Dermatologic surgery
Mohs micrographic surgery for melanoma: A prospective multicenter study

https://doi.org/10.1016/j.jaad.2019.05.057Get rights and content

Background

Single-institution studies show that frozen section Mohs micrographic surgery (MMS) is an effective treatment modality for cutaneous melanoma, but no multi-institutional studies have been published.

Objective

To characterize the use of MMS in the treatment of melanoma at 3 academic and 8 private practices throughout the United States, to recommend excision margins when 100% histologic margin evaluation is not used, and to compare actual costs of tumor removal with MMS vs standard surgical excision.

Methods

Prospective, multicenter, cohort study of 562 melanomas treated with MMS with melanoma antigen recognized by T cells 1 immunostaining.

Results

Primary trunk and extremity melanomas (noninvasive and invasive melanoma) achieved histologically negative margins in 97% of tumors with 10-mm margins, whereas 12-mm margins were necessary to achieve histologically negative margins in 97% of head and neck melanomas. Overall average cost per tumor treated was $1328.46.

Limitations

Nonrandomized and noncontrolled study.

Conclusions

MMS with melanoma antigen recognized by T cells 1 immunostaining safely provides tissue conservation and same-day reconstruction of histologically verified tumor-free margins in a convenient, single-day procedure. When comprehensive margin evaluation is not used, initial surgical margins of at least 10 mm for primary trunk/extremity and 12 mm for head/neck melanomas should be used to achieve histologically negative margins 97% of the time.

Section snippets

Patients

This study was initiated after Western Institutional Review Board review and approval (approval #20122132). The study consisted of 518 patients with 562 melanomas treated with MMS with MART-1 immunostaining prospectively recruited between April 8, 2013, and August 28, 2014. Inclusion criteria for our study were primary or recurrent melanoma confirmed by biopsy specimen, age 18 years or older, no clinical signs of regional or systemic disease, and treatment with MMS. All MMS procedures discussed

Patient and tumor characteristics

Demographics, clinical, and histopathologic characteristics of the 562 melanomas are outlined in Table II. When performing MMS, we consider “melanoma in situ”(MIS) and “lentigo maligna”(LM) the same for surgical margin purposes because they have been shown to be identical in prior studies.6, 9, 16 To avoid confusion, all in situ melanomas, regardless of histologic subtype, are referred to as NIM (noninvasive melanoma). Quantitatively, histologically characterized LM tumors (primary and

Discussion

Stronger evidence is needed to support surgical margins in the treatment of melanoma, particularly on the head, neck, hands, and feet. Current guidelines for excision margins are based on randomized controlled trials, but these trials only compared a wide margin against a wider margin, and in each trial, the more narrow margin was just as effective as the wider margin.10, 17, 18, 19, 20, 21, 22 Furthermore, these studies were limited to melanomas on the trunk and proximal extremities, leaving a

Conclusion

To our knowledge, this is the first-ever prospective multicenter study of MMS using frozen sections paired with MART-1 immunostaining for melanoma and represents an important step in refining and affirming information from previously published studies from single institutions on the utility of MMS for melanoma. Its prospective nature and numerous contributors from diverse facilities and geographic locations provides strong support for the value of immediate, complete margin evaluation with

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      Notably, most melanomas included in these landmark trials were located on the trunk and proximal extremities, leading to a paucity of data for melanomas of the head and neck as well as other special sites.1 The advent of MMS, developed and pioneered by Dr Frederic E. Mohs, a general surgeon in the 1930s, revolutionized the definitive management of cutaneous malignancies.5–7 Unlike traditional WLE, which undergoes standard pathologic grossing and processing using “breadloaf,” also known as vertical sectioning and which allows for the histopathologic evaluation of less than 1% of the true surgical margin,6–9 the Mohs micrographic technique processed fresh-frozen tissue in a method that allowed for complete circumferential peripheral and deep margin assessment in real time, allowing for 100% true surgical margin assessment.5–7,9–12

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    Funding sources: 2012 American Society for Dermatologic Surgery Cutting Edge Research Grant ($5000).

    Conflicts of interest: None disclosed.

    The preliminary data were presented as a poster at the 2016 American College of Mohs Surgery on April 28, 2016 and as a brief presentation at the American Society for Dermatologic Surgery on November 6, 2014.

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