Comparison of Outcomes for Malignant Melanoma of the Face Treated with Mohs Micrographic Surgery and Wide Local Excision MARTHA LAURIN COUNCIL, MD*
The author has indicated no significant interest with commercial supporters.
n this issue of Dermatologic Surgery, Chin-Lenn and colleagues1 describe the outcomes of patients with invasive melanoma of the face treated using Mohs micrographic surgery (MMS) versus wide local excision over a 10-year period. Although patient cohorts were notably different, a limitation of the retrospective nature of the study, outcomes of the treated groups were similar with respect to local, regional, and systemic recurrence and diseasespecific survival. The authors claim that this further supports the idea that MMS, in the right hands, is a viable treatment option for select melanocytic lesions.
An informal audience survey at the 2013 Annual Meeting of the American College of Mohs Surgery (ACMS) revealed that while a growing number of ACMS members perform MMS for melanoma in situ, very few are comfortable using the technique for invasive lesions. Recent Medicare usage data analysis estimated that only 0.3% of Mohs cases are performed on melanomas,2 even though melanoma accounts for a greater percentage of skin cancers treated annually.3 The appropriate use criteria for MMS, as a panel of experts from the American Academy of Dermatology, the ACMS, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery described, provides 10 different scenarios in which MMS is
appropriate for the treatment of melanoma in situ.4 Even so, many surgeons are hesitant to provide this therapy to their patients, citing the challenges of reading melanocytic lesions on frozen sections and of performing immunostains in an office setting. Although the controversy surrounding this treatment is new, the concept of micrographic margin control in melanocytic lesions is not. The late Frederic Mohs himself described the chemosurgical treatment of melanoma in the Archives of Dermatology and Syphilology, now JAMA Dermatology, in 1950.5 In his review, Mohs discussed complete margin analysis with permanent section histopathology and cautioned that one should obtain at least a 1 cm margin of uninvolved tissue around the clear margin. Since that time, the Mohs technique has been refined to include frozen sections and, for certain lesions, rapid immunostains such as Melan-A, microphthalmia-associated transcription factor (MITF), and S100.6 The ACMS has made substantial efforts to educate its members on immunohistochemical techniques by publishing the protocol on the resources page of its website and by dedicating educational sessions to the topic at annual meetings. Likewise, Mohs surgeons have demonstrated that melanocytic lesions can be reliably interpreted on
*Division of Dermatology, Washington University, St. Louis, Missouri © 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2013;39:1646–1647 DOI: 10.1111/dsu.12306 1646
frozen sections7 and that patient outcomes are similar regardless of which surgical method is employed.8
3. American Cancer Society. Cancer facts & figures 2013. Available from: http://www.cancer.org/acs/groups/content/ @epidemiologysurveilance/documents/document/acspc-036845. pdf. Accessed January 31, 2013.
Although promising, these studies have been of small sample size and retrospective in nature. The current guidelines for management of melanoma include surgical resection with standard margins (at least 0.5 cm for melanoma in situ; 1–2 cm for invasive lesions) and sentinel lymph node biopsy as indicated by Breslow thickness and other prognostic factors. Until we can demonstrate in a multi-institutional prospective randomized controlled trial that patients treated with Mohs surgery have the same or superior outcomes to patients treated with conventional or staged excision, the debate surrounding the use of the Mohs technique for melanocytic lesions will continue.
4. Connolly SM, Baker DR, Coldiron BM, Fazio MJ, et al. AAD/ ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. Dermatol Surg 2012;38:1582–603. 5. Mohs FE. Chemosurgical treatment of melanoma; a microscopically controlled method of excision. Arch Derm Syphilol 1950;62:269–79. 6. El Tal AK, Abrou AE, Stiff MA, Mehregan DA. Immunostaining in Mohs micrographic surgery: a review. Dermatol Surg 2010;36:275–90. 7. Bene NI, Healy C, Coldiron BM. Mohs micrographic surgery is accurate 95.1% of the time for melanoma in situ: a prospective study of 167 cases. Dermatol Surg 2008;34:660–4. 8. Bricca GM, Brodland DG, Zitelli JA. Cutaneous head and neck melanoma treated with Mohs micrographic surgery. J Am Acad Dermatol 2005;52:92–100.
References 1. Chin-Lenn L, Murynka T, McKinnon JG, Arlette J. Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision. Dermatol Surg 2013;39. 2. Donaldson MR, Coldiron BM. Mohs micrographic surgery utilization in the Medicare population, 2009. Dermatol Surg 2012;38:1427–34.
Address correspondence and reprint requests to: Martha Laurin Council, MD, Division of Dermatology, Washington University, 969 North Mason Road, Suite 200, St. Louis, Missouri 63141, or e-mail: [email protected]