rim (7/18 patients) and the earlobe (6/18 patients). The average depth of invasion was 2.02mm (range 0.4-6.0mm). Sentinel lymph node biopsy was performed in 13 cases, of which only one was positive. The local control rate was 100%, overall survival was 72% (13/18 patients), and disease-specific survival was 89% (16/18 patients). Average follow-up was 30.5months (range 1-61). The rates for local control, overall survival, and disease-specific survival were excellent. These data indicate that for the majority of ear melanomas, cartilage-sparing wide local excision is an acceptable means of treatment.

Primary cutaneous melanoma of the breast: A case report

BackgroundPrimary cutaneous melanoma of the breast is a very rare tumour, accounting for < 5% of all malignant melanomas.Case presentationA young lady was seen in the breast clinic for a skin lesion in the right breast. Clinical examination and investigations confirmed a diagnosis of a primary cutaneous melanoma of the breast. The lesion was excised and the patient made good recovery. She has shown no signs of local recurrence and is under regular follow-up in the dermatology clinic.ConclusionThis case is educational as it shows that the treatment of breast cutaneous melanoma is similar to that for any skin parts with surgery remaining the main therapeutic option. It also shows that mastectomy is unnecessary as it does not improve the results obtained by wide local excision of melanoma.

The cuticular purse string suture: a modified purse string suture for the partial closure of round postoperative wounds

The purse string suture can be used to provide primary closure for small skin defects or as a partial closure for larger round wounds. The size of the defect is reduced secondary to the tension placed on the suture, which uniformly advances the skin from the entire periphery of the wound. We reviewed retrospectively the features of 98 consecutive patients for whom a total of 100 cuticular purse string sutures were used to partially close their postoperative surgical defects. The location and types of the tumors removed were also summarized. Postoperative wounds were created following Mohs' micrographic excision of nonmelanoma skin cancer (basal cell carcinoma, 44; squamous cell carcinoma, 25), wide local excision of melanoma (29), or conservative excision of benign cutaneous neoplasms (two). The incidence of purse string suture for partial closure of each tumor was 4.1% for basal cell carcinoma, 7.3% for squamous cell carcinoma, and 46.3% for melanoma. The tumors were equally distributed on the trunk, head and neck, and extremities; however, purse string closures for basal cell carcinomas were more frequent on the trunk, head, and neck, relative to squamous cell carcinomas and melanomas, which were more common on the extremities. Concurrent medical problems and/or the use of an agent with anticoagulant or antiplatelet effects were noted in more than 50% of patients. Absorbable material of thicker diameter was most frequently used for the suture, and the postoperative wound area decreased by 6-90% (mean, 60%) following purse string partial closure. The suture was usually removed after 3-4 weeks. Postoperative complications occurred in six patients: allergic contact dermatitis in two, wound infection in two, exuberant granulation tissue in one, and hypertrophic scar in one. All of the wounds healed completely with either a round or linear scar. The cuticular purse string suture is a rapid and simple procedure that provides complete or partial closure of round skin defects and excellent long-term cosmetic and functional results. This closure provides uniform tension to the wound, enhances hemostasis at the tissue edge, and significantly decreases the size of the defect. Partial wound closure with the purse string suture may be advantageous following the local excision of melanoma, either as definitive surgical wound management or as a temporary partial wound closure prior to subsequent complete repair of the surgical defect. The purse string suture is also useful following nonmelanoma skin cancer removal in patients who insist on maintaining an active lifestyle in the immediate postoperative period, who are receiving one or more systemic anticoagulant and/or antiplatelet agents, and who have large surgical wounds that would require either a skin graft or a local cutaneous flap in order to close the postoperative defect.

The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival.

The surgical management of primary cutaneous malignant melanoma usually involves an excision biopsy of the suspected lesion followed by wide local excision. No study has addressed whether a delay between these two surgical procedures influences patient outcome. To determine if the surgical interval (SI) between the diagnostic excision biopsy and wide local excision for primary cutaneous malignant melanoma affects recurrence or survival outcome. A cohort of 986 patients who had a diagnostic excision biopsy followed by wide local excision was identified from those registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. The cohort was divided into five arbitrary groups determined by the length of the SI as follows:< or =14 days, 15-28 days, 29-42 days, 43-91 days and > or = 92 days. Overall survival, disease-free survival and recurrence-free interval between the groups were compared univariately and multivariately. The mean age at excision biopsy was 47.4 years and the median period of follow-up was 5 years (range 27 days to 20.7 years). The median SI was 30 days (range 1-468 days). The SI was: (i)< or =14 days for 130 (13%); (ii) 15-28 days for 320 (33%); (iii) 29-42 days for 262 (27%); (iv) 43-91 days for 251 (25%); and (v) > or = 92 days for 23 (2%) patients. The latter group was older, had thinner melanomas, a higher percentage of lesions on the head and neck, fewer superficial spreading malignant melanomas and ulceration present less often compared with patients treated earlier. Univariately, there was no significant difference in overall survival (P = 0.60) or disease-free survival (P = 0.24) between the groups. Although there was a statistically significant difference in the percentage of recurrence-free patients between the groups (P = 0.011), the better recurrence-free rates occurred in the 29-42 and 43-91 day groups. After adjusting for age, sex, tumour thickness, site, histology, ulceration and mitotic activity using Cox's proportional hazards model, there was no statistically significant difference in overall survival, disease-free survival and recurrence-free percentages between the surgical groups (P = 0.88, P = 0.44 and P = 0.084, respectively). There was no evidence that survival outcome or recurrence was related to the time interval between the diagnostic excision biopsy and wide local excision of melanoma.

Recommended width of excision for primary malignant melanoma.

Wide local excision for melanoma with margins of 3 to 5 cm have been advocated in the literature for nearly 140 years. These reports have grouped all stages of melanoma rather than addressing primary early stage disease. Breslow first advocated limited excision margins for these tumors. We have been excising all thicknesses of melanoma with a limited margin (1.00-1.50 cm, mostly 1.00 cm) since 1975. We advocate a 1 cm excision margin irrespective of tumor thickness. Clark has shown that melanoma invades in a vertical fashion, and thus one would expect to be more generous in depth than in width on a pathologic basis. Two studies have shown that there is no difference in the increase in locoregional recurrence and no change in death rate from the disease with more conservative treatment margins. Excision of this lesion is not an office procedure. It should be performed meticulously in an operating room, preferably under light general anesthesia.