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The ••Spaghetti Technique••: an Alternative to Mohs Surgery Or The ‘‘spaghetti technique’’: An alternative to Mohs surgery or staged surgery for problematic lentiginous melanoma (lentigo maligna and acral lentiginous melanoma) Caroline Gaudy-Marqueste, MD, PhD,a Anne-Sophie Perchenet, MD,b Anne-Marie Tase´i, MD,c Nika Madjlessi, MD,a Guy Magalon, MD, PhD,b Marie-Aleth Richard, MD, PhD,a and Jean-Jacques Grob, MD, PhDa Marseille, France Background: Lentigo maligna (LM) and acral lentiginous melanoma (ALM) are often large and clinically ill defined. The surgical challenge is to spare tissue while still achieving clear margins. Objective: We sought to provide a retrospective assessment of a two-phase surgical technique for lentiginous melanomas (MM) not suitable for en bloc resection. Methods: In the first phase, a narrow band of skin, ‘‘the spaghetti’’, is resected just beyond the clinical outline of the MM, immediately sutured, and sent for pathological examination without removing the MM. The same procedure is repeated beyond the segments which are shown to be not tumor free and so forth until the minimal tumor-free perimeter is outlined. No operative wound is left between operative sessions. In the second phase, the MM resection and reconstruction are performed at the same time. Results: In 21 patients with LM (n = 16) or ALM (n = 5), the mean operative defect size was 27.5 cm2 (range, 1.97-108.4 cm2). The mean number of steps in the procedure was 1.55 (1-4). Grafts were used for reconstruction in all cases. The relevance of the ‘‘spaghetti’’-defined outline was confirmed in 19 of 21 patients. After a median follow-up period of 25.36 months (range, 0-72 months), the local control rate was 95.24% with one case (4.76%) of in-transit invasive recurrence after 48 months. Limitations: This study was performed at a single center and included a limited number of patients. The follow-up time was relatively brief. Conclusion: The ‘‘spaghetti technique’’ is simple and reliable for LM and ALM. Unlike Mohs surgery, it does not require specific training of surgeons or pathologists. Unlike staged surgery, it does not leave patients with an open wound on the face or soles before final reconstruction. ( J Am Acad Dermatol 2011;64:113-8.) Key words: lentiginous melanomas; margins assessment; surgery. INTRODUCTION Abbreviations used: The lentiginous subtypes of melanoma (MM), ALM: acral lentiginous melanoma LM: lentigo maligna namely lentigo maligna (LM) and acral lentiginous MM: melanoma MM (ALM), share common characteristics: (1) the MMS: Mohs micrographic surgery lentiginous phase can be very subtle with little or no SS: staged surgery From the Service de Dermatologie, Hoˆpital Ste Marguerite,a 4th European Association of Dermato-Oncology Congress, Service de Chirurgie Plastique, Hoˆpital La Conception,b and Marseille, June 19-21, 2008. the Service d’Anatomopathologie, Hoˆpital La Timone, Univer- Reprint requests: Dr Caroline Gaudy-Marqueste, Dermatology site´ de la Me´diterrane´e.c Department, Ste Marguerite Hospital, 270 Blvd Ste Marguerite, Funding sources: None. 13009 Marseille, France. E-mail: [email protected]. Conflict of interest: None declared. 0190-9622/$36.00 This work was presented as an oral communication during the 7th ª 2010 by the American Academy of Dermatology, Inc. International Conference on Adjuvant Therapy of Melanoma e doi:10.1016/j.jaad.2010.03.014 113 114 Gaudy-Marqueste et al JAM ACAD DERMATOL JANUARY 2011 pigmentation and can thus go undetected for months Technique to years before they become nodular or ulcerate and Phase I: Outlining the limits of the MM. After (2) because of clinically ill-defined and not always biopsy confirmation of the LM or ALM diagnosis and pigmented peripheral margins, their extent tends to the obtaining of a provisional Breslow thickness, a 2- be underestimated, with a risk of insufficient resec- mm strip of skin, the so-called ‘‘spaghetti,’’ is tion. Margins of at least 10 mm are therefore usually resected under local anesthesia, 3 to 5 mm beyond recommended for complete excision of LM, even for the clinically apparent perimeter of the tumor (Fig 1). in situ lesions.1-6 LM and ALM The resulting linear defect is grow on skin areas with ma- immediately sutured without jor aesthetic or functional im- CAPSULE SUMMARY ablation of the central area plications (face, soles), including the MM (Fig 1). d Lentiginous melanomas are often large which accounts for the ten- The ‘‘spaghetti’’ is further di- and clinically ill defined. dency to minimize resection, vided into anatomically iden- in a conscious or uncon- d Surgical assessment of margins before tified segments and sent for scious manner, increasing resection is recommended to avoid dermatopathologic examina- the risk of insufficient mar- incomplete resection and to spare tissue. tion. Each segment is ana- gins. Recurrences are there- d The ‘‘spaghetti technique’’ is a simple lyzed along its longitudinal fore frequent, unless a way to evaluate margins and does not axis, in en-face sections. precise control of limits is require special surgical or When a segment of the ‘‘spa- performed, either by the dermatopathology training. ghetti’’ is tumor positive, the techniques of Mohs micro- procedure is repeated 5 mm graphic surgery (MMS) or beyond the corresponding staged surgery (SS). MMS uses frozen horizontal involved segment and again sutured, as shown in sections and gives good results in terms of safety Fig 1, B, so that no operative wound is left between and tissue sparing.2-8 MMS can be performed in 1 day, sessions. The procedure is repeated as often as but is complex and requires specific training; thus it is necessary until the last segment of ‘‘spaghetti’’ is not considered cost-effective in many countries. found to be tumor free. The smallest peripheral area Multi-step variants of MMS with paraffin sections free of any tumor is outlined by the most external line require days or weeks with open wounds. Various SS of sutures of the successive ‘‘spaghetti’’ procedures procedures have been described in the literature.9,10 (see Fig 2) and thus defines the central area to be When SS is applied to large LMs or ALMs, additional resected. Fig 3 represents the first phase of the tissue excisions are often needed until tumor-free procedure showing clinical pictures together with margins can be obtained, allowing for secondary the histologic examination. Fig 4 represents a phase I reconstruction. Patients thus remain with an open procedure photographic sequence. wound on the face or soles with a potential major Phase II. Resection of the tumor and functional, social, and psychological impact. reconstruction. The optimal surgical reconstruc- In the search for a technique more simple than tion to be applied is determined by the final shape of MMS applicable to large LMs and ALMs, combining the area to be resected. Resection of the central area minimal resection with margin control and avoiding and reconstruction (graft or flap) are performed at a prolonged open wound, we designed a two-phase the same time. The final tumor specimen is analyzed procedure based on the sampling of a ‘‘spaghetti- with serial vertical sections. like’’ band of tissue to ascertain margins before Review of the cases. The medical records of all tumor removal. This procedure helps to determine patients treated by this technique between 2002 and the most likely shape and extension of LMs and ALMs 2008 in our Dermatology department were retrospec- before they are resected, so that the patient has a tively reviewed. Clinical, surgical, and histologic data single procedure with immediate reconstruction. were recorded, including demographic data (age and Herein we report our retrospective experience. sex), the tumor location and thickness, the number of steps required in the procedure, the margin status on the final excision report, and the recurrence rate. METHODS Indications RESULTS We used the so-called ‘‘spaghetti technique’’ in Patients patients with ALM or LM who were initially referred Twenty-one patients (4 men and 17 women) for SS. Indications included ill-defined borders, large underwent the ‘‘spaghetti’’ procedure. Mean age at size of lesion, or reconstruction issues. diagnosis was 71 years (range, 53-90 years). JAM ACAD DERMATOL Gaudy-Marqueste et al 115 VOLUME 64, NUMBER 1 Fig 1. A, First step of the procedure. Resection of the ‘‘spaghetti’’ and immediate suture of the defect. B, New ‘‘spaghetti’’ procedure is performed beyond the nonetumor-free segments until tumor-free margins are obtained. C, Second step: Resection of the entire area including the tumor and immediate reconstruction of the defect. Tumor characteristics used grafts in all cases. No immediate complications Twenty one lentiginous MMs were treated, in- occurred. cluding 16 LMs (76.2%) and 5 ALMs (23.8%). All the LMs were located on the face: 8 on the cheek, 3 on the Pathological data ear, one on the temple, one on the eyebrow, one on The mean number of ‘‘spaghetti’’ steps during the nose, one on the inferior eyelid, and one on the phase I was 1.55 (range, 1-4). Several steps were inferior lip. All the ALMs were located on the soles. required in 9 cases. After final excision, 10 MM were Surgical data found to be in situ, whereas 11 were invasive, with a Mean size of the resected area in phase II was mean thickness of 1.90 mm (range, 0.65-10). The 27.54 cm2 (range, 1.97-108.33 cm2). Reconstruction limits of the central skin specimen including the MM 116 Gaudy-Marqueste et al JAM ACAD DERMATOL JANUARY 2011 identified limits of the lentiginous MM, and the objective is to check the periphery of this geometric figure before resection. In the ‘‘spaghetti technique’’, the objective is to define, step by step as closely as possible, the real (pathologically defined) shape and extension of the lentiginous MM, which in turn will allow, a posteriori, determination of the optimal shape and size of the resection for reconstruction.
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