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. The ‘‘spaghetti technique’’ for LM and ALM has many advantages. The first is safety. The clinical limits of LM and ALM are often misleading and underestimated, as shown by a mean of 1.55 (up to Fig 2. Determination of tumor margins before tumor 4) successive samplings of ‘‘spaghetti’’ before a resection following 3 spaghetti procedures. tumor-free strip is found. This is in line with previous studies in LM showing a mean of 1.67 (up to 5) stages 13 were tumor free in 15 cases, thus supporting the in SS of LM. Safety is also linked to the comprehen- efficacy of the technique. A focus of intraepithelial sive longitudinal en face dermatopathologic control MM was found close to the limits of the central part of of the periphery. As compared to serial sections, the the resection in 6 cases (30%), raising doubts about use of en face sections minimizes the risk of missing a the validity and safety of the tumor-free limit defined radial extension of MM between sections. However, these sections may sometimes be difficult to inter- by the ‘‘spaghetti procedure’’. 14 Therefore, these 6 patients were offered an extra pret since they do not allow an assessment of the 5-mm skin resection beyond the last suspect limit change in density from the center to the periphery, or after reconstruction. One patient refused this addi- an estimation of the difference between LM and a tional resection. A focus of intraepithelial MM was background of severely sun damaged skin. When found again in one case. The samples were tumor compared to MMS, the use of paraffin sections is free in the 4 remaining cases, thus confirming the more reliable than frozen ones. As a whole, the safety ‘‘spaghetti’’-defined limit. of the ‘‘spaghetti’’ technique is supported by the The relevance of the ‘‘spaghetti technique’’ to confirmation of the ‘‘spaghetti’’-defined limits as define tumor extension could thus be confirmed by shown by the serial sections of the final excision, in pathological examination in 19 of the 21 patients and 90.45% of patients (19/21) and by a 95% control rate remained uncertain in one case. after a median of 2 years. This follow-up period is too short, however, to draw firm conclusions. The risk of seeding of the wound is only theoretical as the Follow-up ‘‘spaghetti’’ technique is performed in the in situ After a mean follow-up of 25.36 months (maxi- part of the lentiginous MM and as the surgery is mum 72 months) after the final surgical procedure, performed after the last positive strip and within a the local control rate was 95.24%. In one case few weeks. (4.76%), an in-transit invasive recurrence was ob- Like MMS, the ‘‘spaghetti’’ technique guarantees served after 48 months. the sparing of tissue, due to the step-by-step centrif- ugal process following closely the tumor-free margin DISCUSSION of the MM. This is especially crucial for lesions on the We describe our experience with an easy and safe face and soles. As compared to SS, as well as to the two-phase method, the ‘‘spaghetti technique,’’ which ‘‘perimeter’’ or ‘‘square’’ technique, the sparing of is well adapted to the specific problems of margin tissue is probably optimized. In contrast to MMS, the control and potential aesthetic sequelae encoun- technique can be performed by any surgeon and tered in the resection of lentiginous MMs. The pathologist without any additional training. The over- concept of pathological control of the margins all ‘‘spaghetti’’ procedure is of greater duration than before resection of MM has also been applied in classic MMS using frozen sections, but probably sim- the so-called ‘‘square technique’’10,11 or ‘‘perimeter ilar to MMS using paraffin sections.15 When compared technique’’.12 The two strategies are, however, some- with the usual SS, the ‘‘spaghetti’’ technique, as well as what different. In the ‘‘square’’ or ‘‘perimeter’’ tech- the ‘‘square’’ technique, are much more comfortable nique, the geometric shape (square, triangle, for patients, who do not have open wounds on the pentagons) for an optimal resection is determined face or the soles for several days or weeks during the a priori by adding safety margins to the clinically different steps leading to margin control. JAM ACAD DERMATOL Gaudy-Marqueste et al 117 VOLUME 64, NUMBER 1
Fig 3. Outlining limits of a lentiginous melanoma: Resection of the spaghetti, division into anatomically defined segments, suture of the defect (upper panel ). Macroscopic appearance of the spaghetti segment together with histologic sections (lower panel ).
Fig 4. Photographic sequence of the first step of the ‘‘spaghetti’’ procedure. 118 Gaudy-Marqueste et al JAM ACAD DERMATOL JANUARY 2011
Finally, outlining the true shape of LM and ALM immunostaining: University of Minnesota experience. Derma- prior to resection allows for a single surgical resec- tol Surg 2006;32:690-6. tion with immediate reconstruction. It also allows a 8. Temple CL, Arlette JP. Mohs micrographic surgery in the treatment of lentigo maligna and melanoma. J Surg Oncol choice of the most suitable graft or flap, combining 2006;94:287-92. safety, simplicity, minimal resection and manage- 9. Bub JL, Berg D, Slee A, Odland PB. Management of lentigo ment of comfort, function, and aesthetics. maligna and lentigo maligna melanoma with staged excision: a 5-year follow-up. Arch Dermatol 2004;140:552-8. 10. Johnson TM, Headington JT, Baker SR, Lowe L. Usefulness of REFERENCES the staged excision for lentigo maligna and lentigo maligna 1. Huilgol SC, Selva D, Chen C, Hill DC, James CL, Gramp A, et al. melanoma: the ‘‘square’’ procedure. J Am Acad Dermatol Surgical margins for lentigo maligna and lentigo maligna 1997;37:758-64. melanoma: the technique of mapped serial excision. Arch 11. Anderson KW, Baker SR. Management of early lentigo maligna Dermatol 2004;140:1087-92. and lentigo maligna melanoma of the head and neck. Facial 2. Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision Plast Surg Clin North Am 2003;11:93-105. of primary cutaneous melanoma. J Am Acad Dermatol 1997; 12. Mahoney MH, Joseph M, Temple CL. The perimeter technique 37:422-9. for lentigo maligna: an alternative to Mohs micrographic 3. Zalla MJ, Lim KK, Dicaudo DJ, Gagnot MM. Mohs micrographic surgery. J Surg Oncol 2005;91:120-5. excision of melanoma using immunostains. Dermatol Surg 13. Hazan C, Dusza SW, Delgado R, Busam KJ, Halpern AC, Nehal 2000;26:771-84. KS. Staged excision for lentigo maligna and lentigo maligna 4. Cohen LM, McCall MW, Zax RH. Mohs micrographic surgery for melanoma: a retrospective analysis of 117 cases. J Am Acad lentigo maligna and lentigo maligna melanoma. A follow-up Dermatol 2008;58:142-8. Epub 2007 Oct 29. study. Dermatol Surg 1998;24:673-7. 14. Prieto VG, Argenyi ZB, Barnhill RL, Duray PH, Elenitsas R, From 5. Robinson JK. Margin control for lentigo maligna. J Am Acad L, et al. Are en face frozen sections accurate for diagnosing Dermatol 1994;31:79-85. margin status in melanocytic lesions? Am J Clin Pathol 2003; 6. Agarwal-Antal N, Bowen GM, Gerwels JW. Histologic evalua- 120:203-8. tion of lentigo maligna with permanent sections: implications 15. Stonecipher MR, Leshin B, Patrick J, White WL. Management of regarding current guidelines. J Am Acad Dermatol 2002;47: lentigo maligna and lentigo maligna melanoma with paraffin- 743-8. embedded tangential sections: utility of immunoperoxidase 7. Bhardwaj SS, Tope WD, Lee PK. Mohs micrographic surgery for staining and supplemental vertical sections. J Am Acad lentigo maligna and lentigo maligna melanoma using Mel-5 Dermatol 1993;29:589-94.