Determination of the impact of melanoma surgical timing on survival using the National Cancer Database.

BACKGROUND: The ideal timing for melanoma treatment, predominantly surgery, remains undetermined. Patient concern for receiving immediate treatment often exceeds surgeon or hospital availability, requiring establishment of a safe window for melanoma surgery. OBJECTIVE: To assess the impact of time to definitive melanoma surgery on overall survival. METHODS: Patients with stage I to III cutaneous melanoma and with available time to definitive surgery and overall survival were identified by using the National Cancer Database (N = 153,218). The t test and chi-square test were used to compare variables. Cox regression was used for multivariate analysis. RESULTS: In a multivariate analysis of patients in all stages who were treated between 90 and 119 days after biopsy (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.01-1.18) and more than 119 days (HR, 1.12; 95% CI, 1.02-1.22) had a higher risk for mortality compared with those treated within 30 days of biopsy. In a subgroup analysis of stage I, higher mortality risk was found in patients treated within 30 to 59 days (HR, 1.05; 95% CI, 1.01-1.1), 60 to 89 days (HR, 1.16; 95% CI, 1.07-1.25), 90 to 119 days (HR, 1.29; 95% CI, 1.12-1.48), and more than 119 days after biopsy (HR, 1.41; 95% CI, 1.21-1.65). Surgical timing did not affect survival in stages II and III. LIMITATIONS: Melanoma-specific survival was not available. CONCLUSION: Expeditious treatment of stage I melanoma is associated with improved outcomes.

Comorbidity scores associated with limited life expectancy in the very elderly with nonmelanoma skin cancer.

BACKGROUND: There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined. OBJECTIVE: Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC. METHODS: A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation-27 (ACE-27) and age-adjusted Charlson comorbidity index (ACCI). Dates of death, follow-up, and overall survival were determined. RESULTS: ACE-27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not. LIMITATIONS: Retrospective study design and referral bias. CONCLUSIONS: ACE-27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.

Survival in patients with primary dermatofibrosarcoma protuberans: National Cancer Database analysis.

BACKGROUND: The predictors of mortality, second surgery, and postoperative radiation therapy for treating dermatofibrosarcoma protuberans (DFSP) are not well described. OBJECTIVE: We sought to determine the impact of patient demographics, tumor characteristics, and treatment site and modality on survival after primary DFSP. METHODS: A retrospective analysis of data from the National Cancer Database was performed for patients diagnosed with DFSP during 2003-2012. RESULTS: A total of 5249 cases were identified. Of these, 3.1% of patients died during an average of 51.4 months of follow-up. After adjusting for relevant factors, lack of insurance, Medicaid and Medicare insurance, anaplastic histology, and positive postoperative margins all predicted mortality, while treatment at an Integrated Network Cancer Program predicted survival (P < .05). Higher odds of postoperative radiation therapy were directly associated with large tumor size, anaplastic and poorly differentiated histology, and positive postoperative margins and inversely associated with treatment at high volume facilities, and non-head and neck tumors. Higher second surgery rates were associated with Hispanic ethnicity, and lower rates were associated with female sex. LIMITATIONS: Survival data was not cancer-specific. CONCLUSION: Better understanding of factors affecting survival outcomes might help improve management of DFSP and delineate other potential causes of increased morbidity and mortality.

Demographics and outcomes of stage I and II Merkel cell carcinoma treated with Mohs micrographic surgery compared with wide local excision in the National Cancer Database.

BACKGROUND: The optimal surgical approach (wide local excision [WLE] vs Mohs micrographic surgery [MMS]) for treating Merkel cell carcinoma (MCC) is yet to be determined. OBJECTIVE: To compare survival outcomes in patients with early-stage MCC treated with MMS versus with WLE. METHODS: A retrospective review of all cases in the National Cancer Database (NCDB) of MCC of clinical stage I or II MCC treated with WLE or MMS was performed. RESULTS: A total of 1795 cases of stage I or II MCC who underwent WLE (n = 1685) or MMS (n = 110) were identified. There was no difference in residual tumor on surgical margins between the 2 treatment groups (P = .588). On multivariate analysis, there was no difference in overall survival between the treatment modalities (adjusted hazard ratio, 1.02; 95% confidence interval, 0.72-1.45; P = .897). There was no difference in overall survival between the 2 groups on propensity score-matched analysis. LIMITATIONS: Disease-specific survival was not reported, as these data are not available in the National Cancer Database. CONCLUSIONS: MMS appears to be as effective as WLE in treating early-stage MCC.

A retrospective study of 1- versus 2-cm excision margins for cutaneous malignant melanomas thicker than 2 mm.

BACKGROUND: Most guidelines recommend at least 2-cm excision margin for melanomas thicker than 2 mm. OBJECTIVE: We evaluated whether 1- or 2-cm excision margins for melanoma (>2 mm) result in different outcomes. METHODS: This is a retrospective cohort study on patients with melanomas (>2 mm) who underwent tumor excision with 1-cm (228 patients) or 2-cm (97 patients) margins to investigate presence of local recurrences, locoregional and distant metastases, and disease-free and overall survival. RESULTS: In all, 325 patients with mean age of 61.84 years and Breslow thickness of 4.36 mm were considered for the study with a median follow-up of 1852 days (1995-2012). There was no significant difference in the frequency of locoregional and distant metastasis between the 2 groups (P = .311 and .571). The survival analysis showed no differences for disease-free (P = .800; hazard ratio 0.948; 95% confidence interval 0.627-1.433) and overall (P = .951; hazard ratio 1.018; 95% confidence interval 0.575-1.803) survival. LIMITATIONS: The study was not prospectively randomized. CONCLUSIONS: Our study did not show any significant differences in important outcome parameters such as local or distant metastases and overall survival. A prospective study testing 1- versus 2-cm excision margin is warranted.

Life expectancy after Mohs micrographic surgery in patients aged 90 years and older.

BACKGROUND: The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. OBJECTIVE: We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. METHODS: A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. RESULTS: Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. LIMITATIONS: Specific causes of death were not accessible. CONCLUSION: This growing section of the population may safely undergo MMS.

Surgical margins for melanoma in situ.

BACKGROUND: A controversy in the treatment of melanoma in situ is the required width of surgical margin. The currently accepted 5-mm margin is based on a 1992 consensus opinion, despite data since then showing this is inadequate. OBJECTIVE: We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ. METHODS: A prospectively collected series of 1072 patients with 1120 melanoma in situs was studied. All lesions were excised by Mohs micrographic surgery with frozen-section examination of the margin. The minimal surgical margin was 6 mm, and the total margin was calculated by adding an additional 3 mm for each subsequent stage required. The minimum surgical margin that would successfully remove 97% of all tumors was calculated. Local recurrence was also tabulated. RESULTS: In all, 86% of melanoma in situs were successfully excised with a 6-mm margin; 9 mm removed 98.9% of melanoma in situs. The superiority of 9-mm to 6-mm margins was significant (P < .001). Gender, location, and diameter did not affect results. Recurrence rate for this set of patients treated with Mohs micrographic surgery was 0.3% (n = 3). LIMITATIONS: Margins less than 6 mm were not studied. This is a referral center for melanoma in situ and 10% of tumors were previously treated before presentation to our clinic. CONCLUSION: The frequently recommended 5-mm margin for melanoma is inadequate. Standard surgical excision of melanoma in situ should include 9 mm of normal-appearing skin, similar to that recommended for early invasive melanoma.

Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up.

BACKGROUND: Basal cell carcinoma (BCC) is the most common form of cancer among Caucasians and its incidence continues to rise. Surgical excision (SE) is considered standard treatment, though randomised trials with long-term follow-up are rare. We now report the long-term results of a randomised trial comparing surgical excision with Mohs' micrographic surgery (MMS) for facial BCC. METHODS: 408 facial, high risk (diameter at least 1cm, H-zone location or aggressive histological subtype) primary BCCs (pBCCs) and 204 facial recurrent BCCs (rBCCs) were randomly allocated to treatment with either SE or MMS between 5th October 1999 and 27th February 2002. The primary outcome was recurrence of carcinoma. A modified intention to treat analysis was performed. FINDINGS: For primary BCC, the 10-year cumulative probabilities of recurrence were 4.4% after MMS and 12.2% after SE (Log-rank test χ(2) 2.704, p=0.100). For recurrent BCC, cumulative 10-year recurrence probabilities were 3.9% and 13.5% for MMS and SE, respectively (Log-rank χ(2) 5.166, p=0.023). A substantial proportion of recurrences occurred after more than 5years post-treatment: 56% for pBCC and 14% for rBCC. INTERPRETATION: Fewer recurrences occurred after treatment of high risk facial BCC with MMS compared to treatment with SE. The proportion of recurrences occurring more than 5years post-treatment was especially high for pBCC, stressing the need for long-term follow-up in patients with high risk facial pBCC.