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Suboptimal Compliance with NCCN Melanoma Guidelines: Who Is at Risk?
*Danielle S. Comissiong, *Andrew M Blakely, *Saad Ajmal, Michael P. Vezeridis, Thomas J. Miner
Rhode Island Hospital/Brown University, Providence, RI

Objective: To identify patient populations at-risk for suboptimal compliance with National Comprehensive Cancer Network (NCCN) melanoma guidelines regarding surgical excision margins and indications for sentinel lymph node biopsy (SLNB).
Design: Retrospective review of prospectively-maintained database. Setting: Tertiary care center, institutional practice.
Patients: Adult patients who underwent wide local excision with/without SLNB for melanoma from June 2005 to December 2014.
Interventions: Wide local excision, SLNB.
Main Outcome Measure: Compliance with NCCN excision and SLNB guidelines.
Results: 887 patients underwent melanoma surgery. Median age was 64 years (range 12-109 years, SD 16.9). 820 patients (92.5%) fulfilled both NCCN guidelines. Recommended surgical margins were achieved in 858 patients (96.7%) and SLNB was appropriately performed when indicated in 842 patients (94.9%); 7 patients (0.8%) were deficient for both. Patients not meeting criteria were older (median age 79 versus 63 years, p<0.0001). Head and neck tumors were associated with failure to meet criteria (4.7% trunk/extremity versus 20.5% head/neck; p<0.0001). Failure to meet criteria was associated with ulceration (17.9% versus 5.9%, p6/mm2 (23.7% versus 5.9%, p<0.0001). During follow-up, 36 patients (4.1%) experienced local recurrence, which was associated with inadequate resection margins (p=0.007) but not lack of indicated SLNB (p=0.52). Distant metastasis (n=60, 6.8%) was also associated with inadequate margins (p=0.040) but not lack of indicated SLNB (p=0.76).
Conclusion: NCCN excision and SLNB guidelines were generally fulfilled. Patients at-risk for not meeting criteria include the elderly and those with head and neck tumors or high-grade lesions. Because local recurrence and distant metastasis were associated with insufficient margins, surgeons must carefully balance the risks of not following NCCN guidelines, especially in elderly patients and those with head and neck lesions.


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