Outcomes of Staged Excision With Circumferential en Face Margin Control for Lentigo Maligna of the Head and Neck

Liu, Annie; Botkin, Alexis; Murray, Christian; Solish, Nowell; Kitchen, Jessica; Chan, An‐Wen

doi:10.1177/1203475420952425

Cited by 3 publications

(5 citation statements)

References 48 publications

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“…2 No local recurrences (0/97) were reported following HH-RCM usage before SE with complete margin assessment, a weighted mean ± SD (range) follow-up of 33.1 ± 15.9 (10-44) months, 58,67 compared to 2% (29/1270) without the use of HH-RCM. 38,47,49,56,[60][61][62]66,68,73,74 We were unable to compare the recurrence rates of LM and LMM separately, as in only 35% (n = 74) of the local recurrences, the initial lesion subtype was reported on.…”

Section: Clinical Outcomementioning

confidence: 99%

“…SE or MMS), the margins were more often found to be involved, with a 5 mm surgical margin resulting in negative margins in 59% (350/598). 36,39,47,48,[56][57][58][59][60][61] The weighted mean ± SD (range) surgical margin necessary for negative histological margins was 7.7 ± 2.0 mm (6.6-13.2) (n = 568). 42,43,46,47,49,56,61,62 Lentigo maligna melanoma.…”

Section: Surgical Marginsmentioning

confidence: 99%

See 1 more Smart Citation

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Elshot

Tio

With

et al. 2023

Acad Dermatol Venereol

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Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non‐Randomized Studies instrument. Meta‐analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline‐recommended margin was insufficient in 21.6%–44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%–1.9%), and highest for WLE (13%; 95% CI, 7.2%–21.6%). The mean follow‐up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld‐RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma‐associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH‐RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.

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Section: Clinical Outcomementioning

confidence: 99%

Section: Surgical Marginsmentioning

confidence: 99%

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Elshot

Tio

With

et al. 2023

Acad Dermatol Venereol

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“…Table 1 summarizes the data for the 57 included studies; 6,9,10,27–81 all were retrospective or prospective cohort studies. The studies included a total of 12,043 patients, including 12,590 cases of melanoma encompassing 67.7% melanoma in situ (MIS), 31.6% invasive melanoma, and 0.7% tumors of unreported invasion status; 6,796 (54.0%) of tumors were located on the head and neck, whereas 2,460 (19.5%) did not have the anatomic location reported.…”

Section: Resultsmentioning

confidence: 99%

“…In all, 23 studies 28,29,32,33,35–38,44,52–55,63,64,68,69,71,72,76–79 used H&E staining alone encompassing 2,851 patients with 2,894 tumors with an average reported Breslow depth of 0.58 mm for invasive tumors; 17 studies 31,34,39–43,46,48–50,52,54,57,60,74,75 used IHC staining for all cases encompassing 3,835 patients with 3,907 tumors with an average reported Breslow depth of 0.84 mm for invasive tumors; 19 studies 6,9,27,30,45,47,51,56,58,59,61,62,65–67,70,73,80,81 included a mix of patients treated with either H&E alone or with IHC encompassing 5,357 patients with 5,789 tumors with an average reported Breslow depth of 1.0 mm for invasive tumors. Two studies included patient subsets treated with H&E alone and IHC alone, so the total sum of articles included in this meta analysis is 57.…”

Section: Resultsmentioning

confidence: 99%

Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis

O'Hern,

Crum,

Demer

et al. 2024

Dermatol Surg

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BACKGROUND Mohs micrographic surgery (MMS) is increasingly used to treat cutaneous melanoma. However, it is unclear whether intraoperative immunohistochemistry (IHC) improves surgical outcomes. OBJECTIVE To determine whether intraoperative IHC during MMS and staged excision is associated with a decreased risk of poor surgical outcomes. MATERIALS AND METHODS Search of 6 databases identified comparative and noncomparative studies that reported local recurrence after MMS or staged excision with or without IHC for melanoma. Random-effects meta-analysis was used to estimate pooled local recurrence rates, nodal recurrence, distant recurrence, and disease-specific mortality. RESULTS Overall, 57 studies representing 12,043 patients with cutaneous melanoma and 12,590 tumors met inclusion criteria. Combined MMS and staged excision with IHC was associated with decreased local recurrence in patients with invasive melanoma (0.3%, 95% CI: 0–0.6) versus hematoxylin and eosin alone (1.8%, 95% CI: 0.8%–2.8%) [p < .001]. Secondary outcomes including nodal recurrence, distant recurrence, and disease-specific mortality were not significantly different between these 2 groups. Study heterogeneity was moderately-high. CONCLUSION Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC. These findings suggest that the use of intraoperative IHC during MMS or staged excision should strongly be considered, particularly for invasive melanoma. Trial Registration PROSPERO Identifier: CRD42023435630.

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“…15 As an alternative to Mohs surgery, staged margin controlled excision is available to any plastic surgeon and can be useful in poorly delimited lesions in critical anatomical locations. 16,17 [See Video 1 (online), which displays perimeter excision (staged marginal excision) for lentigo maligna. This enables a non-Mohs surgeon the ability to offer 100% peripheral en face margin evaluation, which should result in a high cure rate in poorly delineated tumors in critical anatomical locations.…”

Section: In Situ Tumorsmentioning

confidence: 99%

Current Controversies in Melanoma Treatment

Temple‐Oberle¹,

Nicholas²,

Rojas-García³

2023

Plastic &Amp; Reconstructive Surgery

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Learning Objectives: After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. Summary: Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

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Outcomes of Staged Excision With Circumferential en Face Margin Control for Lentigo Maligna of the Head and Neck

Cited by 3 publications

References 48 publications

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Lentigo maligna (melanoma): A systematic review and meta‐analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy

Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis

Current Controversies in Melanoma Treatment

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