› Forums › General Melanoma Community › Mohs vs. WLE for likely MIS on cheek
- This topic has 12 replies, 3 voices, and was last updated 11 years, 11 months ago by
Liz C.
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- September 27, 2012 at 10:45 pm
A shave biopsy in early July, reviewed by 2 top dermatopaths and UCSF, indicates likely MIS. Am trying to figure out how to proceed to get the highest possiblity of cure (most important) while minimizing scar visibility.
This article from the April 2012 Dermatology Journal is influencing my decision greatly. http://dermatology.jwatch.org/cgi/content/full/2012/406/
A shave biopsy in early July, reviewed by 2 top dermatopaths and UCSF, indicates likely MIS. Am trying to figure out how to proceed to get the highest possiblity of cure (most important) while minimizing scar visibility.
This article from the April 2012 Dermatology Journal is influencing my decision greatly. http://dermatology.jwatch.org/cgi/content/full/2012/406/
"To clear the melanomas, 6-mm margins were sufficient in 86% of cases, 9-mm margins cleared 98.9%, 1.2 cm cleared 99.4%, 1.5 cm cleared 99.6%, and 100% of lesions were cleared with 3-cm margins. The 9-mm margins were significantly superior to 6-mm margins (P<0.001).
My Mohs surgeon (former 11 yr. chief of derm surg at major medical center) is offering 2-3 mm margins to start with and immediate closure. The plastic surgeon is offering a WLE with 5 mm to start, closure, and if that is not enough, the next cut is 5 mm further out past the first margin.
In the article, 6mm margins has proven to be better — and 9 mm is much better. So, I'm considering wider margins than have been offered to me.
It's very tempting to go with the Mohs surgeon — the slow Mohs approach. I will only accept path report on stained, permanent slides (with several en face cuts to the tissue so the margins can be examined well). The path report will be done at UCSF — where Mohs surgeons are trained.
In this particular location, on the cheek, I'm unclear about WHEN the value of Mohs surgery starts to drop off (if it does?) and WHEN does WLE start to offer better cure. Does the Mohs surgical site marking technique still carry much value — if the best way to handle MIS is to keep expanding the margin until no more abnormal melanocytes are found?
Thank you very, very much for any clarification you may be able to offer — or documents to suggest.
p.s. FYI, separating Mohs surgery from the pathology work (by sending tissue elsewhere) is considered by AETNA to not be Mohs surgery at all.
Aetna Note: 2012: Note: Mohs micrographic surgery requires a single physician to act in 2 integrated, but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports his/her services separately, the use of the Mohs micrographic surgery CPT codes is inappropriate.
Source: http://www.aetna.com/cpb/medical/data/300_399/0383.html
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- September 28, 2012 at 1:30 am
Mohs is most valuable when doing frozen section pathology. In comparing your slow Mohs to a WLE, I'm not sure it offers much benefit especially if your goal is wider margins. With a WLE, you take X margins and that is it unless the WLE tissue shows obvious melanoma close to a margin. With a slow Mohs, you look for the clean tissue and then add margins to that. Typically, Mohs would have less clear margins taken because of the more detailed analysis of the staged approach. Is your melanoma in situ Superficial Spreading or Lentigo Maligna? That might influence my decision as Lentiga Maligna has a much higher local recurrence rate than Superficial Spreading.
I'll propose a solution that is going through a clinical trial at my institution. Aldara on the melanoma in situ lesion for several weeks and THEN Mohs. The Aldara shrinks the lesion by up to 2/3 and then the Mohs is done leaving a much smaller defect. They are doing this for Lentigo Maligna, not Superficial Spreading. The local recurrence rate using this method is reduced to roughly 5% instead of 50%. As I said, this is only done on Lentigo Maligna which has the higher local recurrence rate. My cutaneous oncologist (Mohs surgeon) is very excited by the results.
I think if my lesion were Superficial Spreading, I'd probably go with the WLE with whatever margins you want and just get it over with. If my lesion were Lentigo Maligna, I would probably consider the slow Mohs given the nature of LM and local recurrences.
You've obviously done your research, there's not really much we can add. In the end, it's about what makes YOU comfortable, not anyone else.
Janner
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- September 28, 2012 at 1:30 am
Mohs is most valuable when doing frozen section pathology. In comparing your slow Mohs to a WLE, I'm not sure it offers much benefit especially if your goal is wider margins. With a WLE, you take X margins and that is it unless the WLE tissue shows obvious melanoma close to a margin. With a slow Mohs, you look for the clean tissue and then add margins to that. Typically, Mohs would have less clear margins taken because of the more detailed analysis of the staged approach. Is your melanoma in situ Superficial Spreading or Lentigo Maligna? That might influence my decision as Lentiga Maligna has a much higher local recurrence rate than Superficial Spreading.
I'll propose a solution that is going through a clinical trial at my institution. Aldara on the melanoma in situ lesion for several weeks and THEN Mohs. The Aldara shrinks the lesion by up to 2/3 and then the Mohs is done leaving a much smaller defect. They are doing this for Lentigo Maligna, not Superficial Spreading. The local recurrence rate using this method is reduced to roughly 5% instead of 50%. As I said, this is only done on Lentigo Maligna which has the higher local recurrence rate. My cutaneous oncologist (Mohs surgeon) is very excited by the results.
I think if my lesion were Superficial Spreading, I'd probably go with the WLE with whatever margins you want and just get it over with. If my lesion were Lentigo Maligna, I would probably consider the slow Mohs given the nature of LM and local recurrences.
You've obviously done your research, there's not really much we can add. In the end, it's about what makes YOU comfortable, not anyone else.
Janner
-
- September 28, 2012 at 1:30 am
Mohs is most valuable when doing frozen section pathology. In comparing your slow Mohs to a WLE, I'm not sure it offers much benefit especially if your goal is wider margins. With a WLE, you take X margins and that is it unless the WLE tissue shows obvious melanoma close to a margin. With a slow Mohs, you look for the clean tissue and then add margins to that. Typically, Mohs would have less clear margins taken because of the more detailed analysis of the staged approach. Is your melanoma in situ Superficial Spreading or Lentigo Maligna? That might influence my decision as Lentiga Maligna has a much higher local recurrence rate than Superficial Spreading.
I'll propose a solution that is going through a clinical trial at my institution. Aldara on the melanoma in situ lesion for several weeks and THEN Mohs. The Aldara shrinks the lesion by up to 2/3 and then the Mohs is done leaving a much smaller defect. They are doing this for Lentigo Maligna, not Superficial Spreading. The local recurrence rate using this method is reduced to roughly 5% instead of 50%. As I said, this is only done on Lentigo Maligna which has the higher local recurrence rate. My cutaneous oncologist (Mohs surgeon) is very excited by the results.
I think if my lesion were Superficial Spreading, I'd probably go with the WLE with whatever margins you want and just get it over with. If my lesion were Lentigo Maligna, I would probably consider the slow Mohs given the nature of LM and local recurrences.
You've obviously done your research, there's not really much we can add. In the end, it's about what makes YOU comfortable, not anyone else.
Janner
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