Role of lasers and photodynamic therapy in the treatment of cutaneous malignancy

Tumor therapy is not a common indication for the use of lasers, as it is in the treatment of benign vascular skin lesions, since many alternative treatment modalities exist. However, certain patients may benefit from laser therapy of premalignant and malignant skin tumors. Skin tumors can be treated by laser excision, laser coagulation, laser vaporization, or photodynamic therapy (PDT). For these purposes, the carbon dioxide laser, the neodymium:yttrium aluminum garnet laser and the argon laser are particularly suitable. PDT is a therapeutic approach based on the photosensitization of the target tissue by topical or systemic photosensitizers and subsequent irradiation with light from a laser or a lamp inducing cell death via generation of reactive oxygen species. Laser therapy and PDT have shown good results in the curative treatment of actinic keratoses, superficial basal cell carcinoma, Bowen's disease and cheilitis actinica. However, they are not recommended for primary malignant melanoma and invasive squamous cell carcinoma. In some patients, lasers and PDT might also be used effectively for the palliative treatment of cutaneous metastases. In selected patients, lasers and PDT may offer some advantages over routine procedures, e.g. reduction of scarring and better cosmetic results. However, when treating invasive tumors with curative intention, one has to bear in mind the lack of histologic control and the limited depth of tissue penetration of most laser and PDT therapies.

Immunohistochemical staining of lentigo maligna during Mohs micrographic surgery using MART-1

BACKGROUND

Lentigo maligna (LM) often displays extensive subclinical spread. Mohs micrographic surgery (MMS) has been proposed to help delineate the true histologic margin; however, visualizing atypical melanocytes on frozen section is challenging and often requires confirmatory permanent paraffin sections.

OBJECTIVE

Our aim was to use a monoclonal antibody to rapidly stain frozen sections during MMS to facilitate better visualization of atypical melanocytes.

METHODS

Frozen sections of LM during MMS were stained with MART-1 (melanoma antigen recognized by T cells) and compared with paraffin-embedded sections.

RESULTS

We found 100% correlation between frozen sections stained with MART-1 and paraffin-embedded sections.

CONCLUSIONS

Atypical melanocytes can be better visualized on frozen sections of LM by using MART-1 rather than hematoxylin and eosin. This allows for easier identification during MMS and better chance of complete removal of LM lesions.

[Safety margins in the excision of primary malignant melanoma. Proposals based on controlled clinical trials]

Excisional biopsy is recommended as the procedure of choice whenever there is suspicion of malignant melanoma. Incisional biopsies are only rarely indicated. For nearly seventy years the debate about the optimum resection safety margin around the primary tumor was influenced by historical case reports and paradigms. Recently, controlled clinical studies have provided new insights. Accumulating evidence over the last two decades shows that narrower surgical margins influence neither the rate of satellites or in-transit-metastases nor the occurrence of advanced metastatic disease. Local recurrence is rare (approx. 0.1%) when primary tumors are thin and is seen more often (approx. 10%) in primary tumors of greater thickness (> 4 mm). Analysis of the overall survival in randomized trials shows equal prognosis for malignant melanoma for narrow and wide resection margins. Due to these findings in-toto excisional biopsy for in-situ melanoma, a resection margin of 1 cm for thin primary tumors (< 1 cm tumor thickness) and a resection margin of 1 to 2 cm for primary tumors greater than 1 mm appears sufficient. With these recommendations, primary closure of wounds will be possible in nearly all cases, reducing surgical costs and morbidity. This article should serve as a basis of discussion for the proposed revision of the current guidelines of the German Dermatologic Society (DDG) on the primary surgical care of melanoma patients.

A conservative surgical approach to the treatment of 'locally invasive' lentigo maligna melanoma of the face

Lentigo maligna has the potential for malignant change, and is managed in many cases by wide local excision. However, there are clinical situations in which aggressive surgical management is inappropriate or unsuccessful. We present three such cases, in which a more conservative surgical approach was adopted and maintained over several decades.

Treatment of head and neck melanoma, lentigo maligna subtype: a practical surgical technique

Melanoma with the lentigo maligna histological pattern often provides a significant and difficult challenge to the head and neck surgeon. The lentigo maligna subtype is the most common type of melanoma on the head and neck. This potentially lethal form of cancer is associated with greater nonvisual lesional extension that is often not clinically apparent. Failure to excise the entire lesion results in a higher risk of local recurrence and a poorer prognosis. The staged excision technique described herein results in histological interpretation of 100% of the peripheral margins using formalin-fixed vertical sections. Definitive local excision and soft tissue reconstruction are performed in a subsequent stage, with an assurance that 100% of the peripheral margins have been evaluated and interpreted as free of disease.

Ultraviolet-Assisted Punch Biopsy Mapping for Lentigo Maligna Melanoma

Lentigo maligna melanoma (LMM) accounts for a substantial incidence of all locally recurrent melanoma. In addition, the head and neck area accounts for 60% to 90% of all LMMs, which has important functional and cosmetic implications. The difficulty in the identification of the true borders of LMM may account for the high incidence of local recurrence. The purpose of this study was to evaluate the efficacy of ultraviolet-assisted punch biopsy mapping to identify clear margins using identified, 2-mm circumferentially arranged punch biopsies at the junction of the pigmented and nonpigmented borders. A retrospective chart review of 20 patients with biopsy-confirmed LMM of the head and neck was performed. Using ultraviolet identification, 2-mm circumferentially arranged biopsy specimens were obtained and sent for formal pathological review, including immunohistochemical staining. The average time for completion of pathological review was 5 to 7 days. If the punch biopsies were positive for lentigo maligna or LMM, punch biopsies were obtained more peripherally. Once clear, margins were obtained and definitive resection was performed. Twenty patients with biopsy-proved LMM were evaluated. Follow-up ranged from 6 months to 3 years (mean follow-up, 1 year). Fourteen patients were cleared after their first series of biopsies, 3 patients required a second series of biopsies, 2 patients required a third session, and 1 patient required a fourth biopsy session. To date, there has been no evidence of recurrence. No patients required reexcision for positive surgical margins. One complication has been local cellulitis of a punch biopsy site requiring a short course of antibiotics. Ultraviolet-assisted punch biopsy mapping of LMM is a safe, well-tolerated, and accurate technique for identifying the true histological margin of LMM. The procedure reduces the need for repeat surgical excisions to obtain clear margins and may decrease the risk for recurrence by mapping accurately the true histological margin.

Treatment of lentigo maligna

Lentigo maligna (LM) is an indolent form of melanoma in situ with the potential to progress to invasive melanoma. Early detection and adequate treatment prior to development to invasive melanoma are essential. Definitive excision with negative margins is currently the treatment of choice for LM. Conventional excision, Mohs micrographic surgical excision, and nonexcisional methods of treatment of LM will be discussed.

Spread of a recurrent lentigo maligna into a graft: a case for conservative treatment

Lentigo maligna is an in situ malignant melanoma for which the treatment of choice is surgical excision. The recurrence rate in lentigo maligna is high and hence other treatments, such as cryotherapy, laser therapy, radiotherapy and Mohs' chemosurgery, have been described. Despite the high recurrence rate, spread of a lentigo maligna into a skin graft is rare. We describe a case of a recurrent lentigo maligna spreading into a skin graft, which, along with the cases described in the literature, highlights the presence of a group of low-grade malignant lentiginous lesions that may be managed by careful follow-up and observation.

Survey of U.K. current practice in the treatment of lentigo maligna

BACKGROUND

Lentigo maligna (LM) is the in situ phase of LM melanoma (LMM). There is a paucity of data on the natural history of LM, the risk factors for progression to LMM and on treatment outcomes of the various modalities used.

OBJECTIVES

To investigate our impression that this, combined with the difficulties of treatment for large lesions particularly in the elderly and infirm, has led to considerable variation between dermatologists in the management of LM within the U.K.

METHODS

A postal questionnaire survey was performed to establish current practice.

RESULTS

One hundred and seventy clinicians representing one-third of U.K. consultant dermatologists responded. Fifty-seven per cent of the dermatologists reported treating only one to four LMs per year, 30% treated five to 10 LMs per year and only 13% treated more than 10 LMs per year. Ninety-four per cent of the respondents routinely took an initial biopsy to confirm the diagnosis and plan treatment. The preferred treatment option was dependent on the age of the patient. Dermatologists were far more likely to use surgery for patients under the age of 60 years and more likely to use cryotherapy/radiotherapy or merely to observe with increasing age. Where surgery was used, the excision margins chosen ranged from 0 to 10 mm.

CONCLUSIONS

This survey highlights that a significant proportion of U.K. dermatologists is managing small numbers of LMs each year. On the basis of this current practice and the data in the literature on the recurrence rates for the different modalities, we propose an algorithm for treatment options. The survey, however, showed no consensus between dermatologists regarding surgical margins for excision, which is reflected in the literature; further studies to establish this are required.

Amelanotic malignant melanoma following cryosurgery for atypical lentigo maligna

Cryosurgery is an alternative treatment option to surgical excision for lentigo maligna. Clinical evidence of recurrence is usually characterized by repigmentation at the treated site. We report two patients who developed amelanotic malignant melanoma following cryosurgery for a pigmented lentigo maligna. These cases illustrate the potential risk of treating lentigo maligna with cryosurgery.

Surgical management of primary melanoma

Melanoma precursor lesions and stage I malignant melanomas are preferentially removed by excisional surgery. Several studies have supported the concept of a more conservative excision strategy. Reduced safety margins with a maximum of 2-3 cm enable us to cover most defects by simple skin flap techniques. In critical anatomical sites and in lentigo maligna melanoma micrographic surgery has recently gained importance. The value of adjuvant surgical procedures remains controversial. Possibly, the technique of sentinel-node-biopsy provides a better approach towards a more selective use of lymphadenectomy in patients with clinically occult micrometastases.

Utility of rush paraffin-embedded tangential sections in the management of cutaneous neoplasms

BACKGROUND

Mohs micrographic surgery (MMS) modified by the use of tangential, formalin-fixed, paraffin-embedded histologic specimens is advantageous in treating selected skin neoplasms.

OBJECTIVE

To review the use of our experience with a modification of MMS to treat lentigo maligna melanoma (LMM), lentigo maligna (LM) and other melanoma in situ (MIS) lesions, dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and angiosarcoma.

METHODS

Our experience utilizing a modification of MMS in the treatment of 77 patients with LM or other MIS, 23 patients with LMM, 11 patients with DFSP, 1 patient with AFX, and 1 patient with angiosarcoma was reviewed. Length of follow-up and rate of recurrence were examined. A literature review of this pertinent modification of the Mohs technique was performed.

RESULTS

One hundred fourteen patients underwent MMS for melanocytic (LM, MIS, LMM), spindle cell (DFSP, AFX), and vascular malignant neoplasms. One patient developed locally recurrent LM and one patient with LMM developed satellite metastasis. Regional lymph node metastasis occurred in one patient with LMM and in a patient with angiosarcoma.

CONCLUSION

The use of Mohs micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.

Curettage, electrosurgery and skin cancer

The scientific literature is replete with reports extolling the virtues of curettage and electrosurgery in the treatment of skin disease. Published cure rates for selected skin cancers consistently equal those for other treatment modalities, including scalpel excision. Despite this, curettage is often overlooked as a first line treatment for skin cancer. We review the evidence-based literature for patient selection criteria and curettage and electrosurgery techniques.

Patterns of local horizontal spread of melanomas: consequences for surgery and histopathologic investigation

Understanding local spreading patterns of melanomas is a precondition for the localized surgical treatment and histopathologic investigation. We used hematoxylin and eosin-stained paraffin sections for a two-phase, cellular and microscopic study of patterns of lateral spread in superficial spreading melanomas (SSMs), nodular melanomas (NMs), lentigo maligna melanomas (LMMs), and acral lentiginous melanomas (ALMs). Complete histologic examination of vertical excisional margins was carried out with paraffin sections 5 mm beyond the clinical tumor border of 1395 SSMs, 376 NMs, 179 LMMs, 46 ALMs, and 37 acrally located SSMs or NMs. Further sections of embedded material were analyzed when tumor-positive margins were found. In case of continuous tumor spread, reoperations were continued until the tissue was free of tumor cells. In case of noncontinuity, a final excision was made to a minimum safety margin of 10 to 20 mm. Concentrically consecutive, 5-microm thick hematoxylin and eosin-stained sections were taken from the outside of a 10-mm safety margin inward to the clinical borders of 34 SSMs, five NMs, 10 LMMs, and five ALMs. Noncontinuous subclinical spread was found in all SSMs and NMs in the form of few isolated cell nests at the epidermis-dermis junction. Ninety-two percent of these were located within 6 mm of the central tumor. All LMMs and ALMs showed a clearly demonstrable, uninterrupted spread into the periphery at the epidermis-dermis junction, too, usually in groups of outgrowths. The probability of finding these outgrowths 5 mm beyond the clinical tumor border was 54% in LMM and ALM. Complete histologic examination of vertical excisional margins (micrographic surgery) is therefore the therapy of choice only for LMM and ALM and is inefficient for SSM and NM.

Amelanotic lentigo maligna melanoma: a unique case presentation

Amelanotic melanomas comprise only 2% of melanomas and are commonly a difficult clinical diagnosis, due to the lack of melanin pigment typically found in melanomas. Even rarer is the amelanotic lentigo maligna, which may have an unusual clinical presentation, such as erythema, pruritus, or edema. Biopsy is the key to diagnosis. Multiple therapies for amelanotic lentigo malignas have been tried, but excision, with margin control (Mohs micrographic surgery-frozen or paraffin sections), remains the treatment of choice.

Q-switched neodymium:yttrium-aluminum-garnet laser treatment of lentigo maligna

Lentigo maligna is a premalignant lesion of atypical melanocytes that typically arises on the head and neck of elderly patients. It is considered a melanoma in situ with a significant risk for transformation to invasive lentigo maligna melanoma. Surgery is the preferred method of treatment; however, because of the advanced age of the typical patient with lentigo maligna, the frequency of complicating medical problems, and the cosmetic or functional aspects of treatment, surgical excision is not always feasible. The purpose of this pilot study was to evaluate the efficacy and safety of Q-switched neodymium:yttrium-aluminum-garnet laser treatment of lentigo maligna. Eight patients were treated with 532 and/or 1064 nm wavelengths from the laser. All patients showed a response to laser therapy, and 2 patients treated with 1 treatment from each wavelength had complete eradication of the LM, with no evidence of recurrence in 42 months. Further study is warranted, but Q-switched neodymium:yttrium-aluminum-garnet laser is a promising alternative treatment for lentigo maligna.

Surgical treatment of lentigo maligna and lentigo maligna melanoma

Lentigo maligna (LM) is well known as an irregularly pigmented macular lesion usually presenting on the sun-damaged head and neck of older patients. Lentigo maligna (LM) has the potential to develop into invasive melanoma (LMM). A method of surgical excision for the treatment of LM and LMM using paraffin sections with tissue mapping to ensure clear margins before delayed defect closure is described. The results of applying this method in the treatment of 66 cases over a 40 month period are presented. Thirty-eight per cent of cases required two excisions or more to clear the tumour and 32% of cases showed evidence of invasive melanoma. Only one case has recurred thus far, and none have developed metastatic disease.

Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. A follow-up study

BACKGROUND

We previously reported our experience using Mohs micrographic surgery (MMS) for 45 patients with lentigo maligna (LM) and lentigo maligna melanoma (LMM). The patients were treated between 1985 and 1992. In our initial publication, all of the patients were free of local disease and evidence of metastases at an average of 29.2 months after therapy.

OBJECTIVE

The purpose of this study was to report long-term follow-up of our previously published data.

METHODS

MMS was performed in 26 patients with LM and 19 patients with LMM using frozen sections followed by rush permanent sections. Follow-up was obtained by contacting the referring physician, examination by one of our two Mohs surgeons, or by contacting the patient or his or her family.

RESULTS

After a median follow-up of 58.0 months (214.3 patient-years), there was one recurrence. This patient was a 56-year-old woman with five prior recurrences before MMS. Six patients were decreased of other causes during the study.

CONCLUSIONS

MMS using frozen and rush permanent sections resulted in a 97% cure rate for LM and LMM. Because MMS minimizes the removal of normal tissue, and the cure rate exceeds that of conventional therapies, the authors recommend this technique for the treatment of LM and LMM.

Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the "square" procedure

BACKGROUND

Management of lentigo maligna (LM) and lentigo maligna melanoma (LMM) may present problems because of the characteristic, yet unpredictable, subclinical peripheral and periadnexal extension of atypical junctional melanocytic hyperplasia beyond the visible margins.

OBJECTIVE

We used paraffin-embedded (permanent) peripheral vertical section margin control in a staged fashion in the management of LM and LMM.

METHODS

We used a modification of surgical excision in a staged fashion by means of a two-bladed knife with permanent peripheral vertical section margin control.

RESULTS

This method is technically easy and results in complete histologic evaluation of the peripheral margins without compromising the measurement of tumor thickness of the primary melanoma.

CONCLUSION

The use of the "square" procedure, a staged excision with permanent peripheral vertical section margin control, is useful in the management of LM and LMM.

Treatment of lentigo maligna

Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM) and, if left untreated, 30-50% of cases will progress to LMM, which is now thought to behave as aggressively as any other melanoma. Literature on the of treatment of LM including conventional surgery, micrographic Mohs surgery, cryosurgery, radiotherapy, electrodesiccation and curettage. 5-fluorouracil (5-FU), azelaic acid, retinoic acid and lasers are reviewed. It is concluded that micrographic Mohs surgery has the lowest recurrence rates and that conventional surgery, cryosurgery and radiotherapy all have recurrence rates in the order of 7-10%. Therefore, on the basis of the current literature available, all three of these methods could be recommended as primary treatment of LM. It is extremely important when choosing one of the above treatments that the physician is adequately trained in the appropriate technique and understands the limitation of the method used and the need for close follow up of the patient.

Recurrent lentigo maligna invading a skin graft successfully treated with Mohs' micrographic surgery

Lentigo maligna (LM) is a pigmented lesion occurring on sun-exposed skin that may become lentigo maligna melanoma (LMM). The tumor can behave in an aggressive fashion, causing significant cosmetic disfigurement, often extending significantly further than the clinical margin. Complete surgical excision is the treatment of choice. We describe a 74-year-old woman with a large LM of the left cheek, upper and lower eyelids, and preauricular skin that had recurred twice. The tumor was removed using Mohs' micrographic surgery (MMS) with rush permanent sections and was found to infiltrate extensively the split-thickness skin graft that had been placed five years earlier. LM can invade and replace a skin graft. Although destructive modalities and conventional surgery are recommended by some authors, MMS offers the greatest likelihood of cure, the ability to examine nearly 100 percent of the surgical margins, and maximal tissue sparing. Complete excision of LM at its earliest recognition may prevent invasive LMM and will limit cosmetic disfigurement.

Laser Doppler imaging of axial and random pattern flaps in the maxillo-facial area. A preliminary report

Objective, non-invasive examination, techniques in addition to clinical parameters, are required to follow-up the wound healing of flaps. With the new laser Doppler Scanner (LDI DIM 1.0 Lisca Development AB, Sweden) it is possible, for the first time, to measure and image the microcirculation continuously, non-invasively and without contact with the wound, in an area of 12 cm square maximum. We performed measurements and simultaneous two-dimensional imaging of the microcirculation 24, 48, 72 h and 5 and 14 days postoperatively in 20 patients, who had had reconstruction procedures performed using random or axial pattern flaps. The perfusion diagrams were correlated to the clinical appearance. Necrotic areas, venous stasis and normal course of wound healing can be clearly visualized and differentiated from one another. The new laser Doppler imaging system seems to be an excellent aid for following up and planning of flaps in plastic and reconstructive surgery.

Aggressive amelanotic lentigo maligna

A 66-year-old woman had a long-standing, scaly erythematous lesion on her left temple which histologically showed features of amelanotic lentigo maligna. It had recurred on numerous occasions over a period of 17 years, in spite of multiple attempts at curative surgery. There were also recurrences within a skin graft which, to our knowledge, has not been documented previously with lentigo maligna. In spite of the prolonged course, and extensive intraepidermal melanocytic proliferation amounting to melanoma in situ, there has been no evidence of dermal invasion. The lack of pigmentation in such lesions means that clinical definition of margins is highly inaccurate. In view of the aggressive horizontal growth phase of this lesion, with rapid recurrence following surgery, it was treated with electron beam therapy, and this has resulted in complete clinical remission. This most unusual case illustrates the potential difficulties in diagnosis and management of amelanotic lentigo maligna.

Lentigo maligna of the head and neck. Results of treatment by radiotherapy

BACKGROUND AND DESIGN

Although surgical excision is considered the treatment of choice for lentigo maligna, some elderly patients presenting with large lesions in the head and neck region may not be suitable candidates for surgical management. Radiotherapy has been used for this tumor at the Princess Margaret Hospital, Toronto, Ontario, for over the past 20 years with encouraging results. Fifty-four patients treated between 1968 and 1988 were identified, and their records were reviewed to determine treatment outcome.

RESULTS

Younger patients with smaller lesions were treated with surgical excision (n = 18) and achieved an actuarial tumor control rate of 94% at 3 years. Older patients with larger lesions located in the head and neck area were treated by radiotherapy (n = 36), with an actuarial tumor control rate of 86% at 5 years. Three of the four patients not achieving tumor control by radiation were successfully treated with surgical excision, and two of them proved to have malignant melanomas (both Clark's level II) when examined histologically. One patient with residual pigmentation 4 months after treatment was unavailable for follow-up. No patients developed metastatic melanoma. The late cosmetic appearance was acceptable in the majority of irradiated patients, with 11% showing poor cosmesis due to progressive skin pallor, atrophy, and telangiectasia in the treated area.

CONCLUSION

Conventional fractionated radiation therapy with superficial x-rays is a simple and effective method of management for lentigo maligna of the head and neck region. It is an excellent alternative treatment to surgical excision, with low morbidity and acceptable long-term cosmetic results.

[Malignant lentigo melanoma]

Malignant melanoma (MM) arises either from a pre-existing, pigmented nevus, from clinically normal skin, or in rare cases from the non-nevoid lesion named lentigo maligna (LM). We present two cases of LM, one in a 75-year old woman and one in an 89-year old woman, which progressed to MM over ten and two years respectively.

Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defects

The blood supply and reliability of cervicofacial rotation-advancement flaps for cheek reconstruction can be improved significantly by dissecting the flap in the deep plane (i.e., below the superficial musculoaponeurotic system and the platysma). This modification, similar in technique to that used in composite or deep-plane face lift, was used successfully in seven patients, including several heavy cigarette smokers who were unlikely to have achieved a successful outcome with a conventional cervicofacial flap. No facial nerve weaknesses were observed. We now believe that the deep plane is the level of choice for dissection of cervicofacial flaps when used for reconstruction of cheek or other facial defects.

Cryosurgery for lentigo maligna

BACKGROUND

The need for treatment of lentigo maligna is related to the cosmetic benefits and to the potential for malignant change. The usual treatment is excision, but often lesional size or location preclude this.

OBJECTIVE

Our purpose was to show that cryosurgery is an effective alternative treatment modality for lentigo maligna.

METHODS

Thirty white patients were treated with cryosurgery. The lesions ranged from 1.3 to 4.5 cm in diameter. Treatment consisted of freezing with liquid nitrogen delivered by open spray.

RESULTS

The lesion recurred in two patients, yielding a recurrence rate of 6.6% during the average follow-up period of 3 years. The two recurrent lesions were successfully re-treated with cryosurgery. Eleven patients observed for more than 5 years showed no recurrence.

CONCLUSION

Cryosurgery provides excellent cosmetic and curative results. These results are favorably comparable to excisional surgery.

Margin control for lentigo maligna

BACKGROUND

Lentigo maligna is an in situ malignant melanoma for which the treatment of choice is surgical excision. The current recommendation is local resection with a 0.5 to 1.0 cm margin of normal skin. Because many lesions occur on the face, the narrowest possible margin reduces the amount of scarring. Controversy surrounds the use of Mohs micrographic surgery to preserve normal skin and resect the lentigo maligna.

OBJECTIVE

The purposes of this prospective study were to determine the narrowest possible margin of resection of lentigo maligna and the accuracy of frozen and fixed histologic specimens from those margins. In addition, the benefit of adjunctive immunoperoxidase staining with antibodies to S-100 protein and HMB-45 monoclonal antibody was examined retrospectively.

METHODS

A Wood's light was used to delineate the clinical margin in 16 cases of lentigo maligna that were resected with serial excisions 0.3, 0.6, 1.0, and 1.3 cm from the clinical border of the tumor. Frozen sections were confirmed by fixed histopathologic specimens. Subsequently these tissue blocks were examined with antibodies to S-100 protein and HMB-45 monoclonal antibodies. Patients were observed 5 to 9 years.

RESULTS

One of the 16 patients had a recurrence 8 years after surgery. Although lesions with a diameter less than 2.0 cm had narrower margins of resection, the majority of lesions were resected with a margin of 0.6 to 1.0 cm. Lesions larger than 3.0 cm in diameter required a margin of resection greater than 1.0 cm. The antibody to S-100 protein was neither sensitive nor specific enough to assist with identification of the process. HMB-45 monoclonal antibody was sensitive and assisted in the identification of atypical melanocytes.

CONCLUSION

The modifications of Mohs micrographic surgery including the use of fixed histopathologic specimens and the use of HMB-45 monoclonal antibody to help delineate atypical melanocytes offer the possibility of narrower margins of resection for lentigo maligna.

Successful treatment of lentigo maligna and lentigo maligna melanoma with Mohs' micrographic surgery aided by rush permanent sections

BACKGROUND

Lentigo maligna (LM) is a pigmented neoplasm on sun-exposed skin of elderly patients. LM slowly increases in size and may become lentigo maligna melanoma (LMM), a potentially fatal malignancy. Complete excision is the treatment of choice. Mohs' micrographic surgery (MMS) with frozen and permanent sections may be used for complete eradication of the lesion, while sparing as much normal tissue as possible. The authors studied the efficacy of MMS for the treatment of LM and LMM.

METHODS

Between 1985 and 1992, 45 patients with LM (26) and LMM (19) were treated with MMS. The authors' technique was to use examination of frozen sections and rush permanent sections (prepared and read within 24 hours). Positive frozen sections warranted further excision. For negative or equivocal frozen sections, surgery was interrupted until the examination of permanent sections was performed.

RESULTS

All 45 patients were free of local disease and evidence of metastases at an average of 29.2 months (range, 4-81 months) after therapy.

CONCLUSIONS

MMS aided by rush permanent sections yielded a prolonged disease free survival for all 45 patients with LM or LMM. Because the MMS technique minimizes the removal of normal tissue, and the local cure rate in this study was superior to that reported for conventional surgery, the authors recommend this technique for the treatment of LM and LMM.

Conjunctival melanoma after excision of a lentigo maligna melanoma in the ipsilateral eyelid skin

Images

Management of lentigo maligna and lentigo maligna melanoma with paraffin-embedded tangential sections: utility of immunoperoxidase staining and supplemental vertical sections

BACKGROUND

The use of frozen sections in the management of lentigo maligna and lentigo maligna melanoma has been the focus of some controversy.

OBJECTIVE

Our purpose was to utilize paraffin-embedded tangential sections in the management of two cases of lentigo maligna and three cases of lentigo maligna melanoma.

METHODS

A modification of Mohs micrographic surgery using rush paraffin-embedded sections with adjunctive immunoperoxidase staining (HMB-45) and supplemental vertical sections was employed.

RESULTS

This method resulted in enhanced histologic evaluation of section margins and did not compromise the diagnosis of the primary invasive melanoma or Breslow measurements.

CONCLUSION

Mohs micrographic surgery modified by the use of rush paraffin-embedded sections allows adjunctive immunoperoxidase staining and supplemental vertical sections that may be helpful in the management of lentigo maligna and lentigo maligna melanoma.

Recommendations for therapy of head and neck cutaneous melanoma

PURPOSE

The essential element in the treatment of a primary cutaneous malignant melanoma is an adequate definitive excision. The breadth and depth of such excisions and the appropriateness of a prophylactic neck dissection, however, remain a source of controversy.

METHOD

A review of our experiences with 500 patients with head and neck malignant melanoma treated in our clinic between 1967 and 1987 is presented.

RESULTS AND CONCLUSIONS

The thickness of the lesion, the factor that correlated most closely with potential for metastatic development, can be used as a guide for determining the extent of excision and the appropriateness of elective node dissection. Wide excision of invasive lesions varies in their margins from 1 cm for lesions that measure less than .75 mm in thickness to 3 cm if the melanomas measure greater than .75 mm or show ulcerations or have a scalp localization. Prophylactic neck dissection is necessary for lesions between .75 and 1.5 mm in thickness, whereas in tumors with a depth of invasion greater than 1.5 mm the outcome of the disease is not improved by prophylactic neck dissection.