Elshot Y S, Tio D C K S, van Haersma-de With A S E, Ouwerkerk W, Zupan-Kajcovski B, Crijns M B, Limpens C E J M, Klop W M C, Bekkenk M W, Balm A J M, de Rie M A
Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
J Eur Acad Dermatol Venereol. 2023 May;37(5):871-883. doi: 10.1111/jdv.18880. Epub 2023 Jan 31.
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non-Randomized Studies instrument. Meta-analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline-recommended margin was insufficient in 21.6%-44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%-1.9%), and highest for WLE (13%; 95% CI, 7.2%-21.6%). The mean follow-up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld-RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma-associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH-RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
由于恶性雀斑样痣（黑色素瘤）（LM/LMM）手术治疗后局部复发风险增加，最佳手术技术仍存在争议。我们旨在评估不同手术技术和反射式共聚焦显微镜（RCM）对局部复发和生存结果的影响。我们检索了截至2022年5月20日的MEDLINE、Embase和PubMed数据库。纳入≥10个病灶的随机和观察性研究。使用非随机研究方法学指标工具进行偏倚评估。由于其他临床结局的事件数量不足，仅对局部复发进行了荟萃分析。我们纳入了41项研究，其中有5059例LM和1271例LMM。手术技术包括广泛局部切除（WLE）（n = 1355）、分期切除（n = 2442）和莫氏显微外科手术（MMS）（n = 2909）。六项研究纳入了RCM。在21.6%-44.6%的LM/LMM中，指南推荐的切缘不足。接受MMS联合免疫组织化学治疗的患者局部复发率最低（<1%；95%CI，0.3%-1.9%），而接受WLE治疗的患者局部复发率最高（13%；95%CI，7.2%-21.6%）。根据手术技术不同，平均随访时间从27个月到63个月不等，MMS和WLE存在中度至高异质性。手持式RCM降低了组织学切缘阳性率（p < 0.0001）和必要的手术分期（p < 0.0001）。大多数区域复发（17/25）和远处复发（34/43）发生在接受WLE治疗的患者中。黑色素瘤相关死亡率较低（1.5%；32/2107），更多患者死于无关原因（6.7%；107/1608）。这项系统评价表明，与WLE相比，使用显微镜控制的手术技术可明显降低局部复发率。即使与WLE联合使用，HH-RCM的使用也显示出不完全切除和局部复发减少的趋势。由于选择偏倚、异质性、III/IV期疾病患病率低以及生存数据有限，无法确定不同手术技术对生存结果的影响。
