Department of Dermatology, University of Minnesota, Minneapolis.
Now with Department of Dermatology, Mayo Clinic, Rochester, Minnesota.
JAMA Dermatol. 2021 Jan 1;157(1):84-89. doi: 10.1001/jamadermatol.2020.3950.
Although previous database studies suggest that Mohs micrographic surgery (MMS) treatment is associated with improved overall survival (OS) for head and neck melanomas, outcomes for trunk and extremity (T&E) tumors have not been adequately evaluated.
To assess survival outcomes for patients with melanomas of the T&E treated with MMS vs wide local excision (WLE).
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined deidentified data from the National Cancer Database between 2004 and 2015. Inclusion criteria for the analysis included diagnosis of trunk, upper extremity, or lower extremity melanoma; known Breslow depth; removal by MMS or WLE; and known last date of survival status.
Five-year all-cause mortality (ACM) rates.
A total of 188 862 in situ and invasive melanomas were included in the analysis (MMS, 2.3%; WLE, 97.7%); the mean (SD) age of patients included was 58.8 (16.0) years, and 52.7% were male. Multivariate analysis demonstrated no OS difference among trunk (WLE hazard ratio [HR], 1.097; 95% CI, 0.950-1.267; P = .21), upper extremity (WLE HR, 1.013; 95% CI, 0.872-1.176; P = .87), lower extremity (WLE HR, 0.934; 95% CI, 0.770-1.134; P = .49), or combined T&E (WLE HR, 1.031; 95% CI, 0.941-1.130; P = .51) tumors. Factors associated with increased risk of ACM on multivariate analysis of all tumors included increasing age (HR, 1.043; 95% CI, 1.042-1.044; P < .001), no insurance or nonprivate insurance (none: HR, 1.921 [95% CI, 1.782-2.071]; Medicaid: HR, 2.410 [95% CI, 2.242-2.591]; Medicare: HR, 1.237 [95% CI, 1.194-1.281]; other government insurance: HR, 1.279 [95% CI, 1.117-1.465]; P < .001 for all), positive surgical margins (HR, 1.609; 95% CI, 1.512-1.712; P < .001), a Charlson-Deyo comorbidity score greater than 0 (Charlson-Deyo score of 1: HR, 1.340; 95% CI, 1.295-1.385; P < .001; Charlson-Deyo score of ≥2: HR, 2.044; 95% CI, 1.934-2.159; P < .001), tumor ulceration (HR, 2.175; 95% CI, 2.114-2.238; P < .001), and increasing Breslow depth (HR, 1.002 [per 0.1 mm]; P < .001). Female sex (HR, 0.698; 95% CI, 0.680-0.716; P < .001) and nonnodular subtype (lentigo maligna/lentigo maligna melanoma: HR, 0.743; 95% CI, 0.686-0.805; P < .001; superficial spreading: HR, 0.739; 95% CI, 0.710-0.769; P < .001; other subtype: HR, 0.817; 95% CI, 0.790-0.845; P < .001; nodular: HR, 1 [reference]) were associated with improved OS.
This cohort study of patients surgically treated for melanomas of the trunk and/or extremities found that, compared with WLE, MMS was not associated with significantly different OS for T&E melanomas.
虽然之前的数据库研究表明 Mohs 显微外科手术（MMS）治疗与改善头颈部黑素瘤的总生存率（OS）相关，但躯干和四肢（T&E）肿瘤的结果尚未得到充分评估。
评估 MMS 与广泛局部切除（WLE）治疗 T&E 黑素瘤患者的生存结局。
设计、地点和参与者：这项回顾性队列研究分析了 2004 年至 2015 年期间国家癌症数据库的匿名数据。分析的纳入标准包括诊断为躯干、上肢或下肢黑素瘤；已知 Breslow 深度；MMS 或 WLE 切除；以及最后生存状态的已知日期。
五年全因死亡率（ACM）率。
分析共纳入 188862 例原位和侵袭性黑素瘤（MMS，2.3%；WLE，97.7%）；纳入患者的平均（SD）年龄为 58.8（16.0）岁，52.7%为男性。多变量分析显示，躯干（WLE 风险比[HR]，1.097；95%CI，0.950-1.267；P=0.21）、上肢（WLE HR，1.013；95%CI，0.872-1.176；P=0.87）、下肢（WLE HR，0.934；95%CI，0.770-1.134；P=0.49）或 T&E 联合（WLE HR，1.031；95%CI，0.941-1.130；P=0.51）肿瘤之间的 OS 无差异。所有肿瘤多变量分析中，与 ACM 风险增加相关的因素包括年龄增加（HR，1.043；95%CI，1.042-1.044；P<0.001）、无保险或非私人保险（无保险：HR，1.921[95%CI，1.782-2.071]；医疗补助：HR，2.410[95%CI，2.242-2.591]；医疗保险：HR，1.237[95%CI，1.194-1.281]；其他政府保险：HR，1.279[95%CI，1.117-1.465]；所有 P<0.001）、阳性切缘（HR，1.609；95%CI，1.512-1.712；P<0.001）、Charlson-Deyo 合并症评分大于 0（Charlson-Deyo 评分 1：HR，1.340；95%CI，1.295-1.385；P<0.001；Charlson-Deyo 评分≥2：HR，2.044；95%CI，1.934-2.159；P<0.001）、肿瘤溃疡（HR，2.175；95%CI，2.114-2.238；P<0.001）和 Breslow 深度增加（HR，1.002[每 0.1mm]；P<0.001）。女性（HR，0.698；95%CI，0.680-0.716；P<0.001）和非结节亚型（原位黑色素瘤/恶性黑色素瘤：HR，0.743；95%CI，0.686-0.805；P<0.001；浅表扩散：HR，0.739；95%CI，0.710-0.769；P<0.001；其他亚型：HR，0.817；95%CI，0.790-0.845；P<0.001；结节型：HR，1[参考]）与 OS 改善相关。
这项对躯干和/或四肢黑素瘤手术治疗患者的队列研究发现，与 WLE 相比，MMS 与 T&E 黑素瘤的 OS 无显著差异。
