Frequency of and risk factors for tumor upstaging after wide local excision of primary cutaneous melanoma

Etzkorn, Jeremy R.; Sharkey, John M.; Grunyk, John W.; Shin, Thuzar M.; Sobanko, Joseph F.; Miller, Christopher J.

doi:10.1016/j.jaad.2017.03.018

Cited by 54 publications

(39 citation statements)

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“…Among SLNB‐eligible patients, 4 of the unsuccessful SLNBs occurred in patients who underwent SLNB after surgical resection with MMS‐IHC. Head and neck location is a risk factor for upstaging of melanoma during excision 63 . Although studies have shown that SLNB can be performed with accuracy after excision of the primary melanoma, 4,64,65 thorough tumor sampling is recommended for accurate staging before the excision of head and neck melanomas.…”

Section: Discussionmentioning

confidence: 99%

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

MacArthur

Baumann

Sobanko

et al. 2021

Cancer

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Background Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen‐section MART‐1 immunohistochemical stains (MMS‐IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS‐IHC. Methods This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS‐IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes. Results In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a‐T4b) were treated with MMS‐IHC. The median patient age was 69 years (range, 25‐101 years). Ninety‐two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB‐eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB‐eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%). Conclusions Combining SLNB and MMS‐IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS‐IHC.

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Section: Discussionmentioning

confidence: 99%

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

MacArthur

Baumann

Sobanko

et al. 2021

Cancer

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“…3 The need to return to the operating room for SLNB when T-upstaging resulted is slightly higher in the head and neck than in other regions of the body and is very possibly due to the higher incidence of T-upstaging in cutaneous melanoma of the head and neck versus other body regions. 11…”

Section: Discussionmentioning

confidence: 99%

“…These data provide insight into recent studies that found that cutaneous melanoma of the head and neck is more likely to be upstaged and more likely to have positive margins on the DWLE specimen when compared with cutaneous melanoma of other regions of the body. 11,13…”

Section: Discussionmentioning

confidence: 99%

“…2,[7][8][9][10] Cutaneous melanoma of the head and neck is more likely to be T-upstaged after DWLE when compared with cutaneous melanoma of other body locations. 11 The typical treatment of primary cutaneous melanoma often involves 2 procedures ( Figure 1): the first is a biopsy to obtain a diagnosis; the second is definitive surgical management (DWLE 6 sentinel lymph node biopsy [SLNB]) selected per the staging information obtained from the biopsy. Some patients will need to return to the operating room after definitive surgical management for a third procedure, which we define as an early unexpected reoperation so that surgeons can (1) perform an SLNB based on T-upstaging and patient inclusion criteria or (2) obtain adequate margins after finding positive margins on the DWLE specimen (ie, per the diagnostic details of the final pathology report).…”

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confidence: 99%

“…2,7-10 Cutaneous melanoma of the head and neck is more likely to be T-upstaged after DWLE when compared with cutaneous melanoma of other body locations. 11…”

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Impact of Biopsy Modality on the Management of Cutaneous Melanoma of the Head and Neck

Namin

Zitsch

2017

Otolaryngol.--head neck surg.

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Objective The purpose of this study was to examine how biopsy modality affects the treatment course and outcomes of patients with cutaneous melanoma of the head and neck. Specifically, we investigated if partial biopsy techniques are associated with positive margins on definitive wide local excision (DWLE), the need for early reoperation to obtain adequate margins or sentinel lymph node biopsy, and survival. Study Design Retrospective case series. Setting Tertiary care academic center. Subjects and Methods Subjects (N = 170) included all patients who were surgically treated for primary cutaneous melanoma of the head and neck at the University of Missouri-Columbia between January 1, 2000, and December 31, 2015. For analysis, patients were divided into 4 groups based on biopsy modality: shave (n = 61), excisional (n = 62), punch (n = 33), and incisional (n = 14). Results The shave biopsy group ( P = .0324) and the punch biopsy group ( P = .0479) were significantly more likely to have positive margins on DWLE. The shave biopsy group ( P = .0042) and the punch biopsy group ( P = .0479) were also significantly more likely to need early reoperation. The mean number of sentinel nodes and incidence of positive sentinel nodes detected on pathologic examination did not differ significantly across biopsy modality ( P = .3600). Overall survival ( P = .4605) and disease-free survival ( P = .5011) did not differ significantly among the groups. Conclusions Patients diagnosed with shave and punch biopsy techniques are significantly more likely to have positive margins after DWLE and more frequently require early reoperation. Biopsy modality does not appear to influence the number of sentinel nodes detected, the incidence of detecting regional metastases in sentinel nodes, the overall survival, or the disease-free survival.

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Health Economic Consequences Associated With COVID-19–Related Delay in Melanoma Diagnosis in Europe

Maul,

Jamiolkowski,

Lapides

et al. 2024

JAMA Netw Open

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ImportanceThe COVID-19 pandemic resulted in delayed access to medical care. Restrictions to health care specialists, staff shortages, and fear of SARS-CoV-2 infection led to interruptions in routine care, such as early melanoma detection; however, premature mortality and economic burden associated with this postponement have not been studied yet.ObjectiveTo determine the premature mortality and economic costs associated with suspended melanoma screenings during COVID-19 pandemic lockdowns by estimating the total burden of delayed melanoma diagnoses for Europe.Design, Setting, and ParticipantsThis multicenter economic evaluation used population-based data from patients aged at least 18 years with invasive primary cutaneous melanomas stages I to IV according to the American Joint Committee on Cancer (AJCC) seventh and eighth editions, including melanomas of unknown primary (T0). Data were collected from January 2017 to December 2021 in Switzerland and from January 2019 to December 2021 in Hungary. Data were used to develop an estimation of melanoma upstaging rates in AJCC stages, which was verified with peripandemic data. Years of life lost (YLL) were calculated and were, together with cost data, used for financial estimations. The total financial burden was assessed through direct and indirect treatment costs. Models were building using data from 50 072 patients aged 18 years and older with invasive primary cutaneous melanomas stages I to IV according to the AJCC seventh and eighth edition, including melanomas of unknown primary (T0) from 2 European tertiary centers. Data from European cancer registries included patient-based direct and indirect cost data, country-level economic indicators, melanoma incidence, and population rates per country. Data were analyzed from July 2021 to September 2022.ExposureCOVID-19 lockdown-related delay of melanoma detection and consecutive public health and economic burden. As lockdown restrictions varied by country, lockdown scenario was defined as elimination of routine medical examinations and severely restricted access to follow-up examinations for at least 4 weeks.Main Outcomes and MeasuresPrimary outcomes were the total burden of a delay in melanoma diagnosis during COVID-19 lockdown periods, measured using the direct (in US$) and indirect (calculated as YLL plus years lost due to disability [YLD] and disability-adjusted life-years [DALYs]) costs for Europe. Secondary outcomes included estimation of upstaging rate, estimated YLD, YLL, and DALY for each European country, absolute direct and indirect treatment costs per European country, proportion of the relative direct and indirect treatment costs for the countries, and European health expenditure.ResultsThere were an estimated 111 464 (range, 52 454-295 051) YLL due to pandemic-associated delay in melanoma diagnosis in Europe, and estimated total additional costs were $7.65 (range, $3.60 to $20.25) billion. Indirect treatment costs were the main cost driver, accounting for 94.5% of total costs. Estimates for YLD in Europe resulted in 15 360 years for the 17% upstaging model, ranging from 7228 years (8% upstaging model) to 40 660 years (45% upstaging model). Together, YLL and YLD constitute the overall disease burden, ranging from 59 682 DALYs (8% upstaging model) to 335 711 DALYs (45% upstaging model), with 126 824 DALYs for the real-world 17% scenario.Conclusions and RelevanceThis economic analysis emphasizes the importance of continuing secondary skin cancer prevention measures during pandemics. Beyond the personal outcomes of a delayed melanoma diagnosis, the additional economic and public health consequences are underscored, emphasizing the need to include indirect economic costs in future decision-making processes. These estimates on DALYs and the associated financial losses complement previous studies highlighting the cost-effectiveness of screening for melanoma.

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Frequency of and risk factors for tumor upstaging after wide local excision of primary cutaneous melanoma

Abstract: Clinicopathologic characteristics, particularly anatomic location on the head, neck, hands, feet, genitals, or pretibial leg and subtotal diagnostic biopsies, identify melanomas with an increased risk for upstaging.

Cited by 54 publications

References 47 publications

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

Impact of Biopsy Modality on the Management of Cutaneous Melanoma of the Head and Neck

Health Economic Consequences Associated With COVID-19–Related Delay in Melanoma Diagnosis in Europe

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