Dermatologic surgery
The “collerette” technique for skin excision and biopsy: an efficient method for managing lentigo maligna of the head and neck Komenan Kassi1,2, MD, Romain Vanwijck3, MD, and Jean-Marie Kanga1, MD
1 Department of Dermatology and Infectious Disease, School of Medicine, University of Cocody-Abidjan, 2Dermatology Center, Treichville University Hospital, Abidjan, Ivory Coast, and 3Department of Plastic and Esthetic Surgery,Catholic University of Louvain, Brussels, Belgium
Correspondence Kassi Komenan, MD 449 Cocody Djibi I Abidjan, 21 BP 5151 Abidjan, Ivory Coast E-mail: [email protected]
Abstract Background Melanoma is responsible for 75% of all skin cancer-related deaths. Lentigo maligna (LM), the most prevalent melanoma in situ (MIS), accounts for 79–83% of all MIS. Its location in the head and neck area requires that tissue be spared in the course of clearing the tumor. Methods We conducted a therapeutic study based on our practice experience with the socalled “collarette” skin biopsy technique used in the management of LM. Results Thirty-one patients were diagnosed with LM in the head and neck area. These included 16 women and 15 men with a mean standard deviation (SD) age of 64.4 13.6 years (range: 33–88 years). The majority (36%) of lesions were located on the cheek. To clear the tumor, surgery was performed using margins of >10 mm in 71% of cases. The average surface area of the surgical defect was 5.8 cm2 (range: 1.1–15.5 cm2).
Conflicts of interest: None.
Reconstructive skin grafts were performed in the majority (68%) of cases. After the removal of the central tumor, 16 cases of MIS and 15 cases of invasive melanoma were identified. Only one patient experienced recurrence over a mean SD follow-up of 31 16 months. Conclusions The so-called “collarette” or “spaghetti” skin excision and biopsy technique is an advantageous and efficient way to achieve tumor clearance and represents an equally effective alternative to Mohs micrographic surgery in the treatment of LM in the head and neck area.
Introduction Although melanoma represents only 5% of all occurrences of skin cancers in the USA, it is responsible for 75% of all skin cancer-related deaths.1 Lentigo maligna (LM) has slow growth and tends to be localized in the head and neck area, or the most sun-exposed area, frequently in elderly people.2 Skin biopsy represents the first step in tumor management and is intended to confirm the diagnosis and to determine the maximum depth of the tumor’s penetration (Clark level and Breslow index) in order to establish a protocol for further surgical management.3,4 The frequent location of LM in the head and neck area can present an esthetic challenge to the dermatologic surgeon, who must obtain complete clearance of the tumor while seeking to minimize the surgical defect. The classic surgical excision with a 5-mm safety margin leads to a high rate of recurrence5 in 8–20% of cases, because LM lesions frequently exhibit significant subclinical spread.6–9 ª 2013 The International Society of Dermatology
Mohs surgery decreases the recurrence rates of LM of the head and neck, leading to cure in about 90% of patients,6,10,11 but a lack of resources and qualified personnel mean that this technique is not available in all geographic locations. In addition, it is time-consuming and does not allow for immunohistochemical staining. We conducted this study based on our practice experience to demonstrate the effectiveness of the so-called collarette technique for skin excision and biopsy as an alternative method for the management of head and neck LM. Materials and methods Patients with biopsy-confirmed LM in the head and neck area, and managed using the collarette technique of skin excision and biopsy, were included in the study after their provision of oral consent. Patients with positron emission tomography with computed tomography (PET-CT) confirmed metastases were excluded from the study. Demographic, clinical, therapeutic, and histopathologic data were recorded, including tumor location and thickness, the International Journal of Dermatology 2014, 53, 899–903
899
900
Dermatologic surgery
Kassi et al.
Skin excision and biopsy in lentigo maligna of the head and neck
number of steps required in the procedure, the area of the surgical defect, and the recurrence rate.
In the laboratory, each segment is cut into longitudinal and en face sections. After one week, the dermatopathologist sends
The collarette technique for skin excision and biopsy is
the result to the surgeon. If a segment is positive for tumor, the
performed under local anesthesia and starts with the harvesting
procedure is repeated to 5 mm beyond the corresponding
of a 2-mm strip of skin beyond the 5-mm classical margins from
segment until the segment of the collarette is found to be
the tumor edge (Fig. 1). The incision is made with the blade at
tumor-free. The central tumor is then removed and sent for final
a perpendicular angle to the tumor surface (Fig. 2). The
histologic examination. Reconstruction is achieved by direct
collarette of skin excised is adjusted according to clock direction
closure with a skin graft or local flap after the final shape of the
and divided into four segments as follows: A = 12 o’clock to 3 o’clock; B = 3 o’clock to 6 o’clock; C = 6 o’clock to 9 o’clock,
surgical defect has been determined. Data were analyzed using Epi Info Version 3.5 (Centers for
and D = 9 o’clock to 12 o’clock (Fig. 3). The resulting linear
Disease Control and Prevention, Atlanta, GA, USA).
surgical defect is then closed (Fig. 4), and the segments and
Frequencies were calculated with 95% confidence intervals, and
accompanying drawings are sent for histopathologic
Fisher’s exact test was performed to establish statistically
examination and immunohistochemistry if necessary.
significant differences.
Figure 1 In a patient with lentigo maligna of the cheek (0.6 9 0.4 cm), the collarette is delineated beyond the 5-mm margins of the macroscopic tumor
Figure 3 The four segments of the strip are fixed by needles according to clock quadrant: A = 12 oclock to 3 oclock; B = 3 oclock to 6 oclock; C = 6 oclock to 9 oclock, and D = 9 oclock to 12 oclock
Figure 2 The surgical defect surrounding the central tumor after harvesting of the strip International Journal of Dermatology 2014, 53, 899–903
Figure 4 Direct closure of the surgical defect after excision of
the strip ª 2013 The International Society of Dermatology
Kassi et al.
Skin excision and biopsy in lentigo maligna of the head and neck
Approximate lesion and surgical defect surface areas were obtained using this formula: surfaceðcm2 Þ ¼ ðp long axis short axis=4Þ:
Results
Dermatologic surgery
80-year-old patient diagnosed with MIS, at 24 months of follow-up. Multivariable analysis
Fisher’s exact test for correlation showed a statistical association between the surface area of the LM and the surface area of the surgical defect (P = 0.0017) (Table 1).
Sociodemographic characteristics
Thirty-one patients diagnosed with LM in the head and neck area were managed using the collarette technique. Sixteen (52%) of these patients were women, and 15 (48%) were men. Their mean standard deviation (SD) age at diagnosis was 64.4 13.6 years (range: 33–88 years). The majority of the patients had phototype II (52%) or phototype III (45%) skin. Clinical features of the tumors
The most common locations of the lesions in the present study were the cheek and temple (36% and 16% of cases, respectively). The mean clinical tumor surface area was 1.6 cm2 (range: 0.5–7.3 cm2), and the majority (65%) of tumors showed a surface area of 10 mm were required in 22 (71%) patients. The mean SD excision margin was 13.2 4.6 mm. The mean area of the surgical defect was 5.8 cm2 (range: 1.1–15.5 cm2). Skin graft was the most common reconstruction type (21 of 31 patients, 68%), followed by the local flap (six patients, 19%) and direct closure (four patients, 13%).
Discussion In 1992, the US National Institutes of Health (NIH)12 consensus statement established surgical excision with 5-mm clinical margins as representing the standard of care to be delivered in the treatment of MIS.12 However, 5-mm margins are often inadequate for the histologic clearance of this tumor. Zalla et al.11 reported that a mean margin of 8.5 mm was required for tumor clearance in 46 patients with head and neck MIS. Hazan et al.13 found the average widths of the margins required to clear LM and LMM were 7.1 mm and 10.3 mm, respectively. The latter authors used a staged excision technique with rush paraffin sections to confirm clearance.13 In addition, Debloom et al. reported that a mean surgical margin of 15 mm was necessary to achieve tumor clearance in 97% of 231 patients.1 The mean margin widths reported in the literature are similar to the mean surgical margin of 13.2 mm identified in the present study. We noticed that margins of >10 mm in width were required to clear the tumor in 71% of cases. The mean number of surgical procedures required to obtain tumor clearance was 2.2 (range: one to three steps), and more than one step was performed in 87% of patients. Moreover, Bub et al. found that the diameter of the MIS was proportional to the margin required to clear it.8 This implies that the clearance of larger tumors requires larger surgical margins. Bub et al. reported that tumors with diameters of 0.99 cm2, n (n0 ) Total, n
20 (16.26) 1 (4.74) 21
4 (7.74) 6 (2.26) 10
24 7 31
Fisher’s exact test: P 0.0017 with 95% confidence interval. The numbers in brackets represent the theoretical number calculated by the Fisher test. International Journal of Dermatology 2014, 53, 899–903
901
902
Dermatologic surgery
Skin excision and biopsy in lentigo maligna of the head and neck
of 6–9 mm, but tumors with long axes of >2.0 cm required surgery with margins of 8–12 mm in order to achieve 95% clearance.8 We confirmed these findings; the tumor surface area was strongly associated with the area of the surgical skin defect in our series. One difficulty linked to LM in the head and neck area refers to this tumor’s subclinical features because the tumor may expand beyond the visible margins. Therefore, several methods have been developed to overcome these specific problems of margin control. Among them, staged excision techniques and Mohs micrographic surgery (MMS) are techniques of choice. The square technique proposed by Johnson et al. is a staged excision technique.14 A double-bladed knife is used to remove a 2–4-mm strip surrounding the lesion. These strips are reserved for permanent section. The procedure is repeated every 1–2 weeks until clearance is achieved, at which point the central tumor is removed and reconstruction is performed.14 Mahoney et al. proposed the perimeter technique, which is very similar to the square technique.15 In the perimeter technique, a margin of 5 mm is added to the clinical lesion, and vertical strips of 2 mm in width are harvested from around this area. Excision of the central tumor and repair are delayed. No instances of recurrence were noted among the 11 patients reported by these authors over a follow-up period of 1–13 months.15 Finally, another technique of margin control was proposed by Gaudy-Marqueste et al., who used the so-called spaghetti technique in 21 patients.16 This technique is identical to our collarette skin excision and biopsy technique, with the exception that tumor edges are delineated without dermoscopy and the strip is harvested 3–4 mm beyond the clinically apparent margins of the tumor. In the present series, the use of dermoscopy to define tumor edges facilitated our achievement of smaller surgical defects, which amounted to
The “collerette” technique for skin excision and biopsy: an efficient method for managing lentigo maligna of the head and neck Komenan Kassi1,2, MD, Romain Vanwijck3, MD, and Jean-Marie Kanga1, MD
1 Department of Dermatology and Infectious Disease, School of Medicine, University of Cocody-Abidjan, 2Dermatology Center, Treichville University Hospital, Abidjan, Ivory Coast, and 3Department of Plastic and Esthetic Surgery,Catholic University of Louvain, Brussels, Belgium
Correspondence Kassi Komenan, MD 449 Cocody Djibi I Abidjan, 21 BP 5151 Abidjan, Ivory Coast E-mail: [email protected]
Abstract Background Melanoma is responsible for 75% of all skin cancer-related deaths. Lentigo maligna (LM), the most prevalent melanoma in situ (MIS), accounts for 79–83% of all MIS. Its location in the head and neck area requires that tissue be spared in the course of clearing the tumor. Methods We conducted a therapeutic study based on our practice experience with the socalled “collarette” skin biopsy technique used in the management of LM. Results Thirty-one patients were diagnosed with LM in the head and neck area. These included 16 women and 15 men with a mean standard deviation (SD) age of 64.4 13.6 years (range: 33–88 years). The majority (36%) of lesions were located on the cheek. To clear the tumor, surgery was performed using margins of >10 mm in 71% of cases. The average surface area of the surgical defect was 5.8 cm2 (range: 1.1–15.5 cm2).
Conflicts of interest: None.
Reconstructive skin grafts were performed in the majority (68%) of cases. After the removal of the central tumor, 16 cases of MIS and 15 cases of invasive melanoma were identified. Only one patient experienced recurrence over a mean SD follow-up of 31 16 months. Conclusions The so-called “collarette” or “spaghetti” skin excision and biopsy technique is an advantageous and efficient way to achieve tumor clearance and represents an equally effective alternative to Mohs micrographic surgery in the treatment of LM in the head and neck area.
Introduction Although melanoma represents only 5% of all occurrences of skin cancers in the USA, it is responsible for 75% of all skin cancer-related deaths.1 Lentigo maligna (LM) has slow growth and tends to be localized in the head and neck area, or the most sun-exposed area, frequently in elderly people.2 Skin biopsy represents the first step in tumor management and is intended to confirm the diagnosis and to determine the maximum depth of the tumor’s penetration (Clark level and Breslow index) in order to establish a protocol for further surgical management.3,4 The frequent location of LM in the head and neck area can present an esthetic challenge to the dermatologic surgeon, who must obtain complete clearance of the tumor while seeking to minimize the surgical defect. The classic surgical excision with a 5-mm safety margin leads to a high rate of recurrence5 in 8–20% of cases, because LM lesions frequently exhibit significant subclinical spread.6–9 ª 2013 The International Society of Dermatology
Mohs surgery decreases the recurrence rates of LM of the head and neck, leading to cure in about 90% of patients,6,10,11 but a lack of resources and qualified personnel mean that this technique is not available in all geographic locations. In addition, it is time-consuming and does not allow for immunohistochemical staining. We conducted this study based on our practice experience to demonstrate the effectiveness of the so-called collarette technique for skin excision and biopsy as an alternative method for the management of head and neck LM. Materials and methods Patients with biopsy-confirmed LM in the head and neck area, and managed using the collarette technique of skin excision and biopsy, were included in the study after their provision of oral consent. Patients with positron emission tomography with computed tomography (PET-CT) confirmed metastases were excluded from the study. Demographic, clinical, therapeutic, and histopathologic data were recorded, including tumor location and thickness, the International Journal of Dermatology 2014, 53, 899–903
899
900
Dermatologic surgery
Kassi et al.
Skin excision and biopsy in lentigo maligna of the head and neck
number of steps required in the procedure, the area of the surgical defect, and the recurrence rate.
In the laboratory, each segment is cut into longitudinal and en face sections. After one week, the dermatopathologist sends
The collarette technique for skin excision and biopsy is
the result to the surgeon. If a segment is positive for tumor, the
performed under local anesthesia and starts with the harvesting
procedure is repeated to 5 mm beyond the corresponding
of a 2-mm strip of skin beyond the 5-mm classical margins from
segment until the segment of the collarette is found to be
the tumor edge (Fig. 1). The incision is made with the blade at
tumor-free. The central tumor is then removed and sent for final
a perpendicular angle to the tumor surface (Fig. 2). The
histologic examination. Reconstruction is achieved by direct
collarette of skin excised is adjusted according to clock direction
closure with a skin graft or local flap after the final shape of the
and divided into four segments as follows: A = 12 o’clock to 3 o’clock; B = 3 o’clock to 6 o’clock; C = 6 o’clock to 9 o’clock,
surgical defect has been determined. Data were analyzed using Epi Info Version 3.5 (Centers for
and D = 9 o’clock to 12 o’clock (Fig. 3). The resulting linear
Disease Control and Prevention, Atlanta, GA, USA).
surgical defect is then closed (Fig. 4), and the segments and
Frequencies were calculated with 95% confidence intervals, and
accompanying drawings are sent for histopathologic
Fisher’s exact test was performed to establish statistically
examination and immunohistochemistry if necessary.
significant differences.
Figure 1 In a patient with lentigo maligna of the cheek (0.6 9 0.4 cm), the collarette is delineated beyond the 5-mm margins of the macroscopic tumor
Figure 3 The four segments of the strip are fixed by needles according to clock quadrant: A = 12 oclock to 3 oclock; B = 3 oclock to 6 oclock; C = 6 oclock to 9 oclock, and D = 9 oclock to 12 oclock
Figure 2 The surgical defect surrounding the central tumor after harvesting of the strip International Journal of Dermatology 2014, 53, 899–903
Figure 4 Direct closure of the surgical defect after excision of
the strip ª 2013 The International Society of Dermatology
Kassi et al.
Skin excision and biopsy in lentigo maligna of the head and neck
Approximate lesion and surgical defect surface areas were obtained using this formula: surfaceðcm2 Þ ¼ ðp long axis short axis=4Þ:
Results
Dermatologic surgery
80-year-old patient diagnosed with MIS, at 24 months of follow-up. Multivariable analysis
Fisher’s exact test for correlation showed a statistical association between the surface area of the LM and the surface area of the surgical defect (P = 0.0017) (Table 1).
Sociodemographic characteristics
Thirty-one patients diagnosed with LM in the head and neck area were managed using the collarette technique. Sixteen (52%) of these patients were women, and 15 (48%) were men. Their mean standard deviation (SD) age at diagnosis was 64.4 13.6 years (range: 33–88 years). The majority of the patients had phototype II (52%) or phototype III (45%) skin. Clinical features of the tumors
The most common locations of the lesions in the present study were the cheek and temple (36% and 16% of cases, respectively). The mean clinical tumor surface area was 1.6 cm2 (range: 0.5–7.3 cm2), and the majority (65%) of tumors showed a surface area of 10 mm were required in 22 (71%) patients. The mean SD excision margin was 13.2 4.6 mm. The mean area of the surgical defect was 5.8 cm2 (range: 1.1–15.5 cm2). Skin graft was the most common reconstruction type (21 of 31 patients, 68%), followed by the local flap (six patients, 19%) and direct closure (four patients, 13%).
Discussion In 1992, the US National Institutes of Health (NIH)12 consensus statement established surgical excision with 5-mm clinical margins as representing the standard of care to be delivered in the treatment of MIS.12 However, 5-mm margins are often inadequate for the histologic clearance of this tumor. Zalla et al.11 reported that a mean margin of 8.5 mm was required for tumor clearance in 46 patients with head and neck MIS. Hazan et al.13 found the average widths of the margins required to clear LM and LMM were 7.1 mm and 10.3 mm, respectively. The latter authors used a staged excision technique with rush paraffin sections to confirm clearance.13 In addition, Debloom et al. reported that a mean surgical margin of 15 mm was necessary to achieve tumor clearance in 97% of 231 patients.1 The mean margin widths reported in the literature are similar to the mean surgical margin of 13.2 mm identified in the present study. We noticed that margins of >10 mm in width were required to clear the tumor in 71% of cases. The mean number of surgical procedures required to obtain tumor clearance was 2.2 (range: one to three steps), and more than one step was performed in 87% of patients. Moreover, Bub et al. found that the diameter of the MIS was proportional to the margin required to clear it.8 This implies that the clearance of larger tumors requires larger surgical margins. Bub et al. reported that tumors with diameters of 0.99 cm2, n (n0 ) Total, n
20 (16.26) 1 (4.74) 21
4 (7.74) 6 (2.26) 10
24 7 31
Fisher’s exact test: P 0.0017 with 95% confidence interval. The numbers in brackets represent the theoretical number calculated by the Fisher test. International Journal of Dermatology 2014, 53, 899–903
901
902
Dermatologic surgery
Skin excision and biopsy in lentigo maligna of the head and neck
of 6–9 mm, but tumors with long axes of >2.0 cm required surgery with margins of 8–12 mm in order to achieve 95% clearance.8 We confirmed these findings; the tumor surface area was strongly associated with the area of the surgical skin defect in our series. One difficulty linked to LM in the head and neck area refers to this tumor’s subclinical features because the tumor may expand beyond the visible margins. Therefore, several methods have been developed to overcome these specific problems of margin control. Among them, staged excision techniques and Mohs micrographic surgery (MMS) are techniques of choice. The square technique proposed by Johnson et al. is a staged excision technique.14 A double-bladed knife is used to remove a 2–4-mm strip surrounding the lesion. These strips are reserved for permanent section. The procedure is repeated every 1–2 weeks until clearance is achieved, at which point the central tumor is removed and reconstruction is performed.14 Mahoney et al. proposed the perimeter technique, which is very similar to the square technique.15 In the perimeter technique, a margin of 5 mm is added to the clinical lesion, and vertical strips of 2 mm in width are harvested from around this area. Excision of the central tumor and repair are delayed. No instances of recurrence were noted among the 11 patients reported by these authors over a follow-up period of 1–13 months.15 Finally, another technique of margin control was proposed by Gaudy-Marqueste et al., who used the so-called spaghetti technique in 21 patients.16 This technique is identical to our collarette skin excision and biopsy technique, with the exception that tumor edges are delineated without dermoscopy and the strip is harvested 3–4 mm beyond the clinically apparent margins of the tumor. In the present series, the use of dermoscopy to define tumor edges facilitated our achievement of smaller surgical defects, which amounted to
