Highlights from the Literature Two
Understanding Melanoma in situ: Lentigo maligna surgical treatment terminology and guideline adherence, a targeted review.
By Sherrif F. Ibrahim, MD, PhD, FACMS
In this article, the authors comprehensively define the national guideline recommendations for surgical techniques used to treat malignant melanoma in-situ – lentigo maligna (LM). A targeted literature review was performed spanning a 32-year time period (1990 – 2022) and resulted in the most detailed single source to review the myriad approaches for the treatment of these challenging tumors. Because many different techniques have been described in the literature, adherence to guidelines can prove challenging for the dermatologic surgeon. Details such as types of tissue processing (permanent vs frozen sectioning), orientation of sectioning, and type of surgical excision are described in detail.
The manuscript goes on to explain in detail the differences between wide excision, standard Mohs micrographic surgery (MMS), modified MMS, staged excision, slow-Mohs, “spaghetti” sectioning, square sectioning, and mapped serial excision. Of particular impact are the tables in the paper. Table I describes the aforementioned techniques, their detailed associations, processing, and specific advantages and disadvantages. Table II lists key national guideline recommendations when using any tissue-sparing technique for the treatment of LM including guidelines for margins, depth of excision, and processing of the central debulking specimen. Table III outlines the variations in staged excision techniques.
With the growing number of LM tumors encountered in dermatologic surgery, it is critical that we communicate with a common language and approach to treatment. This paper provides the most comprehensive and up-to-date review of guidelines and description of surgical techniques and specimen processing in the literature. For those providers treating these tumors in any capacity, it can serve as a useful resource and clarify confusion regarding variations in surgical management.