Original research regarding the role of surgical delay in outcomes from Merkel cell carcinoma.

1. Lopez-Aguiar AG, Okonkwo P, Hewitt DB, Beane J, Contreras C
The Ohio State University Wexner Medical Center
Association Between Surgical
Delay and Survival in the
Treatment of Merkel Cell
Carcinoma

2. The authors do not have any relevant financial relationship(s) with any commercial interest
that pertains to the content of my presentation.
Disclosures

3. Association Between Surgical Delay and Survival in the
Treatment of Merkel Cell Carcinoma
• MCC is a highly malignant skin cancer with a propensity for nodal
metastasis.
• Surgical resection remains the primary treatment modality.
• However, there are limited studies evaluating outcomes related to a
delay in surgery.

4. Specific Aims
• To evaluate the association between surgical delay and overall
survival among patients with MCC.
• To evaluate predictors of lymph node positivity among patients with
MCC.

5. Methods
• Querying the National Cancer Database (NCDB), we examined time
to surgery in patients with clinically node-negative MCC from 2004-
2018.
• Surgical delay was defined as ≥45 days from diagnosis to resection.
• Multivariable logistic regression and Cox proportional-hazards
models were constructed to examine relationships between surgical
delay, lymph node positivity, and outcomes.

6. Methods
Stage 0 or Stage IV disease (n=1,510)
Clinically Positive Lymph Nodes (n=3,064)
No surgical excision, no specimen
sent to pathology (n=3,861)
Time to surgery >365 days (n=6)
All Adult MCC Patients from 2004-2018
(n=20,809)
Clinically Node Negative MCC
(n=16,235)
MCC with Surgical Resection within 1
year of Diagnosis
(n=12,368)

7. Results
Baseline Variables n (%)
Age (yrs), mean + SD 67 ± 17
Male, n (%) 7655 (62)
Comorbidities, n (%)
0
>1
9163 (74)
3205 (26)
Ethnicity, n (%)
Non-Hispanic Origin
Hispanic Origin
11571 (97.5)
295 (2.5)
Race, n (%)
White
African-American
Other
11975 (98)
126 (1)
167 (1)
Facility Type, n (%)
Community Cancer Program
Comprehensive Community Cancer Program
Academic/NCI
Integrated Network Cancer Program
529 (4)
3917 (32)
5767 (47)
2109 (17)

8. Results
Operative and Pathologic Variables n (%)
Tumor Location, n (%)
Arm/Leg
Trunk
Head/Neck
5638 (46)
1138 (9)
5473 (45)
T Category, n (%)
T1
T2
T3
T4
4991 (72)
1610 (23)
228 (3)
92 (1)
Positive Margins, n (%) 819 (7)
Lymph Node Positive, n (%) 2545 (30)
Lymphovascular Invasion, n (%) 1923 (20)
Surgical Delay >45 Days, n (%) 3135 (26)
Time to Definitive Surgery, n (%)
1-30 Days
31-44 Days
45-60 Days
61-365 Days
5951 (49)
2957 (25)
1683 (14)
1452 (12)

9. Results: Overall Survival
p<0.001

10. Results: Logistic Regression
Clinicopathologic Variables
Surgical Delay
OR (95% CI) p-value
Age (yrs.)
<55 yrs
55-64 yrs
65-74 yrs
75+ yrs
Ref
1.21 (0.9-1.6)
1.14 (0.8-1.6)
1.46 (1.1-2.0)
--
0.188
0.405
0.013
Sex
Male
Female
Ref
0.94 (0.9-1.0)
--
0.256
Comorbidities
>1 1.07 (1.0-1.2) 0.170
Ethnicity
Non-Spanish, Non-Hispanic Origin
Spanish or Hispanic Origin
Ref
1.58 (1.2-2.1)
--
0.002
Race
White
Black
Ref
1.85 (1.2-2.9)
--
0.006
Facility Type
Community Cancer Program
Comprehensive CCP
Academic/NCI
Integrated Network Cancer Program
Ref
0.86 (0.7-1.1)
1.36 (1.0-1.8)
1.02 (0.8-1.4)
--
0.272
0.028
0.889

11. Results: Logistic Regression
Clinicopathologic Variables
Positive Lymph Nodes
OR (95% CI) p-value
Surgical Delay > 45 Days 1.14 (1.0-1.3) 0.035
Age (yrs.)
<55 yrs
55-64 yrs
65-74 yrs
75+ yrs
Ref
1.21 (0.9-1.6)
1.22 (0.9-1.6)
1.46 (1.1-1.9)
--
0.162
0.177
0.007
Female Sex 0.84 (0.8-0.9) 0.003
Comorbidities >1 1.00 (0.9-1.1) 0.946
Spanish or Hispanic Origin 1.17 (0.7-1.9) 0.491
Black Race 1.31 (0.82-2.4) 0.321
Tumor Location
Arm/Leg
Trunk
Head/Neck
Ref
1.41 (1.2-1.7)
0.98 (0.9-1.1)
--
<0.001
0.739
T Category
T1
T2
T3
T4
Ref
2.23 (1.9-2.6)
3.82 (2.8-5.2)
2.93 (2.2-3.9)
--
<0.001
<0.001
<0.001

12. Results: Cox Regression
Clinicopathologic Variables
Overall Survival
HR (95% CI) p-value
Surgical Delay > 45 Days 1.13 (1.0-1.2) 0.015
T category
T1
T2
T3
T4
Ref
1.19 (1.1-1.3)
1.58 (1.3-1.9)
2.08 (1.6-2.6)
--
0.001
<0.001
<0.001
Female Sex 0.66 (0.6-0.7) <0.001
Comorbidities >1 1.44 (1.3-1.6) <0.001
Spanish or Hispanic Origin 0.63 (0.4-0.9) 0.016
Black Race 0.61 (0.4-1.1) 0.080
Academic/NCI Facility 0.70 (0.6-0.9) 0.003
Lymph Node Positive 2.00 (1.8-2.2) <0.001

13. Limitations
• Retrospective design
• Analyses were limited by missing values for several clinicopathologic
variables

14. Conclusions
• Delay in the surgical resection of Merkel Cell Carcinoma is
associated with an increased incidence of nodal positivity and
decreased overall survival.
• Care should be taken to improve health care access among older
and minority patients to ensure timely surgical management of this
disease.

15. Thank You

16. Lopez-Aguiar AG, Okonkwo P, Hewitt DB, Beane J, Contreras C
The Ohio State University Wexner Medical Center
Association Between Surgical
Delay and Survival in the
Treatment of Merkel Cell
Carcinoma