Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: The “square” procedure,☆☆

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Abstract

Background: Management of lentigo maligna (LM) and lentigo maligna melanoma (LMM) may present problems because of the characteristic, yet unpredictable, subclinical peripheral and periadnexal extension of atypical junctional melanocytic hyperplasia beyond the visible margins. Objective: We used paraffin-embedded (permanent) peripheral vertical section margin control in a staged fashion in the management of LM and LMM. Methods: We used a modification of surgical excision in a staged fashion by means of a two-bladed knife with permanent peripheral vertical section margin control. Results: This method is technically easy and results in complete histologic evaluation of the peripheral margins without compromising the measurement of tumor thickness of the primary melanoma. Conclusion: The use of the “square” procedure, a staged excision with permanent peripheral vertical section margin control, is useful in the management of LM and LMM. (J Am Acad Dermatol 1997;37:758-64.)

Section snippets

TECHNIQUE

For LM, the clinical margin of the lesion is outlined during Wood’s lamp examination. With the intent to clear the tumor with the initial surgical procedure, a surgical margin of 0.5 to 1 cm is outlined with geometric angled corners of the lines, such as in the form of a square or rectangle. Geometric configuration with angled corners of the surgical excision margin lines, rather than rounded lines (e.g., circle, oval) is necessary to facilitate tissue processing, enabling the technician to

DISCUSSION

The number of new cases of melanoma continues to rise at a rate faster than that of any other human cancer. 33, 46 Although melanoma represents a relatively small percentage of all skin cancers, it accounts for approximately 75% of the deaths from skin cancer. Several independent factors are useful for prognosis and treatment of melanoma including tumor thickness, ulceration, location, and sex. 33 Other important prognostic factors include angiolymphatic invasion, micro-satellitosis, and

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      Citation Excerpt :

      The deep microscopic margin of the excised central tumor was evaluated with breadloafed formalin-fixed paraffin-embedded sections. “Modified peripheral” MMS is analogous to the “square” technique for melanoma.3 The choice to perform “comprehensive” or “modified peripheral” MMS depended on the Mohs surgeon's judgement and was influenced by lesion size, anticipated duration of surgery, and wound care challenges between MMS and reconstruction with a surgical colleague.

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    Reprint requests: Timothy M. Johnson, MD, University of Michigan, Department of Dermatology, 1910 Taubman Center, Box 0314, Ann Arbor, MI 48109-0314.

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