Lentigo maligna melanoma mapping using reflectance confocal microscopy correlates with staged excision: A prospective study.

BACKGROUND: Lentigo maligna/lentigo maligna melanoma (LM/LMM) can present with subclinical extension that may be difficult to define preoperatively and lead to incomplete excision and potential recurrence. Preliminarily studies have used reflectance confocal microscopy (RCM) to assess LM/LMM margins. OBJECTIVE: To evaluate the correlation of LM/LMM subclinical extension defined by RCM compared with the gold standard histopathology. METHODS: Prospective study of LM/LMM patients referred for dermatologic surgery. RCM was performed at the clinically defined initial surgical margin followed by margin-controlled staged excision with paraffin-embedded tissue, and histopathology was correlated with RCM results. RESULTS: Seventy-two patients were included. Mean age was 66.8 years (standard deviation, 11.1; range, 38-89); 69.4% were men. Seventy of 72 lesions (97.2%) were located on the head and neck with mean largest clinical diameter of 1.3 cm (range, 0.3-5). Diagnostic accuracy for detection of residual melanoma in the tumor debulk (after biopsy) had a sensitivity of 96.7% and a specificity of 66.7% when compared with histopathology. RCM margin assessment revealed an overall agreement with final histopathology of 85.9% (κ = 0.71; P < .001). LIMITATIONS: No RCM imaging beyond initial planned margins was performed. CONCLUSION: RCM showed moderate to excellent overall agreement between RCM imaging of LM/LMM and histopathology of staged excision margins.

Limitations in the literature regarding Mohs surgery and staged excision for melanoma: A critical review of quality and data reporting.

BACKGROUND AND OBJECTIVES: The literature supporting Mohs micrographic surgery and staged excision in treating primary cutaneous melanoma is growing but has not been critically reviewed for bias. METHODS: Articles concerning Mohs micrographic surgery and staged excision for melanoma were assessed using modified "Risk of Bias in Non-randomized Studies of Interventions" (ROBINS-I) criteria, which measures bias in 7 categories. RESULTS: Forty-seven of 48 (97.9%) studies reviewed had serious or critical bias. None were randomized controlled trials. The most frequent cause of critical bias was poorly defined outcomes. The least frequent form of bias observed was change in intervention. LIMITATIONS: The modified ROBINS-I criteria cannot account for all study limitations. Modification of the criteria leads to some degree of subjectivity. CONCLUSION: The current body of literature suffers from limitations due to serious or critical bias in 1 or more ROBINS-I criteria. Local recurrence rate definitions are often poorly defined or not defined at all. Longer follow-up times, clear tumor classifications, and prospective, randomized study designs are necessary to improve the quality of future research.

Understanding melanoma in situ: Lentigo maligna surgical treatment terminology and guideline adherence, a targeted review.

BACKGROUND: Malignant melanoma in-situ, lentigo maligna (MMIS-LM) can be successfully treated with several different surgical techniques; however, the literature is inconsistent in defining them. OBJECTIVE: To comprehensively define and describe the national guideline recommended surgical techniques used to treat MMIS-LM to help clarify and standardize this terminology to ensure compliance with the guidelines. METHODS: A targeted literature review was performed from 1990 to 2022 focusing on articles that discussed the national guideline recommended surgical techniques of wide local excision, Mohs micrographic surgery (MMS), modified Mohs surgery, and staged excision/Slow-Mohs for MMIS-LM, as well as the related methods of tissue processing. National Comprehensive Cancer Network and American Academy of Dermatology guidelines were reviewed to identify how the techniques need to be employed to be compliant with guideline recommendations. RESULTS: We describe the various surgical and tissue processing techniques and discuss advantages and disadvantages of each. LIMITATIONS: This paper was styled as a narrative review defining and clarifying terminology and technique and does not investigate these topics more broadly. CONCLUSION: Understanding the methodology and terminology for these surgical procedures and tissue processing methods is critical so that both general dermatologists and surgeons can employ these techniques effectively for optimal patient care.

Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision.

BACKGROUND: Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. OBJECTIVE: To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. METHODS: A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. RESULTS: Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). LIMITATIONS: Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. CONCLUSION: Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.

Outcomes of Staged Excision With Circumferential en Face Margin Control for Lentigo Maligna of the Head and Neck.

BACKGROUND: Treatment practices vary for lentigo maligna (LM). Staged excision with circumferential margin control (SECMC) has the potential to achieve low recurrence rates. OBJECTIVES: To evaluate the clinical outcomes of SECMC using permanent, paraffin-embedded sections and delayed reconstruction. METHODS: We conducted a retrospective, uncontrolled, observational cohort study involving patients who underwent staged excision for LM of the head and neck at Women's College Hospital in Toronto, Canada, from September 2010 to March 2013. Recurrence and infection rates were ascertained from patient charts and postal surveys. RESULTS: One hundred and two patients (45 female, 57 male) were included with a median follow-up time of 1410.5 (IQR 260-1756) days. The median age was 69 (IQR 61-79) years. Approximately one-fifth (21%, 21/102) of patients required greater than 0.5 cm margins to achieve histological clearance. One patient (1/102) upstaged to invasive melanoma based on the initial stage of excision. The infection rate was 6% (6/102) and the 5-year cumulative recurrence rate was 1.4% (95% CI 0.2-9.6%). CONCLUSION: SECMC using permanent sections and delayed reconstruction appears to be a safe and effective treatment method for LM on the head and neck. Randomized trials are needed to help define the optimal treatment.

Guidelines of care for the management of primary cutaneous melanoma.

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

Is melanocyte density our last hope? Comparison of histologic features of photodamaged skin and melanoma in situ after staged surgical excision with concurrent scouting biopsies.

Differentiating melanocytic hyperplasia (MH) on photodamaged skin from junctional lentiginous melanocytic proliferations (JLMP), early evolving melanoma in situ (MIS), or the periphery of a lesion of MIS on staged excision can be challenging. Although previous cross-sectional studies have elucidated important criteria for distinguishing MH on photodamaged skin from more concerning lesions, this study highlights a technique to treat JLMP and MIS with staged mapped excision and baseline scouting biopsies of adjacent nonlesional photodamaged skin to assist in determination of surgical margin clearance. Additionally, we compare the lesional and photodamaged control biopsies from the same patient to evaluate relevant histologic criteria that may be used to distinguish MH in photodamaged skin from JLMP/MIS, while minimizing confounding factors. There was a statistically significant difference (P ≤ 0.05) found for melanocyte density, irregular melanocyte distribution, melanocyte clustering, follicular infundibulum involvement, and nesting. However, criteria such as nesting, epithelioid cells and melanocyte clustering were seen in both photodamaged skin and MIS. These findings underscore the fact that histologic features of photodamaged skin can overlap with the histopathological features of MIS. Of all of the criteria evaluated, melanocytic density was the most objective histologic criterion and did not show overlap between the sun-damaged and JLMP/MIS groups.

Comparison of treatment options for small to medium congenital melanocytic nevi: A retrospective review of 119 cases.

OBJECTIVES: For small to medium sized congenital melanocytic nevi (CMN), the treatment of choice is staged surgical excision. Ablative lasers or pigment-specific lasers have also been recommended for lesions difficult for surgical removal or to avoid surgery. In this study, we retrospectively analyzed the results of several treatment options for CMN to find out the optimal treatment method. METHODS: Patients with small to medium sized CMN were retrospectively reviewed. Treatment options were categorized into four groups: (i) Excision only; (ii) Excision followed by scar laser; (iii) Excision followed by pigment-specific laser; and (iv) Laser only. Treatment response was assessed by investigator's global assessment (IGA) score on a seven-point scale. RESULTS: A total of 119 cases were included. Lesions were most commonly located on the face (59/119, 49.6%), measured 2 ∼ 10 cm in size (72/119, 60.5%), and treated with excision only (50/119, 42.0%). Among treatment options, excision followed by scar laser showed the highest IGA score of 6.38. Options including surgical methods showed higher IGA scores compared to laser-only treatment (P < 0.01). Staged excisions and single excisions showed no difference in IGA scores. Patient satisfaction scores increased after scar laser treatment of the staged excision scar. CONCLUSIONS: For the treatment of small to medium sized CMN, treatment strategies including surgical methods are cosmetically superior to laser-only treatment. Also, the combination of surgical excision with scar laser has the potential for better clinical outcomes and patient satisfaction. Lasers Surg. Med. 51:62-67, 2019. © 2018 Wiley Periodicals, Inc.

Staged Mosaic Punching Excision of a Kissing Nevus on the Eyelid.

BACKGROUND: A congenital divided nevus, also known as kissing nevus, is a type of congenital compound nevus that affects equal areas of the upper and lower eyelids. The edges of the nevus touch or "kiss" during closure of the lids, owing to its extension to the lid margins. Multiple treatment modalities, such as dermabrasion, cryotherapy, primary closure after excision, and skin grafts, have been proposed; however, complications such as recurrence, ectropion, skin color mismatch, and scar contractures are known to occur. This study aimed to introduce a staged excision using the 10,600-nm CO2 pulsed laser to remove a congenital divided nevus without noticeable complications. MATERIALS AND METHODS: From August 2015 to December 2018, patients with congenital divided nevus underwent staged laser excision. Seven patients underwent staged mosaic pattern punch excision with a laser. Eight patients underwent concomitant excision, and one patient underwent skin grafting of the medial canthus. Patient satisfaction was assessed immediately and at 3 months after the procedure. RESULTS: During the study period, 15 patients (10 women and 5 men), with a mean age of 26.0 years (range 13-73 years), underwent laser excision. Continuity of the eyelid margins was maintained in 13 patients. In one patient, the eyelashes grew inward and developed inflammation. No patient developed complications during the healing process, except for partial loss of cilia. Eleven patients were very satisfied, whereas three were satisfied with the results. One patient discontinued treatment after two laser sessions. CONCLUSION: We performed multiple staged mosaic punching excisions of a congenital divided nevus with the CO2 laser in 15 cases. We observed consistent therapeutic results without definite recurrence, while maintaining the continuity of the eyelid and eyelash. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Staged margin-controlled excision (SMEX) for lentigo maligna melanoma in situ.

BACKGROUND: No consensus exists regarding the best surgical strategy to achieve clear surgical margins while minimizing tissue excision when definitely excising lentigo maligna melanoma in situ (LM). The staged margin controlled excision (SMEX) technique is a modification of the spaghetti technique that allows surgeons to minimize margins and ensure complete excision of LM. OBJECTIVES: Our objectives were twofold: a) to evaluate the effectiveness of SMEX for treatment of LM and b) detail the SMEX technique. METHODS: A retrospective chart review of adult patients who underwent the SMEX technique for treatment of LM from 2011 to 2016 was conducted. RESULTS: Twenty-four patients were identified with predominantly facial lesions. The mean defect size was 12.1 cm2 . A mean number of two SMEX procedures, with an average margin of 9 mm, were required to obtain complete excision of the LM. Using SMEX, we achieved 100% clearance of LM over a median follow up period of 18 months, with a range of 1-63 months. CONCLUSIONS: SMEX offers a reliable surgical excision method that ensures complete excision of LM in a cosmetically sensitive manner. The recurrence outcomes of SMEX are comparable, if not better, than those of alternative excision techniques in the literature.

Lentigo maligna melanoma with a history of cosmetic treatment: Prevalence, surgical outcomes and considerations.

INTRODUCTION: Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes. STUDY DESIGN AND METHODS: Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006-2015). Prior cosmetic treatment and biopsies were recorded. Records were reviewed for demographic data, clinical characteristics, and surgical outcomes. RESULTS: 37/503 (7.4%) patients with LM reported prior cosmetic therapy. Most (95%) were on the head and neck; mean size 1.9 cm. Most patients reported cryotherapy (73%), followed by laser (29.7%), topical bleaching agents (18.9%), and electrodessication, and/or curettage (5.3%). Ten patients (27%) received two or more modalities. Eight patients (21.6%) reported prior benign biopsies. Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (11.7%) upstaged upon excision. Average margin for clearance was 9.1 mm. CONCLUSION: Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins. Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment. Lasers Surg. Med. 49:819-826, 2017. © 2017 Wiley Periodicals, Inc.

Case report: Staged tension-reducing excision of giant acquired vulvar lymphangioma secondary to cervical cancer surgery.

Introduction: Acquired vulvar lymphangioma (AVL), a rare disease caused by the dilation of superficial lymphatic vessels secondary to deep lymphatic vessel injury, is characterized by a wide range of morphological diversity and massive exudate. This morphological heterogeneity has often led to misdiagnosis or non-diagnosis. The management of AVL presents a therapeutic challenge due to the absence of a standardized treatment protocol. Case presentation: A 53-year-old female patient, previously received surgical treatments for stage IIb cervical squamous cell carcinoma, presented with vulvar enlargement and copious amount of yellow exudate seven years post-treatment. Clinically, the patient exhibited chronic vulvar swelling, with easily-exudated nodules. The vulvar biopsy revealed lymphatic vessel dilation with lymphocyte infiltration, consistent with AVL. Due to the extensive lesions and severe exudate, staged excisions of bilateral vulvar lesions were performed at one-month intervals. Follow-up examinations of this patient for one-year post-surgery showed no evidence of recurrence. Conclusion: In this instance, AVL manifest secondary to cervical cancer surgery, as a result of damage to the deep lymphatic vessels of the vulva, with characteristic symptoms of copious amounts of exudate and vulvar lesions with diverse morphologies, which provides a cautionary note for physicians. Besides, the staged resection strategy in this case may offer insights into surgical treatment protocol for extensive AVL.

Staged melanoma excision requires larger margins for tumor clearance and results in low rates of recurrence.

There is controversy regarding the optimal surgical modality and ideal recommended margins for treating melanoma in situ (MIS) and invasive melanoma (IM). Although wide local excision is recommended, staged excision offers excellent margin control and low recurrence rates. In this manuscript, we reviewed a 10-year experience of staged excisions for the treatment of MIS and IM. A retrospective review was performed of 130 MIS and 32 IM cases treated with staged excision from April 2012 to April 2022. Staged excision was performed on the head and neck in 102 (79%) MIS and 23 (72%) IM cases. Approximately 10% of cases required surgical margins above the current recommendations (11 (9%) MIS and 6 (19%) IM). Twenty-three (19%) MIS and 7 (22%) IM cases required more than one excision to obtain clearance. Recurrence rates among MIS and IM were 0.0% and 0.6%, respectively. Upstaging occurred in 5 (4%) MIS and 7 (22%) IM cases. Complex repairs were performed on 82 (63%) MIS and 17 (53%) IM cases. Our findings revealed that staged excision provides effective margin control and low recurrence rates. Approximately 10% of patients required margins greater than the current recommendations, leading to larger defects and more complex repairs.

Lentigo Maligna of the head and neck: A retrospective study assessing surgical excision margins in a South African population.

Background: Lentigo maligna (LM) is a subtype of melanoma in situ that occurs on sun-damaged skin and is associated with significant subclinical extension beyond the clinical margins of the lesion. Objectives: This study aimed to determine if the standard recommended tumor excision margins for LM are adequate to achieve a 97% clearance rate and if any patient or tumor characteristics warranted wider margins. Methods: This study is a retrospective chart review of all patients who were diagnosed with LM of the head and neck and treated with staged excision. Results: The study included 64 patients. With a 6 mm surgical excision margin, only 60.9% of LM were completely excised. A 9 mm margin resulted in complete clearance of 71.9% of LM cases, and a 12 mm margin resulted in complete clearance in 90.6%. A surgical excision margin of 18 mm would have been required to excise 96.7% of tumors completely. Recurrent tumors (P = .01) and tumor size larger than 20 mm were associated with wider surgical excision margins (P = .154). Conclusion: This study of LM in a South African population corroborates that the standard surgical excision margins recommended by international melanoma guidelines for LM are inadequate to achieve a 97% clearance rate.

Staged Excision Technique to Reduce Scar Length.

Patients and surgeons are often disappointed with the scar length after conventional staged excision of large disfiguring skin lesions. We have developed an alternative approach to facilitate scar length reduction. We aimed to report the efficacy of our staged excision method, which includes a hexagonal-pattern excision, wide undermining, and purse-string suture. Sixty-five patients, each with one lesion, were included in the current study. The lesion length and width were recorded, and the scar area was calculated at each stage. The final scar length after performing the altered staged excision method was compared with that obtained after the conventional staged excision method, which was calculated using a theoretical scar model. Patient satisfaction was also evaluated. The mean longest axis length was 9.41 ± 3.83 cm preoperatively, 9.50 ± 3.92 cm after the first stage postoperatively, and 10.19 ± 3.98 cm after the final stage. The mean lesion width was 6.50 ± 3.48 cm preoperatively, 3.60 ± 1.77 cm after the first stage postoperatively, and 0.42 ± 0.31 cm after the final stage. The final scar length obtained using the altered procedure was much shorter than what would be obtained using conventional staged excision. The patient satisfaction score was 8.8 ± 1.1 out of a possible 10.0 rating. Staged excision with a hexagonal-pattern excision, wide undermining, and purse-string closure may improve aesthetic results.

Lentigo Maligna: Clinical Presentation and Appropriate Management.

Lentigo maligna (LM) is a type of melanoma in situ that has distinctive characteristics regarding epidemiology, risk factors and clinical features. In addition, LM has a potential to progress to an invasive tumor with potentially aggressive behavior: lentigo maligna melanoma (LMM). Overall, LM has a very good prognosis, whereas LMM has the same prognosis as other invasive melanomas with similar Breslow thickness. LM/LMM represents a challenging entity not only regarding the diagnosis but also regarding the management. Diagnostic criteria are not well established, and there is an overlap of clinical, dermoscopic and pathological features with other benign pigmented skin lesions such as lentigines, pigmented actinic keratoses or macular seborrheic keratoses. LM/LMM's common appearance within photodamaged skin makes lesion border identification difficult. Wide excisions are often required, but since LM/LMM typically appears on cosmetically sensitive areas such as the face, sometimes large excisions are not possible nor desirable. In this sense, specialized approaches have been developed such as margin-controlled surgery or image-guided treatment using reflectance confocal microscopy. Other treatments for LM such as cryosurgery, imiquimod, radiotherapy or photodynamic therapy have been proposed, although recurrence/persistence is common. The current manuscript reviews extensively the published data regarding the diagnosis, treatment and management of both complex entities LM and LMM.

Recurrence Rate of Melanoma in Situ when Treated with Serial Disk Staged Excision: A Case Series.

BACKGROUND: Cutaneous melanoma is one of the fastest rising cancer diagnoses in recent years. Melanoma in situ (MIS) constitutes a large proportion of all diagnosed melanomas. While surgical excision is considered the standard of therapy, the literature is not clear on which surgical technique minimizes local recurrence. A common technique is serial staged excision (SSE), in which a series of mapped excisions are made according to histopathological examination of tissue. Previously published recurrence rates for SSE ranges from 0-12%, over a range of 4.7-97 months of mean follow-up. OBJECTIVE: To investigate the recurrence rate of MIS when excised using a serial disk staged excision technique with tissue marked at 12 O'clock for mapping, rush permanent processing and histologic examination, 3-suture tagging for subsequent stages, and "breadloafing" microscopic analysis. Additionally, to determine the relationship between initial lesion size and subsequent stages of excision required for clearance, and final surgical margin. METHODS: Single-institution retrospective chart review of 29 biopsy confirmed MIS lesions treated with our variant of SSE. Statistical analysis via independent t-tests. RESULTS: No recurrences were observed with mean follow-up of 31.5 months (SD 13.9), over range of 12-58 months. Mean surgical margin of 13.1 mm (SD 5.9). A trend towards larger surgical margin was seen with increasing pre-operative lesion size. CONCLUSION: This method of SSE for treatment of MIS is comparable in efficacy to other SSE techniques, and may offer physicians a relatively simple, efficacious, and accessible alternative to wide local excision and Mohs micrographic surgery.