Comparison of Survival After Mohs Micrographic Surgery vs Wide Margin Excision for Early-Stage Invasive Melanoma

Abstract

IMPORTANCE Melanoma is among the most common malignant neoplasms in the United States, with 91 270 cases estimated to be diagnosed in 2018. Since 2012, Mohs micrographic surgery (MMS) has gained popularity in the treatment of melanoma in situ. Although current guidelines for invasive melanoma without nodal metastases recommend surgery with wide margin excision (WME), use of MMS for this disease has increased as well, particularly in early stages. How the survival outcomes after each procedure compare with one another for early-stage invasive melanoma is unknown to date. OBJECTIVE To evaluate overall survival of patients with stage I melanoma defined by the American Joint Committee on Cancer Cancer Staging Manual, 8th edition (AJCC-8) after MMS vs traditional WME. DESIGN, SETTING, AND ANALYSIS This retrospective cohort study includes all patients with AJCC-8 stage I melanoma who underwent MMS or WME in the National Cancer Database with a diagnosis from January 1, 2004, through December 31, 2014. The National Cancer Database includes all reportable cases from Commission on Cancer-accredited facilities and represents approximately 50% of all newly diagnosed melanoma cases in the United States. Data were analyzed from November 13, 2018, through June 9, 2019. EXPOSURES MMS vs WME. MAIN OUTCOMES AND MEASURES Overall survival evaluated using multivariable Cox proportional hazards regression analysis. RESULTS A total of 70 319 eligible patients (52.3% male and 47.7% female; median [SD] age, 57.0 [16.2] years) were identified, including 67 085 treated with WME and 3234 treated with MMS. Multivariable Cox proportional hazards regression survival analysis controlling for clinical and tumor factors revealed that treatment with MMS was associated with a modest improvement in overall survival relative to WME (hazard ratio [HR], 0.86; 95% CI, 0.76-0.97). Propensity score-matched analysis of cohorts of patients treated with MMS vs WME also found modestly improved survival for those treated with MMS (HR, 0.82; 95% CI, 0.68-0.98). Academic facilities were more likely to use MMS than nonacademic facilities (odds ratio, 2.03; 95% CI, 1.88-2.18). CONCLUSIONS AND RELEVANCE These findings suggest that Mohs surgery may provide an alternative approach to traditional WME for appropriately selected cases of AJCC-8 stage I melanoma without compromising patient survival.

Skin melanoma survival is not superior in females in the new stage IIID of the 8th edition of the staging system: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database

“…Some studies have found that the most common location of malignant melanoma in women is the lower limb, while that in men is the trunk. The surgical margins and external stresses differ in various parts of the body, which may lead to differences in prognosis (14)(15)(16)(17). Our baseline data also confirm this distribution difference.…”

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

“…The technique eliminates uncertainty about the status of the primary melanoma because it allows same‐day excision and comprehensive margin assessment immediately before reconstruction. The efficacy of MMS‐IHC has been confirmed by numerous retrospective cohorts, with local recurrence rates <1%, 11‐14 and the technique's safety has been supported by several large, multiinstitutional database studies showing equivalent or improved survival after MMS‐IHC versus WLE 10,15‐18 . Consequently, the use of MMS‐IHC for melanoma has grown steadily over the last 2 decades.…”

“…One method to assess the complete histologic margins before reconstruction is Mohs micrographic surgery with frozen‐section immunohistochemical stains (MMS‐IHC) 10 . The technique eliminates uncertainty about the status of the primary melanoma because it allows same‐day excision and comprehensive margin assessment immediately before reconstruction.…”

“…One method to assess the complete histologic margins before reconstruction is Mohs micrographic surgery with frozen-section immunohistochemical stains (MMS-IHC). 10 The technique eliminates uncertainty about the status of Cancer October 1, 2021 the primary melanoma because it allows same-day excision and comprehensive margin assessment immediately before reconstruction. The efficacy of MMS-IHC has been confirmed by numerous retrospective cohorts, with local recurrence rates <1%, [11][12][13][14] and the technique's safety has been supported by several large, multiinstitutional database studies showing equivalent or improved survival after MMS-IHC versus WLE.…”

“…The efficacy of MMS-IHC has been confirmed by numerous retrospective cohorts, with local recurrence rates <1%, [11][12][13][14] and the technique's safety has been supported by several large, multiinstitutional database studies showing equivalent or improved survival after MMS-IHC versus WLE. 10,[15][16][17][18] Consequently, the use of MMS-IHC for melanoma has grown steadily over the last 2 decades.…”