opinions? WLE or modified MOHS on center chest for a local recurrence within my scar

Posted By
5/14/2018 10:19pm
View other posts by
Replies: 2

Hi all. I’m in a bit of dilemma on what treatment to do for this local recurrence. The path report said local recurrence of melanoma in situ which I guess is good if it’s right. Duke is where I’m going for this and they have got my original slides of my previous lentigo maligna MIS biopsy and WLEas well as this recent recurrence biopsy and they are having their dermopathologists come up with their own report to make sure nothing was missed and it matches. The dr seemed to think it would match up but we shall see. She said being that it is still considered insitu that it would not have spread but being in rather freaked out about a few larger than normal lymph nodes in my armpit she is sending me for an ultrasound for my piece of mind. She said that would highly unlikely be why those were a little enlarged. Anyway, her recommendation was to excise with a bit wider margins than last time and get clear margins. She said if the path is correct and it is still considered in situ that she wouldn’t be opposed at me doing MOHS surgery with this but if it came back a thin melanoma versus MIS then she wouldn’t recommend. I had a consult with supposedly the best MOHS surgeon in this area and he said if it were him he would do MOHS. He said that some melanoma like my lentigo maligna has what he calls tentacles that spread out beyond the mole and said it’s like an octopus. He said sometimes those tentacles of cells are further out than what a standard wide local excision would get and can leave some behind which is what happened in my case. He said new studies are showing it to be better than a wide local excision. He said he would do a modified MOHS where he basically does kind of like a wide local excision and does MOHS on all the tissue and surrounding tissue. He says a pathologist is there during surgery and that they stain the skin with some type of stain that lights up melanoma cells and they remove them. He says if they keep seeing cells beyond the margins they keep going until it’s clear. Sounds good right? But from what I’ve read it’s mainly for the other types of skin cancers. He says he does MOHS on melanomas every day. Just want to make the right decision being this is a recurrence because if any gets left behind next time I may not be so lucky and it could end up invasive. What’s everyone’s thoughts on this and has anyone ever expierenced a true local recurrence in their scar? Thanks so much, TSET

My melanoma derm is a Mohs surgeon - spends 4.5 days a week doing all skin surgeries, half a day seeing patients.  The only melanoma he will use Mohs for is Lentigo Maligna.  The other varieties of melanoma he will just do the wide excision.  Most of the time, LM is located in pretty noticable areas (like face) where tissue saving techniques are definitely noticed. 

Mohs typically uses frozen sections for pathology and the other skin cancers show up well.  Melanoma requires staining and that isn't as condusive to quick turn around.  Be aware, you may be around all day while they do the removal, stain samples, check margins and go back and take more if needed.  It's more of a "staged" excision that takes longer than it would for the other skin cancers because of the processing time for the tissue being removed.

LM has the highest local recurrence rate of any melanoma so I'm sure other's have experienced it.  I don't think there is a right or wrong answer here.  Just go with what makes YOU feel the most comfortable.

Thanks for your input Janner. It seems as if this MOHS surgeon would be doing basically a wide local excision but using the MOHS technique to make sure none of the tentacles of melanoma are left behind. He also mentioned that pathologist use something called a breadloafing technique while examing wide local excisions im which they slice it like a loaf of bread to check for cells. He says that is fine in the majortiy but in some people there are cells in between those slices that arent seen.He said that the wide local excision part would not be done that way with his MOHS surgery that they look at the entire tissue to make sure nothing is left behind. It sounds like to me that would be a better option than wide local excision alone on any melanoma lesion especially since a normal derm, plastic surgeon or surgical oncologist would only do a wide local excision with maybe a little wider margins and then when they send that off to path the breadloaf the tissue which can leave cells. Do you have any idea why that wouldnt be recommended for melanoma beyond in situ being he is still doing a WLE and he said he cuts down to the fat? My origional in situ was a LM subtype in situ but even it was really small. This recurrence is even smaller than the origional literally the size of a freckle and looked like a freckle. Ive gotten mixed reviews, an oncologist I spoke with said dont do mohs and the surgical oncologist at duke said thats fine with insitu but not if path report comes back saying not really in situ but thin. Ive talked to 3 different dermatologists and they all recommended MOHS. Its just so confusing.