Mohs' micrographic surgery for the treatment of melanoma

Managing melanoma in situ

Melanoma is a highly aggressive skin cancer with an increasing incidence. Melanoma in situ is an early, non-invasive form in which the tumor is confined to the epidermis. Treatment of melanoma in situ is challenging due to the frequent subclinical microscopic spread and to the presentation on the head and neck in cosmetically sensitive areas with chronic sun damage. Optimizing tumor eradication is imperative to reduce the potential progression into invasive disease and metastasis, all while maintaining cosmesis. Multiple treatment regimens have been implemented for managing difficult melanoma in situ tumors. We provide a thorough review of surgical, and non-surgical, management of melanoma in situ which can pose therapeutic dilemmas due to size, anatomic location, and subclinical spread.

Contemporary Mohs surgery applications

PURPOSE OF REVIEW

The incidence of cutaneous malignancies continues to rise and it is likely that the majority of skin cancers referred to otolaryngologists will have characteristics that necessitate a more complex and aggressive approach. Mohs micrographic surgery is a tissue-sparing technique that allows for excision of cancers under complete microscopic control and thus boasts high cure rates. This paper reviews the Mohs technique and discusses the current indications for Mohs surgery in the head and neck.

RECENT FINDINGS

For high-risk basal cell and squamous cell carcinomas, studies continue to report superior cure rates with Mohs surgery compared with non-Mohs modalities such as standard surgical excision. Despite several supporting studies, Mohs surgery for melanoma continues to be controversial in the literature, as histological identification of melanoma with frozen sections remains challenging despite advances. Other means of margin control remain popular among non-Mohs surgeons, including frozen section analysis and, more recently, photodynamic delineation.

SUMMARY

For cutaneous malignancies of the head and neck, Mohs surgery offers the distinct advantages of complete microscopic margin control coupled with tissue conservation and thus boasts of high cure rates. It is important for otolaryngologists to understand the technique and current indications for Mohs surgery.

A Primer of Mohs Micrographic Surgery: Uncommon Indications

Mohs micrographic surgery has been used for the treatment of tumors other than basal and squamous cell carcinomas. Parameters to be considered when deciding on a treatment include location, size, growth pattern, and recurrence rates. It is important to consider that sometimes the high-risk nature of the tumor is more significant than the need for tissue sparing. Modifications to the Mohs micrographic surgery technique may be used to ensure diagnostic accuracy and confirm complete removal of the lesion (e.g., immunohistochemical staining and paraffin-embedded sections).

Mohs surgery for the treatment of melanoma in situ: a review

BACKGROUND

Controversy exists in the literature regarding the use of Mohs surgery for the treatment of melanoma in situ (MIS). Mohs surgery provides the advantage of complete margin assessment; however, variations in surgical and laboratory techniques employed, make comparison of outcomes difficult.

OBJECTIVE

To review the current literature regarding Mohs surgery for treatment of MIS and to evaluate treatment options.

METHODS

We review the literature regarding traditional excision margins for MIS, the proportion of biopsy-proven MIS lesions that prove to have an invasive component, and the efficacy of Mohs surgery for MIS.

RESULTS

Many authors report a need for surgical margins larger than the recommended 5 mm, particularly with MIS arising in sun-exposed areas. Further, a review of the literature reveals that nearly one-quarter of biopsy-proven MIS lesions are found to contain invasive melanoma after complete surgical removal and pathologic examination. Substantial evidence supports the value of complete margin assessment in the treatment of MIS, particularly in the head and neck region.

CONCLUSION

Complete surgical excision with careful margin assessment is required to adequately treat MIS lesions, particularly given the high rate of invasive melanoma in lesions initially thought to be MIS. Mohs surgery remains the treatment of choice for all clinically ill-defined MIS.

Mohs micrographic surgery and the otolaryngologist

OBJECTIVE

The purpose of this study was to provide an update and overview of the current indications for Mohs micrographic surgery (MMS) for cutaneous and upper aerodigestive tract malignancies.

STUDY DESIGN

Literature review.

METHODS

A comprehensive review of the literature from 1971 to present was completed by using the Medline data base. In addition, interviews were obtained with several otolaryngologists who had used the technique.

RESULTS

MMS offers a superior alternative to standard excision in a variety of cutaneous malignancies. Overall, for the skin cancers likely to be encountered by the otolaryngologist, there is significant evidence that MMS offers increased rates of cure as well as tissue conservation. The role of MMS in upper aerodigestive tract malignancies continues to evolve and multiple issues must be addressed before its general application.

CONCLUSIONS

When confronted with a difficult cutaneous malignancy, the otolaryngologist should consider MMS to optimize treatment results.

Surgical margins for resection of primary cutaneous melanoma

The increasing prevalence of melanoma in the United States is alarming. The limited efficacy of adjuvant therapies in successfully treating regional or distant disease underscores the importance of surgical treatment of primary cutaneous melanoma. The historic paradigm of wide margin excision (5 cm) with or with lymphadenectomy has been proven in multiple clinical trials to show no benefit of improved patient survival. Conservative margin resection of melanoma is a procedure of low morbidity that offers statistically identical outcomes and spares the patient excessive surgical efforts. Mohs micrographic surgery may have a role in the management of melanomas in anatomic sites where standard margins may prove difficult to achieve.