Comparison of surgical margins for lentigo maligna versus melanoma in situ.

BACKGROUND: Multiple studies have shown a 5-mm surgical margin to be inadequate for excision of melanoma in situ. Some have suggested that a wider margin is needed only for the lentigo maligna subtype. OBJECTIVE: To compare subclinical extension of lentigo maligna with that of melanoma in situ. The secondary objective was to investigate the effect of other factors on extent of subclinical extension. METHODS: A prospectively collected series of noninvasive melanomas was studied. Original pathology reports were used to identify lentigo maligna and compare data for that subtype with data for the remaining melanomas in situ. RESULTS: A total of 1506 lentigo maligna cases and 829 melanomas in situ were included. To obtain a 97% clearance rate, both lentigo maligna and melanoma in situ required a 12-mm margin on the head and neck and a 9-mm margin on the trunk and extremities. Only 79% of lentigo maligna and 83% of melanoma in situ were successfully excised with a 6-mm margin (P = .12). Local recurrence was identified in 0.26% (5 facial, 1 scalp, and 1 acral), with a mean follow-up time of 5.7 years. LIMITATIONS: Margins less than 6 mm were not studied. The use of lentigo maligna diagnosis was not used by all dermatopathologists consistently. The degree of surrounding photodamage was not assessed. CONCLUSION: Subclinical extension of lentigo maligna and melanoma in situ are similar. Standard surgical excision of all melanoma in situ subtypes, including lentigo maligna, should include at least 9 mm of normal-appearing skin, which is similar to the amount recommended for early invasive melanoma. Lesions on the head and neck or those with a diameter greater than 1 cm may require even wider margins and are best treated with Mohs micrographic surgery. The perception that lentigo maligna has wider subclinical extension may be related to its frequent location on the head and neck, where photodamage can camouflage the clinical border.

Surgical margins for melanoma in situ.

BACKGROUND: A controversy in the treatment of melanoma in situ is the required width of surgical margin. The currently accepted 5-mm margin is based on a 1992 consensus opinion, despite data since then showing this is inadequate. OBJECTIVE: We sought to develop guidelines for predetermined surgical margins for excision of melanoma in situ. METHODS: A prospectively collected series of 1072 patients with 1120 melanoma in situs was studied. All lesions were excised by Mohs micrographic surgery with frozen-section examination of the margin. The minimal surgical margin was 6 mm, and the total margin was calculated by adding an additional 3 mm for each subsequent stage required. The minimum surgical margin that would successfully remove 97% of all tumors was calculated. Local recurrence was also tabulated. RESULTS: In all, 86% of melanoma in situs were successfully excised with a 6-mm margin; 9 mm removed 98.9% of melanoma in situs. The superiority of 9-mm to 6-mm margins was significant (P < .001). Gender, location, and diameter did not affect results. Recurrence rate for this set of patients treated with Mohs micrographic surgery was 0.3% (n = 3). LIMITATIONS: Margins less than 6 mm were not studied. This is a referral center for melanoma in situ and 10% of tumors were previously treated before presentation to our clinic. CONCLUSION: The frequently recommended 5-mm margin for melanoma is inadequate. Standard surgical excision of melanoma in situ should include 9 mm of normal-appearing skin, similar to that recommended for early invasive melanoma.

Approach to the morbilliform eruption in the hematopoietic transplant patient.

Morbilliform eruptions occur frequently in the hematopoietic transplant population. The differential diagnosis includes drug reaction, viral exanthem, and cutaneous graft versus host disease. Using a typical patient case, we discuss the diagnostic approach to this clinical problem.

Epidermodysplasia verruciformis in the setting of graft-versus-host disease.

We report a case of epidermodysplasia verruciformis (EV)-like lesions in a patient with graft-versus-host disease after peripheral blood stem cell transplantation from his HLA-matched brother. The patient presented with a diffuse papular eruption that was clinically consistent with graft-versus-host disease; however, histopathology demonstrated viral cytopathic changes and polymerase chain reaction confirmed EV human papillomavirus types 8 and 20. Repeated biopsy specimen showed both human papillomavirus cytopathic effect and graft-versus-host disease, and further workup revealed ocular and hepatic involvement. This progressed to a lupuslike syndrome with lichenoid, violaceous, flat-topped papules in a malar distribution and positive antinuclear autoantibodies. Although EV-like lesions have been reported in patients who are immunocompromised, the incidence is low, and may be linked to EV-related haplotypes.

Laser therapy for leg veins.

Visible veins on the leg are a common cosmetic concern affecting approximately 80% of women in the United States (Engel A, Johnson MI, Haynes SG. Health effects of sunlight exposure in the United States: results from the first national health and nutrition examination survey, 1971-1974. Arch Dermatol 1988;124:72-9). Without a quick and noninvasive treatment available, leg veins present a therapeutic challenge. This challenge has been tackled by the design of lasers with longer pulse durations, and the use of lasers with longer wavelengths and cooling devices. Recent studies show the efficacy of laser treatment beginning to approach that of sclerotherapy, the gold standard. This review outlines the principles guiding laser treatment, the current available options, and a clinically oriented approach to treating leg veins.