Considerations for Timing of Defect Reconstruction in Cutaneous Melanoma of the Head and Neck

Abstract

The objective of this study is to identify the incidence and characteristics of cases with positive margins on wide local excision for cutaneous melanoma of the head and neck (CMHN) and therefore provide a potential basis for selectively delaying reconstruction pending final histological clearance of melanoma. A systematic review of English language articles was performed on studies retrieved from PubMed and Web of Science. Original investigations published between July 1999 and June 2018 reporting on margin status of CMHN wide local excision specimens were included in the review. The incidence of positive margins after definitive resection for cutaneous melanoma in the literature ranges from 6 to 20.9%. The incidence is higher in cases of advanced patient age, diagnosis by shave biopsy, lentigo maligna melanoma subtype, desmoplastic subtype, tumor thickness, and ulceration. Delayed reconstruction remains the most oncologically sound decision, allowing for interpretation of margin status on paraffin-embedded tissue sections. However, resection and the resultant defect closure in a single stage is more expedient and potentially a more efficient use of resources. The risk–benefit ratio of immediate versus delayed reconstruction must be considered for each case. The incidence of positive margins is higher in cases of advanced patient age, diagnosis by shave biopsy, lentigo maligna melanoma subtype, desmoplastic subtype, increasing tumor thickness, and the presence of ulceration; delayed reconstruction should be strongly considered in these cases.

Treatment of Cutaneous Melanoma of the Head and Neck With Wide Local Excision Versus Mohs

“…Treatment of melanoma with MMS has demonstrated local recurrence rates of less than 1%, which supports that in appropriately trained hands, complete excision of cutaneous melanoma can reliably be obtained with MMS 1–3 . Clearing melanoma in situ in the head and neck is often challenging because of inapparent tumor spread beyond the visible borders of a lesion, as well as background histologic changes of the sun‐exposed skin of the face including increased number of atypical melanocytes in the basal layer of the epidermis 22 . It is in cases of melanoma in situ, and in particular lentigo maligna, where MMS can be a very powerful technique in clearing the disease and obtaining very low local recurrence rates 4 .…”

Lentigo maligna and intensified ablative fractional laser‐assisted PDT: a promising, minimally invasive treatment approach

“…Surgical excision with adequate safety margins of no less than 12 mm should guarantee a 97% of complete removal of head and neck melanomas, as stated by Ellison, Zitelli, and Brodland, after Mohs micrographic surgery associated with melanoma antigen recognition by T cells immunostaining . Conventional surgery after wide local excision is associated with an incidence of positive margins ranging from 6 to 20.9%, as reported by Namin et al . after reviewing the recent literature.…”

Positive Margins in Cutaneous Melanoma of the Head and Neck: Implications for Timing of Reconstruction

“…A recent review article acknowledged that immediate reconstruction may be a good option for some patients, but it identified a 10.1% (170/1690) incidence of positive margins across 9 studies 12 . In the articles included in this review, the clinicopathologic features of increasing age, ulcerated tumors, T3 and T4 tumors, the lentigo maligna melanoma subtype, and multiple‐ or partial‐biopsy techniques were associated with positive margins 12 .…”

“…12 In the articles included in this review, the clinicopathologic features of increasing age, ulcerated tumors, T3 and T4 tumors, the lentigo maligna melanoma subtype, and multiple- or partial-biopsy techniques were associated with positive margins. 12 Understanding the clinicopathologic features associated with positive margins after wide local excision of CMHN provides the reconstructive surgeon and patient with important data to help guide their decision between immediate and delayed reconstruction. The objectives of this study are to utilize a large national database to identify the incidence of positive margins and the clinicopathologic features that may be associated with positive margins.…”

“…A recent review article acknowledged that immediate reconstruction may be a good option for some patients, but it identified a 10.1% (170/1690) incidence of positive margins across 9 studies 12 . In the articles included in this review, the clinicopathologic features of increasing age, ulcerated tumors, T3 and T4 tumors, the lentigo maligna melanoma subtype, and multiple‐ or partial‐biopsy techniques were associated with positive margins 12 . Understanding the clinicopathologic features associated with positive margins after wide local excision of CMHN provides the reconstructive surgeon and patient with important data to help guide their decision between immediate and delayed reconstruction.…”