Head and Neck Malignant Melanoma

Abstract

Head and neck melanoma often approaches critical structures. Therefore, excision is often limited, leading to positive margins, and increased local recurrence. Immediate reconstruction carries concern for rearrangement or concealment of cancerous tissues. Therefore, reconstruction is often delayed until confirming negative margins on permanent pathology. Our purpose is to identify variables associated with a positive margin and establish criteria for reconstruction timing. We reviewed 117 consecutive patients who underwent wide local excision of head and neck melanoma. Reconstruction was immediate for 107 and delayed for 10. Six percent of patients had a positive margin after wide local excision with no difference in incidence between immediate and delayed reconstruction (P = 0.11). Tumor characteristics associated with a positive margin were locally recurrent, ulcerated, and T4 tumors (P < 0.05); and delayed reconstruction should be considered in these circumstances. Immediate reconstruction is safe for the majority of head and neck melanoma and should be based on knowledge of tumor characteristics.

Recurrence Rates Over 20 Years in the Treatment of Malignant Melanoma: Immediate Versus Delayed Reconstruction

“…Concerns related to higher local recurrence rates following immediate reconstruction have prompted surgeons to delay their reconstructions until after review of final pathology and confirmation of negative margins. 2 , 3 In accordance with Sullivan et al 4 , our study presents comparable rates of positive margins after WLE between immediate and delayed reconstruction. A recent study published by Parrett et al 22 also demonstrate favorable recurrence rates after WLE of HNCMM followed by immediate reconstruction, with low positive margin rates, supporting the safety of immediate reconstruction.…”

“…These findings are consistent with current reports in the literature. 4 , 23 , 24 Although the presence of ulceration is a predictive marker for response to adjuvant interferon therapy, it is negatively associated with survival in cutaneous melanoma. 25 …”

“… 2 , 3 The best oncologic result of low positive margin rates and most optimal aesthetic outcome can be attained when surgical oncologists and plastic surgeons work closely together in the planning and execution of WLE and reconstruction. 4 …”

Correlation Between Appropriate Use Criteria and the Frequency of Subclinical Spread or Reconstruction With a Flap or Graft for Melanomas Treated With Mohs Surgery With Melanoma Antigen Recognized by T Cells 1 Immunostaining

“…Melanomas with indistinct clinical margins are at increased risk for local recurrence or positive pathologic margins with conventional excision. (2, 3) If reconstruction is performed immediately after conventional excision and prior to confirming clear margins, patients may require additional excisions and more complex reconstruction procedures.…”

Management Controversies in Head and Neck Melanoma

“…In that way, the decision to perform immediate reconstruction is based on the likelihood of obtaining a negative margin coupled with the patient’s wishes and wound care concerns until permanent pathologic results are finalized. Positive final margins range from 5% to 12% in large series and have been associated with desmoplastic subtype, T4 stage, ulceration, and treatment of locally recurrent lesions . However, a recent retrospective single-institution study review of 637 patients with head and neck melanoma could identify only age as a predictive variable and could not associate any tumor or treatment-related factors with positive margins .…”