Endocervical crypt involvement by high-grade cervical intraepithelial neoplasia and its association with high-grade histopathological recurrence after cervical excision in women with negative excision margins: a systematic review and meta-analysis.

BACKGROUND: There is a growing body of evidence suggesting that endocervical crypt involvement by high-grade cervical intraepithelial neoplasia (CIN) may represent a risk factor for disease recurrence after cervical treatment. OBJECTIVES: To provide a systematic review and meta-analysis on whether endocervical crypt involvement by high-grade CIN on the excised cervical specimen is associated with high-grade histopathological recurrence during the follow-up of women after cervical excisional treatment. SEARCH STRATEGY: We searched the Medline, Scopus, Central, and Clinical Trials.gov databases from inception till May 2023. SELECTION CRITERIA: Studies that reported on women with a single cervical treatment with any method of excision for CIN2 or CIN3 lesion, negative excision margins, and whose recurrence was defined histopathologically were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated study eligibility. We used the fixed effects model for meta-analysis. MAIN RESULTS: There were 4 eligible studies included in the present systematic review that evaluated 1088 women treated with either large loop excision of the transformation zone (LLETZ) or with cold knife conization (CKC). We found no significant association of endocervical crypt involvement by CIN2-3 with high-grade histopathological recurrence at follow-up after cervical excision (OR 1.93; 95% CI 0.51-3.35). The subgroup analysis of women with LLETZ cervical excision showed again no significant association with high-grade histopathological recurrence at follow-up (OR 2.00; 95% CI 0.26-3.74). CONCLUSION: Endocervical crypt involvement by high-grade CIN does not seem to be a risk factor for high-grade histopathological recurrence after cervical excision with negative excision margins.

Development and validation of two online dynamic nomograms for patients with non-distant metastatic cutaneous melanoma based on surgical approaches.

BACKGROUND AND OBJECTIVES: Surgery is an essential treatment for non-distant metastatic cutaneous melanoma (NMCM). We aim to construct and validate prognostic nomograms based on surgical approaches and the clinicopathological characteristics of NMCM patients. METHODS: Data of patients diagnosed with cutaneous melanoma from 2004 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Two online nomograms were constructed to predict the 3, 5-year melanoma-specific survival (MSS) for NMCM patients based on the surgical approaches. These nomograms were evaluated by the dynamic Harrell's concordance index (C-index), decision curve analysis and clinical impact curve. Both internal and external data verification were conducted. RESULTS: A total of 14,091 NMCM cases were included in this study. The C-index of the nomograms for the excisional surgery group and amputation group were 0.818 and 0.806, respectively, and 0.763 and 0.731, respectively, in our hospital data validation. After internal and bootstrap verification, our two nomograms showed good accuracy and practicality. CONCLUSION: NMCM patients exhibited equal survival rates independent of resection margin size, while those who needed amputation had worse survival rates. We generated two online nomograms distinguished by surgical approach to predict NMCM patient survival based on clinicopathological characteristics.

Spray de barreira para prevenir o apagamento da marcação cirúrgica na cirurgia micrográfica de Mohs / Barrier spray to prevent surgical marking erasure in Mohs micrographic surgery

A preservação do desenho das margens cirúrgicas é essencial durante a realização da cirurgia micrográfica de Mohs. Contudo, a degermação cutânea no ato da antissepsia e o uso da gaze durante a anestesia local, com frequência, promovem a remoção dessas marcações. A utilização da película protetora Cavilon® 3M, ao fixar a tinta da caneta marcadora, mostrou-se eficaz na preservação do mapa cirúrgico, permitindo uma remoção precisa do espécime cirúrgico

The preservation of the surgical margins marking is essential during Mohs micrographic surgery. However, skin degermation during antisepsis and the use of gauze during local anesthesia often remove these markings. The use of the protective film Cavilon® 3M to fix the marking pen ink was effective in preserving the surgical map, allowing an accurate removal of the surgical specimen.

Association between excision margins and local recurrence in 1407 patients with primary in situ melanomas.

Background: Reliable evidence to guide the management of melanoma in situ (MIS) and minimize the risk of recurrence is lacking. Objective: To identify clinicopathological predictors of local recurrence (LR) in patients with MIS and evaluate long-term outcomes according to pathological excision margins. Methods: A case-control study of patients with MIS treated at a large Australian melanoma treatment center from January 2008 to December 2012 was undertaken. Clinicopathological characteristics of patients who developed LR and those who did not were compared. Results: LR developed in 34 of 1407 patients with MIS (2.5%). Median time to LR was 20 months. The primary lesion was removed with pathological margins <4 mm (P < .001) in 67.6 % of patients with LR. Four patients died of metastatic melanoma following LR. Comparing patients with pathological margins <4 mm and ≥4 mm, the former were older (>60y, P < .001), more frequently had MIS on the head or neck (P < .001), had a greater LR rate (P < .001), and had a higher mortality from all causes (P < .001). Limitations: Retrospective, single-institution study. Conclusions: Pathological margins of ≥4 mm should be considered for patients with MIS who are treated with standard surgical excision and assessed by examining serial slices taken from the formalin-fixed, paraffin-embedded specimen.

Relationship between positive margin and residual/recurrence after excision of cervical intraepithelial neoplasia: a systematic review and meta-analysis.

Background: The relationship between endocervical and ectocervical margin status and residual or recurrence after cervical intraepithelial neoplasia (CIN) resection has been controversial. We investigated the relationship between the excision margins and residual/recurrence to assess indicators for the scope of resection and the risk of treatment failure by using meta-analysis. Methods: Literature searches were performed in PubMed, Medline, Embase, Central, Wangfang and CNKI databases. Patients after CIN resection were grouped according to whether there was residual or recurrence, and the differences in exposure factors between the two groups were compared. Or they were grouped by exposure factor, and compare the differences in residual and recurrence rates under different grouping conditions. The observed outcome was postoperative residual or recurrence. The risk of bias in the literature was assessed using the Newcastle-Ottawa Scale (NOS). The chi-square test were used for heterogeneity. Subgroup explored the sources of heterogeneity. Publication bias was assessed using funnel plots and Egger's test. Results: A total of 11 studies were included in this study, 8 studies were at low risk of bias and 3 studies were at high risk of bias. The 11 studies included 3065 patients, 774 patients with positive margins and 2,291 patients with negative margins. The rate of residual/recurrence after excision of CIN in patients with positive margins was significantly higher than in patients with negative margins [odds ratio (OR) =3.99, P<0.00001]. There was no heterogeneity among the studies (P=0.16), with publication bias (P<0.05). The residual/recurrence rate was significantly higher in patients with positive endocervical margins than in patients with negative endocervical margins (OR =2.59, P<0.00001). There was no heterogeneity among studies (P=0.78) and no publication bias (P<0.05). There was no significant difference in residual/recurrence rate between positive and negative ectocervical margins (OR =1.14, P=0.36). There was no heterogeneity among studies (P=0.32) and no publication bias (P<0.05). Conclusions: Positive endocervical margins, but not external cervical margins, are risk factors for residual/recurrence of CIN after resection. Close attention to the status of the endocervical margins is recommended. More aggressive treatment and frequent follow-up are needed for patients with positive endocervical margins.

Can we reduce excision margins for head and neck melanoma? A 12-year retrospective study.

Although wide local excision is the standard treatment for primary melanoma, the surgical margin remains controversial. Melanomas of the head and neck exhibit higher recurrence rates and worse prognosis than lesions in other body locations, and their close proximity to critical anatomical and functional structures means that wide excision margins are often not feasible. Surgeons must therefore achieve a balance of oncological safety and functional and aesthetic needs. The aim of this study was to retrospectively analyse melanoma data over a 12-year period at a large skin surgery unit to identify potential differences in outcomes in patients who had reduced wide local excision margins for primary head and neck melanoma. The study would provide further evidence for the need for large randomised prospective trials to reduce excision margins for head and neck melanoma. Local cancer network data were retrospectively analysed over a period of 12 years (2008-2019). Data included site, initial stage, multidisciplinary team (MDT) meeting recommendations for excision margins and the actual wide local excision margin taken, recurrence rate, and disease-specific and absolute survival. A total of 222/305 patients (73%) had the recommended excision margin, while in 27% margins were reduced due to anatomical or functional considerations. Recurrence rates were similar (recommended 11.7% vs narrow 13.3% excision margins) (p = 0.64). The mean follow-up time for all patients was 48.5 months. In aesthetically and functionally sensitive areas of the head and neck, wide local excision margins need to be carefully considered after MDT discussion and discussion with the patient. This study suggests the need for further multicentre trials to address the uniqueness of head and neck melanoma.

"Clock mapping" prior to excisional surgery in vulvar Paget's disease: tailoring the surgical plan.

INTRODUCTION: Paget disease is a rare neoplasm of the skin that mainly involves the vulvar region. Vulvar Paget's disease (VPD) can spread beyond the apparent edges of the lesion resulting in a high risk of involved surgical margins. Our aim is to verify the efficacy of a preoperative vulvo-vaginal intensive clock mapping in the prediction of the invasiveness and the extension of VPD. MATERIALS AND METHODS: All consecutive patients with primary VPD referred to our institution from July 2005 to December 2018 were subjected to a preoperative intensive biopsy mapping (clock mapping) of the vulvo-vaginal area: inside and outside the vulvar skin visible lesion, according to o'clock positions, and in the vagina. Patients with positive biopsies "only inside" or "also beyond" the visible lesion were included, respectively, in Group A and B. Surgical excision was drawn passing by the points with negative histology. Pathological findings of mapping biopsies were compared with those from radical surgery. RESULTS: A total of 28 women were enrolled. After clock mapping definitive histology: 17 (60.7%) and 11 (39.3%) patients were included in Group A and B. Definitive histology showed non-invasive, micro-invasive and invasive VPD, respectively, in 13 (46.4%), 11 (39.3%) and 4 (14.3%) patients, with 4 patients further upstaged. Overall, negative margins were found in 14 (50%) patients: 9 (32.1%) from Group A and 5 (17.9%) from Group B. In 23 cases (82.1%), clock mapping identified free surgical margins along the vulvo-perineal skin excision front. CONCLUSIONS: Preoperative clock mapping emerged as potentially useful workup tool to predict invasiveness and extension of VPD, to tailor surgical excision.

A study of the effects of delayed patient presentation on cutaneous SCC progression.

BACKGROUND: A cohort study of patients, who underwent cutaneous squamous cell carcinoma (SCC) excision, was undertaken to evaluate the effects of the COVID-19 pandemic on treatment times and histopathological features. METHODS: We identified all patients who had SCCs excised in October 2020 (pandemic group); the control group included all patients who underwent excision of SCCs during October 2019 (pre-pandemic group). Collected data included SCC subtype, thickness, size, clearance margins, referral details, patient comorbidities and operative data. RESULTS: There were 140 patients (174 SCCs; pre-pandemic group=74; pandemic group=100) identified for study inclusion. Both groups were well matched for age, sex, previous history of cancer, cutaneous SCC and histological subtype. There was a delay in median patient presentation time to the GP in the pandemic versus pre-pandemic group (106 days vs. 56 days, p <0.001); this led to a longer overall time to surgery (167 days vs. 110.5 days, p < 0.001). Pandemic group SCCs had larger median Breslow depths (4 mm vs. 3 mm, p = 0.01), a greater proportion of Clark's level 4 and 5 lesions (76.9% vs. 61.1%, p = 0.03), and a higher rate of high (20-40 mm) and very high (>40 mm) risk SCCs as defined by British Association of Dermatology diameter criteria (56.1% vs. 39.2%, p = 0.03), versus the pre-pandemic group. CONCLUSIONS: There was a 57-day median SCC treatment delay, and an associated development of higher risk SCCs by the time of surgery. Despite the challenges of a pandemic, patients should seek early consultation for suspicious skin changes, and healthcare systems should maintain skin cancer treatment pathways.

Recidiva de endometriosis en pared abdominal. Reporte de caso / Recurrence of endometriosis in the abdominal wall. A case report

Introducción: La endometriosis de pared abdominal es una patología infrecuente, que generalmente se desarrolla en una cicatriz quirúrgica posterior a un procedimiento ginecológico y/o ginecoobstétrico. Caso clínico: Mujer de 29 años, G3C2A1V2, antecedentes de esterilización quirúrgica, quien un año después a su última cesárea presenta cuadro de dolor pélvico crónico asociado a ciclo menstrual, que se acompañaba de sangrado menstrual abundante y sensación de masa en hipogastrio. Con diagnóstico de endometriosis en pared abdominal, razón por la cual realizan resección. Sin embargo, tras un año posterior al procedimiento recidiva de endometriosis en pared abdominal, en esta ocasión, con requerimiento de resección amplia de fascia, colocación de malla y cierre por planos. Conclusiones: La endometriosis de pared abdominal es de difícil diagnóstico, ya que comparativamente es una entidad infrecuente, que no ha recibido una adecuada atención. Es importante sospecharla en mujeres con dolor abdominal cíclico y presencia de masa en la pared abdominal, adicionalmente con la utilización de imágenes diagnósticas. La resección quirúrgica es el tratamiento ideal, sin embargo, es importante recalcar la importancia de una resección amplia de márgenes para evitar recidivas. Adicionalmente el cierre por planos que evite defectos en la pared abdominal.(AU)

Introduction: Abdominal wall endometriosis is an uncommon pathology, which usually develops in a surgical scar following a gynaecological and/or gynaecological-obstetric procedure. Case study: Female, 29 years old, G3C2A1V2, history of surgical sterilization. One year after her last cesarean section, she presented with chronic pelvic pain associated with the menstrual cycle, accompanied by heavy menstrual bleeding and a sensation of a mass in the hypogastrium. She was diagnosed with endometriosis in the abdominal wall, and resection was performed. However, one year after the procedure, the endometriosis in the abdominal wall recurred, this time requiring wide fascia resection, mesh placement and layered closure. Conclusions: Abdominal wall endometriosis is difficult to diagnose, since it is a comparatively infrequent entity, which has not received adequate attention. It is important to suspect it in women with cyclic abdominal pain and the presence of a mass in the abdominal wall, in addition to the use of diagnostic imaging. Surgical resection is the ideal treatment, however, it is important to emphasize the importance of a wide margin resection to avoid recurrence. Layered closure is also important to avoid defects in the abdominal wall.(AU)

Role of Dermoscopy in the Assessment of Basal Cell Carcinoma.

Basal cell carcinoma is one of the most common cancers in white people, with a continuous increase worldwide. Dermoscopy, a non-invasive technique, allows early diagnosis based on the presence of typical vascular structures, pigmented structures, and ulceration and the absence of specific melanocytic structures. Moreover, dermoscopy is useful in basal cell carcinoma management, enabling the differentiation between multiple histological subtypes, between pigmented and non-pigmented variants and allowing a more accurate assessment of surgical margins. After non-ablative therapies, dermoscopy allows the accurate detection of residual disease. The purpose of this review is to highlight the dermoscopic features encountered in basal cell carcinoma and to outline the role of dermoscopy for diagnosis and therapeutic response in this cancer.

Cancer Surgery 2.0: Guidance by Real-Time Molecular Technologies.

In vivo cancer margin delineation during surgery remains a major challenge. Despite the availability of several image guidance techniques and intraoperative assessment, clear surgical margins and debulking efficiency remain scarce. For this reason, there is particular interest in developing rapid intraoperative tools with high sensitivity and specificity to help guide cancer surgery in vivo. Recently, several emerging technologies including intraoperative mass spectrometry have paved the way for molecular guidance in a clinical setting. We evaluate these techniques and assess their relevance for intraoperative surgical guidance and how they can transform the future of molecular cancer surgery, diagnostics, patient management and care.

Laterally extended parametrectomy.

OBJECTIVE: To describe the laterally extended parametrectomy (LEP) surgical technique, emphasizing the main challenges of the procedure. METHODS: LEP was designed as a more radical surgical procedure aiming to remove the entire parametrial tissue from the pelvic sidewall. Its initial indications were for lymph node positive Stage Ib (current International Federation of Gynecology and Obstetrics 2018 Stage IIIc) and Stage IIb cervical cancer. Currently, with most guidelines recommending definitive radiochemotherapy for these cases, initial LEP indications have become debatable. LEP is now mainly indicated for removing tumors involving the soft structures of the pelvic sidewall during a pelvic exenteration, aiming to obtain lateral free margins. This expands the lateral borders of the dissection to not only the medial surface of internal iliac vessels, but also to the true limits of the pelvic sidewall. RESULTS: During LEP, the parietal and visceral branches of the hypogastric vessels are divided at the entry and exit level of the pelvis. Consequently, the entire internal iliac system is excised, and no connective or lymphatic tissue remain on the pelvic sidewall. The main technical challenges of LEP are caused by the difficulty in ligating large caliber vessels (internal iliac artery and vein) and the variable anatomic distribution of pelvic sidewall veins. CONCLUSION: LEP is a feasible technique for removing pelvic sidewall recurrences, aiming to obtain surgical free margins.

Long-term outcomes of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities.

BACKGROUND: Microscopic evaluation of the entire surgical margin during excision of cutaneous malignancies results in the highest rates of complete excision and lowest rates of true local scar recurrence. Few studies demonstrate the outcomes of Mohs micrographic surgery specifically for invasive melanoma of the trunk and proximal portion of the extremities. OBJECTIVE: To evaluate the long-term efficacy of Mohs micrographic surgery for invasive melanoma of the trunk and proximal portion of the extremities, including true local scar recurrence rate, distant recurrence-free survival, and disease-specific survival. METHODS: Prospectively collected study of 1416 cases of invasive melanoma of the trunk and proximal portion of the extremities was performed to evaluate long-term outcomes. RESULTS: True local scar recurrences occurred in our cohort at a rate of 0.14% (2/1416), after a mean follow-up period of 75 months and were not associated with tumor depth. The rate of satellite/in-transit recurrences and the disease-specific survival stratified by tumor thickness were superior to historical control values. LIMITATIONS: We used a nonrandomized, single institution, retrospective design. CONCLUSIONS: Mohs micrographic surgery of primary cutaneous invasive melanoma on the trunk and proximal portion of the extremities resulted in local control of 99.86% of tumors and an overall disease-specific death rate superior to that of wide local excision.

Perfil epidemiológico de pacientes portadores de câncer de pele atendidos no Hospital Regional da Asa Norte/DF - Brasil / Epidemiological profile of patients with skin cancer treated at the Regional Hospital of Asa Norte/DF - Brazil

Introdução: O câncer de pele é a neoplasia mais comum na população brasileira, correspondendo a 30% de todos os tumores malignos registrados no país. Os tumores malignos não melanoma são o tipo de câncer de maior incidência e prevalência no Brasil. O carcinoma basocelular (CBC) é o mais comum, correspondendo entre 70% e 75% dos casos. O carcinoma epidermóide (CEC) responde por 20% dos casos. O objetivo é determinar o perfil epidemiológico, os tipos e subtipos encontrados nos resultados de histopatológico, a conduta cirúrgica e sua eficácia, dos pacientes com suspeita de lesão maligna de pele. Métodos: Estudo retrospectivo descritivo, baseado na análise de prontuário eletrônico de ressecção de lesões de pele suspeitas de maligna, pela equipe da Cirurgia Plástica do Hospital Regional da Asa Norte, Brasília/DF, no período de janeiro de 2012 a dezembro de 2016. Resultados: Foram submetidos à cirurgia 533 pacientes, sendo sexo feminino (51,6%), com média de idade de 68,97 anos e 84% com diagnóstico de carcinoma basocelular com subtipo sólido. As margens comprometidas atingiram 11% da amostra. As reconstruções mais prevalentes foram fechamento primário e retalhos locais. Conclusão: O perfil epidemiológico dos pacientes atendidos com lesões suspeitas de câncer de pele demonstrou prevalência em mulheres e acima de 60 anos, com história de exposição solar. A face foi o local mais acometido, sendo o nariz a topografia mais comum. O CBC é tipo mais comum e o subtipo sólido circunscrito foi o mais prevalente. O tipo de reconstrução mais utilizado foi o fechamento primário e o retalho local.

Introduction: Skin cancer is the most common neoplasm in the Brazilian population, corresponding to 30% of all malignant tumors registered in the country. Non-melanoma malignant tumors are the type of cancer with the highest incidence and prevalence in Brazil. Basal cell carcinoma (BCC) is the most common, accounting for between 70% and 75% of cases. Squamous cell carcinoma (SCC) accounts for 20% of cases. The objective is to determine the epidemiological profile, the types and subtypes found in the histopathological results, the surgical conduct and its effectiveness in patients with a suspected malignant skin lesion. Methods: A retrospective descriptive study, based on the analysis of electronic medical records for resection of skin lesions suspected of malignancy, carried out by the Plastic Surgery team at the Regional Hospital of Asa Norte, Brasília/DF, from January 2012 to December 2016. Results: 533 patients were submitted to surgery, being female (51.6%), with a mean age of 68.97 years and 84% diagnosed with basal cell carcinoma with solid subtype. The compromised margins reached 11% of the sample. The most prevalent reconstructions were primary closure and local flaps. Conclusion: The epidemiological profile of patients treated with lesions suspected of skin cancer showed prevalence in women over 60 years with a history of sun exposure. The face was the most affected site, the nose being the most common topography. BCC is the most common type, and the circumscribed solid subtype was the most prevalent. The most used type of reconstruction was primary closure and local flap.

Secretory breast carcinoma in a male child: Case report and literature review.

INTRODUCTION: The secretory breast carcinoma is very rare in children. It represents less than 1% of malignancy cases in childhood and is even less common in males, with 15 cases reported until 2004. Therefore, the aim of this study is to report a male child with breast carcinoma and review literature. PRESENTATION OF CASE: A 14-year-old male patient with a history of a painless slow-growing lump in the left breast and, five years later, onset of yellow discharge from the papilla. Ultrasound scanning demonstrated a well- defined, regular, homogeneous and hypoechoic mass. Nodule excision was initially performed, followed by mastectomy, due to compromised radial margin. Immunohistochemistry revealed weakly positive estrogen and progesterone receptors. Adjuvant therapy was not required. Sixteen months after resection, the patient is well with no complaints or recurrence. DISCUSSION: Due to its rarity, there is no therapeutic guideline. Although the recommended treatment is still surgical excision, there is no consensus as to its extent. Prognosis is usually favorable. Our patient was submitted to mastectomy with sentinel lymph node biopsy due to compromised radial margin. CONCLUSION: Secretory breast carcinoma is a rare form of breast cancer, especially in male children; which hampers standardization of diagnosis, treatment and prognosis establishment.

Reconstructive burden and financial implications of wider excision margins for invasive primary cutaneous melanoma.

BACKGROUND: For invasive primary cutaneous melanoma, wider excision is advocated to reduce local recurrence risk and improve patient outcomes. Excision detail is controversial, especially in intermediate- and high-risk primary melanoma (AJCC pT2-pT4). Guidance varies from sizes 1 to 3 cm (translating into large defects of 2-6 cm). The aim of this study was to determine the reconstructive and resource burden of wider excision margins (EMs). METHODS: Data analysis from our prospective database (2008-2017) included 1184 patients (563F:621 M) with cutaneous melanoma (pT1b-pT4b). Procedure tariff data were sourced from our financial services department. RESULTS: Two hundred twenty-nine patients had a narrower EM (1 cm) and 995 (80.7%) had a wider EM (2-3 cm). Reconstructive requirement significantly increased with a wider EM collectively (11.3% vs 29.3%, odds ratio (OR) = 3.2; p < 0.0001), in the extremities (15.2% vs 42.0%; p < 0.0001), and in the head and neck (H&N) (23.5 % vs 64.7%; p < 0.0001). Reconstruction significantly increased hospitalisation rates (26.6% vs 63.0%, OR = 4.7; p < 0.0001) collectively, in the H&N (26.8 % vs 53.9%), and in the upper (18.9 % vs 42.3%) and lower extremities (34.8% vs 77.3%). Narrower EMs significantly reduced hospitalisation rates in the upper and lower extremities (7.1% vs 28.5%; p = 0.004, 37.9% vs 58.5%; p = 0.005, respectively). Overall procedure cost significantly increased by £180 (mean, p < 0.0001) and £346 (median, p = 0.0004) per patient when reconstruction was required. CONCLUSIONS: Our data suggest substantial impact of wider EM on patients, which more than doubled in the functionally and cosmetically sensitive extremities and the H&N region. Reconstructions add significant financial and healthcare service burden. Without randomised controlled trial (RCT) evidence demonstrating increased efficacy of wider EM, narrower EM is advocated whilst awaiting future planned RCT results specifically investigating on this.

Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline.

Background: For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods: Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results: Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions: Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Mohs micrographic surgery for melanoma: A prospective multicenter study.

BACKGROUND: Single-institution studies show that frozen section Mohs micrographic surgery (MMS) is an effective treatment modality for cutaneous melanoma, but no multi-institutional studies have been published. OBJECTIVE: To characterize the use of MMS in the treatment of melanoma at 3 academic and 8 private practices throughout the United States, to recommend excision margins when 100% histologic margin evaluation is not used, and to compare actual costs of tumor removal with MMS vs standard surgical excision. METHODS: Prospective, multicenter, cohort study of 562 melanomas treated with MMS with melanoma antigen recognized by T cells 1 immunostaining. RESULTS: Primary trunk and extremity melanomas (noninvasive and invasive melanoma) achieved histologically negative margins in 97% of tumors with 10-mm margins, whereas 12-mm margins were necessary to achieve histologically negative margins in 97% of head and neck melanomas. Overall average cost per tumor treated was $1328.46. LIMITATIONS: Nonrandomized and noncontrolled study. CONCLUSIONS: MMS with melanoma antigen recognized by T cells 1 immunostaining safely provides tissue conservation and same-day reconstruction of histologically verified tumor-free margins in a convenient, single-day procedure. When comprehensive margin evaluation is not used, initial surgical margins of at least 10 mm for primary trunk/extremity and 12 mm for head/neck melanomas should be used to achieve histologically negative margins 97% of the time.

Uso da técnica em "spaghetti" para tratamento cirúrgico do lentigo maligno / Use of the "spaghetti" technique for surgical treatment of lentigo maligna

O lentigo maligno (LM) é uma forma de melanoma in situ que mais comumente se apresenta como uma mácula de crescimento lentamente progressivo, pigmentada, na face de idosos com pele danificada pelo sol. Esse melanoma in situ tem um risco (30% a 50%) de progressão para lentigo maligno melanoma. A excisão cirúrgica completa da lesão requer margens de pelo menos 10mm, mesmo para lesões in situ. Porém, quando o crescimento de LM ocorre em áreas de implicações estéticas ou funcionais (face, pescoço, solas), a excisão é frequentemente reduzida para preservar estruturas anatômicas importantes e por razões cosméticas. Além disso, as margens periféricas podem ser clinicamente mal definidas e nem sempre pigmentadas, com extensão subestimada e risco de ressecção insuficiente. A "técnica de espaguete", descrita por Gaudy Marqueste, é uma cirurgia estratégica baseada na amostragem de uma faixa de tecido "spaghettilike" para determinar as margens da lesão antes da remoção do tumor. Após a confirmação anatomopatológica de margens livres de neoplasia, a lesão principal central é ressecada, permitindo a reconstrução do defeito no mesmo procedimento, sendo uma alternativa à cirurgia micrográfica de Mohs.(AU)

Lentigo maligna (LM) is a melanoma in situ that commonly presents as a macula with progressive and irregularly pigmented growth, especially in the face of elderly people with sun-damaged skin. This melanoma in situ has a risk (30-50%) of progression to lentigo maligna melanoma. Complete surgical excision of the lesion requires margins of at least 10 mm, even for lesions in situ. However, when the growth of LM occurs in areas of aesthetic or functional implications (face, neck, and soles), the excision is often reduced to preserve important anatomic structures and for cosmetic purposes. Moreover, the peripheral margins may be clinically ill-defined and not always pigmented, and thus, such cases are associated with underestimated extension and risk of insufficient resection. The "spaghetti" technique, described by Gaudy Marqueste, is a strategic surgical approach based on sampling of a range of "spaghetti-like" strips to determine the margins of the lesion prior to removal of the tumor. After the pathological confirmation of neoplasia-free margins, the main central lesion is resected, allowing reconstruction of the defect in the same procedure, as an alternative to Mohs micrographic surgery. (AU)