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DOI: 10.1007/s10227-002-1161-7
J Cutan Med Surg 2003; 2530
Abstract
Background: The treatment of cutaneous malignant melanoma of the face presents a
challenge to ensure eradication of disease with maximum preservation of tissue. Mohs
micrographic surgery provides a means for histologically controlled removal of malignant melanoma.
Objective: This study evaluates the efficacy of Mohs micrographic surgery, at a single
institution, for the treatment of facial melanoma and assesses the accuracy of margin
control by frozen section techniques.
Methods: Ninety-seven patients with biopsy-confirmed melanoma in situ or invasive
melanoma of the face were treated by Mohs micrographic surgery over a 6-year period.
In 25 patients, tissue margins defined as negative for melanoma at the time of frozen
section were re-evaluated on permanent section histology of formalin-fixed, paraffinembedded tissue.
Results: Ninety-two of 97 patients had followup information available (872 months;
mean 33 months). There were no cases of local recurrence. Eighty-nine of the 92 patients were alive and well with no evidence of disease. One patient died of metastatic
melanoma. In situ or invasive melanoma was not identified on permanent sections of 117
tissue margins which had been interpreted as negative on frozen section.
Conclusion: Mohs micrographic surgery appears to be an effective treatment for facial
melanomas. Our study showed complete correlation between frozen section tissue
margins and permanent section controls.
Sommaire
Antecedents: Le traitement des melanomes du visage est un defi en soi vu quil faut
veiller a` eradiquer comple`tement la maladie tout en enlevant le moins de tissu possible.
Or, la chirurgie micrographique de Mohs presente un moyen denlever les melanomes
qui soit histologiquement controle.
Objectif: Cette etude, menee en un seul etablissement, evalue lefficacite de la chirurgie micrographique de Mohs dans le traitement des melanomes du visage ainsi que
lexactitude de la marge de controle des techniques de coupe en congelation.
Methodes: 97 patients souffrant de melanome du visage in situ ou envahissant, confirme par biopsie, ont ete traites par chirurgie micrographique de Mohs sur une periode
de 6 ans. Chez 25 des patients, les prele`vements de tissu qui ont ete juges libres de
melanome au moment de la coupe en congelation ont ete reevalues sur des sections
permanentes fixeesen formol et imbibees de paraffine.
Resultats: Des donnees de suivi etaient disponibles pour 92 des 97 patients (sur 8 a` 72
mois; moyenne de 33 mois). Aucun cas de recurrence locale na ete rapporte. 89 de ces 92
patients etaient vivants et ne presentaient aucun signe de maladie. Un patient est decede a`
la suite dun melanome. On na trouve aucun signe de melanome in situ ou envahissant
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sur des fragments de 117 tissus dont la coupe en conge lation a montre des re sultats
ne gatifs.
Conclusion: La chirurgie micrographique de Mohs serait un traitement efficace contre
les me lanomes du visage. Notre e tude a montre une correlation directe entre les coupes
en conge lation et les sections tissulaires sous contro le.
Patient followup was conducted by repeat clinical inspection (85/97), letter followup, phone survey, or contact with the referring physician. All patients were
American Anesthesia Society (ASA) Class I (healthy patient, no medical problems) or Class II (mild systemic
disease).
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TABLE I
Lesion demographics for facial melonoma
Type of lesion
Lentigo maligna
Lentigo maligna
melanoma
Malignant melanoma
in situ
Invasive malignant
melanoma
No. of cases
Female
Male
Mean age
(range) (yr)
67
8
33
5
34
3
68 (4189)
72 (5186)
62 (4677)
13
58 (2284)
Depth of Invasion
The lentigo maligna melanomas had an average Breslow
thickness of 0.60 mm with a range of 0.241.60 mm.
Invasive malignant melanomas had an average Breslow
thickness of 0.81 mm with a range of 0.493.00 mm.
and cleaned of mounting medium, and then the tissue
placed negative side down on filter paper in formalin.
After formalin fixation, these negative sections were then
processed in the usual way and embedded in paraffin with
the negative side up; then 5-lm sections were cut and
stained with hematoxylin and eosin. Slides were reviewed
by a dermatopathologist.
Results
Patient Demographics and Followup
Complete followup information was available on 92/97
patients treated (95%); the followup interval was 8 and 72
months (mean 33 months). Two patients had died from
natural causes and had no evidence of local disease at the
time of death. In An 84-year-old male with a level IV,
Breslow thickness 3.0 mm lesion on the left side of the
nose died from metastatic malignant melanoma. The
lesion had been present for one year at the time of diagnosis. There was no evidence of local recurrence.
Eighty-nine patients were alive and well without disease
at the end of the study period.
Fifty patients were female and 47 were male. The
average age was 68 years with a range of 2289 years. All
patients were Caucasian with skin types I, II, or III.
Lesion Demographics
The number of primary lesions was 83, and 14 lesions
were recurrent and had been previously excised. Data is
summarized in Table I. All three patients <30 years of
age had invasive malignant melanomas. Lesion sites are
given in Table II. The most common location of these
melanomas was the cheek. Ear lesions were more
common in males and forehead lesions were more
common in females. There was no correlation between
gender and the side on which the melanoma occurred
(right versus left).
Discussion
This study reviews a series of patients treated for cutaneous melanoma of the face using a fresh frozen tissue
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TABLE II
Anatomic site of facial melanomas
Site
Cheek
Nose
Ear
Forehead
Lip
No. of cases
Female
Male
45
18
18
14
2
20
9
4
10
2
25
9
14
4
0
technique. Mohs micrographic surgery offers the advantage of limiting tissue removal in anatomically sensitive
areas by the direct histological observation of the peripheral margins immediately adjacent to proven malignancy. This permits preservation of the maximum
amount of tissue in the achievement of the highest possible cure rate. There was no evidence of local recurrence
of cutaneous melanoma in any of the 92 patients followed
for a mean of 33 months.
Previous studies have evaluated the effectiveness of
frozen section margins in the treatment of melanoma.22
Mohs micrographic surgery offers survival and metastatic rates as good as wide surgical excision, but allows
narrow margins and without the risk of local recurrence
because of incomplete excision.16 Mohs micrographic
surgery has been successful in the treatment of LM and
LMM in 45 patients whose surgery was aided by rush
permanent sections.13 Long-term followup over 58
months demonstrated one recurrence, giving a 97% cure
rate.14 Low-recurrence rates for LM/LMM treated by
Mohs surgery have also been documented by several
other groups (reviewed by Cohen).19 Similarly, a
square technique, using staged excision with permanent peripheral vertical section margin control, has
shown a very low local recurrence rate (1/150) but with
short-term (<5 years) followup.11,12 In comparison, conventional surgical excision has a reported recurrence rate
of 9% (reviewed by Cohen).19
The demographics of the patients and their lesions
are helpful in understanding the nature of this disease and
the imperative for selecting effective treatment. Facial
malignant melanomas occurred in a wide patient age
range. Patients with invasive malignant melanoma (nonLMM) had the youngest average age (58 years), and,
interestingly, patients with melanoma in situ (non-LM)
were older (average age 62 years) than those with invasive
lesions. Patients with invasive malignant melanoma often
gave histories of rapid appearance and growth of their
lesions. LM occurred at an average age of 68 years, four
years less than for LMM (72 years). No patient developed
LMM before the age of 50. Patients with LMM had the
longest history of gradual evolution of their lesions, some
up to 40 years. Although not statistically significant, the
mean age of patients with LMM was four years older
than patients with LM. All patients with LMM were >50
years of age, while the earliest age of diagnosis of LM in
this series was 41 years. These data support a progressive
change to invasive disease in these lesions over time.
Patients with LMM had an average lesion size of 16.47
cm2 versus LM patients with 11.91 cm2. These two factors (age at diagnosis and size of the defect) emphasize
the importance of early diagnosis and treatment of LM in
order to prevent progression to invasion and greater
surgical defect size.
Most authors consider LM a form of melanoma in
situ.19,23 There have been attempts to subdivide LM into
more aggressive,24 or less aggressive lesions,24 however,
these variants likely represent points on the progression of atypical melanocytic hyperplasia to invasive melanoma.25 Although the risk of progression of LM to
LMM is thought to be low,26 simply following LM does
not prevent the potential for the development of invasive
malignant melanoma.27 This is especially important in
light of the fact that LMM has the same prognosis as any
melanoma of similar depth of invasion.28
The site of lesions revealed that men were three times
more likely to develop cutaneous melanoma on the ear
than women. This is likely related to males having little
protection on their ears through life and women more
often having their ears protected by hair. It is more difficult to hypothesize why women were twice as likely than
men to develop cutaneous melanoma on the forehead,
although men may be more disposed than women to
wearing a cap to cover their forehead. Continuous sunlight exposure leads to melanoma development on the
face in older age group,29 and this is supported by our
findings that the cheek and nose were the most common
sites for developing facial cutaneous melanoma, with
equal distribution between men and women and no
predilection for right versus left side of the face. The
epidemiology of cutaneous melanoma of the head and
neck also shows that the mean age at diagnosis is older
Acknowledgments
The authors would like to thank the technologists in the office of
Dr. Arlette and at Calgary Laboratory Services for preparation of histologic material. Assistance with manuscript preparation was provided by Lori Hanninen.
References
1. Balch CM, Buzaid AC, Soong SJ, et al. Final version of the
American Joint Committee on Cancer staging system for cutaneous
melanoma. J Clin Oncol 2001; 19:36353648.
2. Houghton A, Coit D, Bloomer W, et al. NCCN Melanoma
Practice Guidelines. National Comprehensive Cancer Network,
Oncology (Huntingt) 1998; 12:153177.
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