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Surgical Management of Melanoma-In-Situ Using a Staged Marginal and Central Excision Technique

  • Melanomas
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Abstract

Melanoma-in-situ (MIS) represents 45% of all melanomas. The margins of MIS are often poorly defined with extensive subclinical disease. Standard fusiform excision with 5-mm margins results in positive margins in up to a third of cases. To decrease the incidence of involved margins, we use a staged excision approach for MIS. First, patients undergo excision under local anesthesia of a 2- to 3-mm “contoured” rim of tissue optimally 5 mm beyond the visible extent of the lesion. Formalin-fixed paraffin-embedded en face sections from this excision are then evaluated, if necessary with the aid of immunohistochemical stains. Any positive margins are further excised. When all margins are negative, the central area is then excised and reconstructed. A total of 61 patients with MIS or lentigo maligna melanoma underwent staged contoured excisions from 2004 to 2007 at Moffitt Cancer Center. We analyzed data only from patients with MIS of the head and neck. Patients with known invasive melanoma or non–head and neck primary disease were excluded. Demographics, tumor characteristics, margin status, number of stages, and type of reconstruction and recurrences were evaluated. Forty-nine patients with MIS of the head and neck, 28 (57%) male and 21 (43%) female, 42 to 88-years-old (median 72; mean 70), underwent staged contoured margin excision before definitive central tumor excision and reconstruction. The final surgical defect size ranged from 2 to 130 cm2 (median 16 cm2). Twelve patients (24%) required reexcision of at least one margin; the median number of reexcisions was 1 (range 1–2). There seemed to be a positive association between lesion size and margin status (as well as number of excisions needed to clear the margin). Unsuspected invasive melanoma was found in the central specimen in six patients (12%). Even small tumors could have unsuspected invasive melanoma: invasive cancer was seen in 4 (21%) of 19 tumors ≤2 cm in greatest dimension and 2 (7%) of 30 > 2 cm, respectively. Surgical defects were reconstructed with flaps in 18 (37%), full-thickness grafts in 20 (41%), and split-thickness grafts in 10 patients (20%). Median time from first margin excision to completion/final reconstruction was 7 days (range 7–63 days). No local recurrences have been reported at a median follow-up of 14 months (range 1–36 months). This technique allows for careful margin analysis and subsequent central tumor excision with simultaneous reconstruction. This approach minimizes the need for a second major operation, which would have been necessary in 24% of our patients if treated by a one-stage excisional approach. It is noteworthy that 12% of MIS patients had invasive melanoma in the final excision specimen. This reinforces the importance of adequate full-thickness biopsies of suspicious pigmented lesions before any type of surgical management. With short follow-up, local control has been achieved by this technique in 100% of cases.

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References

  1. Davis T, Zembowicz A. Histological evolution of lentiginous melanoma: a report of five new cases. J Cutan Pathol. 2007;34:296–300.

    Article  PubMed  Google Scholar 

  2. Tannous ZS, Lerner LH, Duncan LM, et al. Progression to invasive melanoma from malignant melanoma in situ, lentigo maligna type. Hum Pathol. 2000;31:705–8.

    Article  PubMed  CAS  Google Scholar 

  3. Cohen LM. Lentigo maligna and lentigo maligna melanoma. J Am Acad Dermatol. 1995;33:923–36.

    Article  PubMed  CAS  Google Scholar 

  4. Wayte DM, Helwig EB. Melanotic freckle of Hutchinson. Cancer. 1968;21:893–911.

    Article  PubMed  CAS  Google Scholar 

  5. Bub JL, Berg D, Slee A, et al. Management of lentigo maligna and lentigo maligna melanoma with staged excision: a 5-year follow-up. Arch Dermatol. 2004;140:552–8.

    Article  PubMed  Google Scholar 

  6. Kelly JW. Following lentigo maligna may not prevent the development of life-threatening melanoma. Arch Dermatol. 1992;128:657–60.

    Article  PubMed  CAS  Google Scholar 

  7. Breuninger H, Schlagenhauff B, Stroebel W, et al. Patterns of local horizontal spread of melanomas: consequences for surgery and histopathologic investigation. Am J Surg Pathol. 1999;23:1493–8.

    Article  PubMed  CAS  Google Scholar 

  8. Cohen LM. Lentigo maligna and lentigo maligna melanoma. J Am Acad Dermatol. 1997;36(6 Pt 1):913.

    PubMed  CAS  Google Scholar 

  9. Weinstock MA, Sober AJ. The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol. 1987;116:303–10.

    Article  PubMed  CAS  Google Scholar 

  10. Jones WO, Harman CR, Ng AK, et al. Incidence of malignant melanoma in Auckland, New Zealand: highest rates in the world. World J Surg. 1999;23:732–5.

    Article  PubMed  CAS  Google Scholar 

  11. Newell GR, Sider JG, Bergfelt L, et al. Incidence of cutaneous melanoma in the United States by histology with special reference to the face. Cancer Res. 1988;48:5036–41.

    PubMed  CAS  Google Scholar 

  12. Swetter SM, Boldrick JC, Jung SY, et al. Increasing incidence of lentigo maligna melanoma subtypes: northern California and national trends 1990–2000. J Invest Dermatol. 2005;125:685–91.

    Article  PubMed  CAS  Google Scholar 

  13. NIH Consensus conference. Diagnosis and treatment of early melanoma. JAMA. 1992 ;268:1314–9.

    Article  Google Scholar 

  14. National Comprehensive Cancer Network clinical practice guidelines in oncology: melanoma. v.2.2007. Available at: http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf. Accessed September 1, 2007.

  15. Balch CM, Urist MM, Karakousis CP, et al. Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multi-institutional randomized surgical trial. Ann Surg. 1993;218:262–7.

    Article  PubMed  CAS  Google Scholar 

  16. Veronesi U, Cascinelli N. Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. Arch Surg. 1991;126:438–41.

    CAS  Google Scholar 

  17. Grande DJ, Koranda FC, Whitaker DC. Surgery of extensive, subclinical lentigo maligna. J Dermatol Surg Oncol. 1982;8:493–6.

    PubMed  CAS  Google Scholar 

  18. Albertini JG, Elston DM, Libow LF, et al. Mohs micrographic surgery for melanoma: a case series, a comparative study of immunostains, an informative case report, and a unique mapping technique. Dermatol Surg. 2002;28:656–65.

    Article  PubMed  Google Scholar 

  19. Osborne JE, Hutchinson PE. A follow-up study to investigate the efficacy of initial treatment of lentigo maligna with surgical excision. Br J Plast Surg. 2002;55:611–5.

    Article  PubMed  CAS  Google Scholar 

  20. Bricca GM, Brodland DG, Zitelli JA. Immunostaining melanoma frozen sections: the 1-hour protocol. Dermatol Surg. 2004;30:403–8.

    Article  PubMed  Google Scholar 

  21. Huilgol SC, Selva D, Chen C, et al. Surgical margins for lentigo maligna and lentigo maligna melanoma: the technique of mapped serial excision. Arch Dermatol. 2004;140:1087–92.

    Article  PubMed  Google Scholar 

  22. Zalla MJ, Lim KK, Dicaudo DJ, et al. Mohs micrographic excision of melanoma using immunostains. Dermatol Surg. 2000;26:771–84.

    Article  PubMed  CAS  Google Scholar 

  23. Agarwal-Antal N, Bowen GM, Gerwels JW. Histologic evaluation of lentigo maligna with permanent sections: implications regarding current guidelines. J Am Acad Dermatol. 2002;47:743–8.

    Article  PubMed  Google Scholar 

  24. Pitman GH, Kopf AW, Bart RS, et al. Treatment of lentigo maligna and lentigo maligna melanoma. J Dermatol Surg Oncol. 1979;5:727–37.

    PubMed  CAS  Google Scholar 

  25. Coleman WP 3rd, Davis RS, Reed RJ, et al. Treatment of lentigo maligna and lentigo maligna melanoma. J Dermatol Surg Oncol. 1980;6:476–9.

    PubMed  Google Scholar 

  26. Anderson KW, Baker SR, Lowe L, et al. Treatment of head and neck melanoma, lentigo maligna subtype: a practical surgical technique. Arch Facial Plast Surg. 2001;3:202–6.

    Article  PubMed  CAS  Google Scholar 

  27. Mahoney MH, Joseph M, Temple CL. The perimeter technique for lentigo maligna: an alternative to Mohs micrographic surgery. J Surg Oncol. 2005;91:120–5.

    Article  PubMed  Google Scholar 

  28. Somach SC, Taira JW, Pitha JV, et al. Pigmented lesions in actinically damaged skin. Histopathologic comparison of biopsy and excisional specimens. Arch Dermatol. 1996;132:1297–302.

    Article  PubMed  CAS  Google Scholar 

  29. Cohen LM, McCall MW, Zax RH. Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. A follow-up study. Dermatol Surg. 1998;24:673–7.

    Article  PubMed  CAS  Google Scholar 

  30. Dawn ME, Dawn AG, Miller SJ. Mohs surgery for the treatment of melanoma in situ: a review. Dermatol Surg. 2007;33:395–402.

    Article  PubMed  CAS  Google Scholar 

  31. Kelley LC, Starkus L. Immunohistochemical staining of lentigo maligna during Mohs micrographic surgery using MART-1. J Am Acad Dermatol. 2002;46:78–84.

    Article  PubMed  Google Scholar 

  32. Davis DA, Kurtz KA, Robinson RA. Ultrarapid staining for cutaneous melanoma: study and protocol. Dermatol Surg 2005;31(7 Pt 1):753–6.

    PubMed  CAS  Google Scholar 

  33. Hendi A, Brodland DG, Zitelli JA. Melanocytes in long-standing sun-exposed skin: quantitative analysis using the MART-1 immunostain. Arch Dermatol. 2006;142:871–6.

    Article  PubMed  Google Scholar 

  34. Megahed M, Schon M, Selimovic D, et al. Reliability of diagnosis of melanoma in situ. Lancet. 2002;359(9321):1921–2.

    Article  PubMed  Google Scholar 

  35. Johnson TM, Headington JT, Baker SR, et al. Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the “square” procedure. J Am Acad Dermatol. 1997;37(5 Pt 1):758–64.

    Article  PubMed  CAS  Google Scholar 

  36. McKenna JK, Florell SR, Goldman GD, et al. Lentigo maligna/lentigo maligna melanoma: current state of diagnosis and treatment. Dermatol Surg. 2006;32:493–504.

    Article  PubMed  CAS  Google Scholar 

  37. Hill DC, Gramp AA. Surgical treatment of lentigo maligna and lentigo maligna melanoma. Australas J Dermatol. 1999;40:25–30.

    Article  PubMed  CAS  Google Scholar 

  38. Jejurikar SS, Borschel GH, Johnson TM, et al. Immediate, optimal reconstruction of facial lentigo maligna and melanoma following total peripheral margin control. Plast Reconstr Surg. 2007;120:1249–55.

    Article  PubMed  CAS  Google Scholar 

  39. Mahoney EJ, Dolan RW, Choi EE, et al. Surgical reconstruction of lentigo maligna defects. Arch Facial Plast Surg. 2005;7:342–6.

    Article  PubMed  Google Scholar 

  40. Temple CL, Arlette JP. Mohs micrographic surgery in the treatment of lentigo maligna and melanoma. J Surg Oncol. 2006;94:287–92.

    Article  PubMed  Google Scholar 

  41. Zitelli JA, Brown C, Hanusa BH. Mohs micrographic surgery for the treatment of primary cutaneous melanoma. J Am Acad Dermatol 1997;37(2 Pt 1):236–45.

    Article  PubMed  CAS  Google Scholar 

  42. Zalaudek I, Horn M, Richtig E, et al. Local recurrence in melanoma in situ: influence of sex, age, site of involvement and therapeutic modalities. Br J Dermatol. 2003;148:703–8.

    Article  PubMed  CAS  Google Scholar 

  43. Stevenson O, Ahmed I. Lentigo maligna: prognosis and treatment options. Am J Clin Dermatol. 2005;6:151–64.

    Article  PubMed  Google Scholar 

  44. Malhotra R, Chen C, Huilgol SC, et al. Mapped serial excision for periocular lentigo maligna and lentigo maligna melanoma. Ophthalmology. 2003;110:2011–8.

    Article  PubMed  Google Scholar 

  45. Walling HW, Scupham RK, Bean AK, et al. Staged excision versus Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. J Am Acad Dermatol. 2007;57:659–64.

    Article  PubMed  Google Scholar 

  46. Bhardwaj SS, Tope WD, Lee PK. Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma using Mel-5 immunostaining: University of Minnesota experience. Dermatol Surg. 2006;32:690–6.

    Article  PubMed  CAS  Google Scholar 

  47. Bricca GM, Brodland DG, Ren D, et al. Cutaneous head and neck melanoma treated with Mohs micrographic surgery. J Am Acad Dermatol. 2005;52:92–100.

    Article  PubMed  Google Scholar 

  48. Bienert TN, Trotter MJ, Arlette JP. Treatment of cutaneous melanoma of the face by Mohs micrographic surgery. J Cutan Med Surg. 2003;7:25–30.

    Article  PubMed  Google Scholar 

  49. Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision of primary cutaneous melanoma. J Am Acad Dermatol. 1997;37(3 Pt 1):422–9.

    Article  PubMed  CAS  Google Scholar 

  50. Dhawan SS, Wolf DJ, Rabinovitz HS, et al. Lentigo maligna. The use of rush permanent sections in therapy. Arch Dermatol. 1990;126:928–30.

    Article  PubMed  CAS  Google Scholar 

  51. Robinson JK. Margin control for lentigo maligna. J Am Acad Dermatol. 1994;31:79–85.

    Article  PubMed  CAS  Google Scholar 

  52. Cohen LM, McCall MW, Hodge SJ, et al. Successful treatment of lentigo maligna and lentigo maligna melanoma with Mohs’ micrographic surgery aided by rush permanent sections. Cancer. 1994;73:2964–70.

    Article  PubMed  CAS  Google Scholar 

  53. Zitelli JA. Surgical margins for lentigo maligna, 2004. Arch Dermatol. 2004;140:607–8.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, SRB 24016, Tampa, FL, 33612, USA

    Mecker G. Möller MD, Jonathan S. Zager MD, Christopher A. Puleo PA-C, L. Frank Glass MD, Jane L. Messina MD, Vernon K. Sondak MD & C. Wayne Cruse MD

  2. Department of Surgery, University of South Florida College of Medicine, Tampa, FL, USA

    Effie Pappas-Politis MD, Luis A. Santiago MD, Vernon K. Sondak MD & C. Wayne Cruse MD

  3. Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, FL, USA

    Jonathan S. Zager MD, Daohai Yu PhD & Vernon K. Sondak MD

  4. Department of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA

    Daohai Yu PhD & Weiwei Zhu MS

  5. Department of Epidemiology and Biostatisctics, University of South Florida College of Medicine, Tampa, FL, USA

    Daohai Yu PhD

  6. Department of Pathology and Cell Biology, University of South Florida College of Medicine, Tampa, FL, USA

    Amy Prakash MD & Jane L. Messina MD

  7. Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine, Tampa, FL, USA

    Adam Kinal MD, Graham S. Clark MD, L. Frank Glass MD & Jane L. Messina MD

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  1. Mecker G. Möller MD
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  2. Effie Pappas-Politis MD
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  8. Graham S. Clark MD
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  9. Weiwei Zhu MS
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  10. Christopher A. Puleo PA-C
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Correspondence to Mecker G. Möller MD.

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Möller, M.G., Pappas-Politis, E., Zager, J.S. et al. Surgical Management of Melanoma-In-Situ Using a Staged Marginal and Central Excision Technique. Ann Surg Oncol 16, 1526–1536 (2009). https://doi.org/10.1245/s10434-008-0239-x

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  • DOI: https://doi.org/10.1245/s10434-008-0239-x

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