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Published on April 8, 2021 by Bharat Yarlagadda

The Role of Moh’s Surgery in the Treatment of Melanoma

Moh’s micrographic surgery (MMS) has very high rates of local control and cure for basal cell and squamous cell carcinoma. When appropriately performed, cure rates exceed 98%, especially for smaller lesions1. The role of MMS for treatment of melanoma is less clear. MMS is predicated on the use of close margins to clear disease, while preserving normal anatomy. This is contrary to the classic teaching of wide margins for clearance of melanoma. We thus ask, is MMS appropriate for melanoma, and in what circumstances?

Techniques:

MMS is performed most frequently in the office setting by a dermatologic surgeon. The skin lesion is debulked, and a thin margin is then taken circumferentially and deep to the tumor. This tissue is processed with H and E staining, in a manner to assess nearly the entirety of the margin, rather than the breadloaf technique which is prone to sampling error. Residual tumor is identified, and the process is repeated until clear margins are achieved. Often, the resection is performed typically in a single office visit, and reconstruction can be immediate or staged, depending on the defect. The process is illustrated here2:

MMS for melanoma has a few technical differences. The debulk and acquisition of the margins are similar. However, the margins are sent to a pathologist for rushed, but otherwise typical, permanent section analysis. The patient is dressed and sent home until the results are finalized, indicating the need for additional stages. This is known as the “slow Moh’s” approach. Some MMS surgeons use rapid MART-1 stains in the Moh’s lab to speed up the process, and offer single-day MMS in select cases3. Regardless of the technique, it is typically recommended to send the debulked central component for permanent section analysis to obtain complete staging information.

On the other hand, wide local excision (WLE) is the current standard of care for in-situ and invasive melanoma. The meaning of “wide” depends of course of the depth of the tumor. According to the National Comprehensive Cancer Network (NCCN), wide margins are as follows4:

Tumor Thickness Recommended Clinical Margin
In situ 0.5 – 1.0
≤ 1.0 mm 1.0 cm (category 1)
> 1.0 – 2 mm 1 – 2 cm (category 1)
> 2.0 – 4 mm 2.0 cm (category 1)
> 4 mm 2.0 cm (category 1)

Obtaining these margins is often done in the operating room, and with delayed reconstruction once complete circumferential and deep margin clearance is verified.

Pros and Cons

A pros and cons comparison between MMS and WLE is summarized in this table by Beaulieu and colleagues5. The article can be found here, and the table here.

In brief, the pros of WLE include the wealth of data demonstrating efficacy, use of permanent section analysis of the specimen, and the relative short duration of the procedure compared to MMS. The primary drawbacks of WLE include the time between the procedure and the final pathology reporting, and the idea that WLE is not necessarily designed to be tissue sparing.

On the contrary, MMS is noted to provide point-of-care pathologic information, with presumed 100% margin analysis. However, there is uncertainty of “clear margins” with in the setting of satellitosis, and the extent / distance of a clear margin is not verified due to the tumor debulking process.

Another drawback of MMS in melanoma is a logistical one with regards to sentinel lymph node biopsy (SLNB). In many cases, SLNB can be performed in the same setting as WLE, typically under general anesthesia, with radionuclide / methylene blue injection into the skin lesion prior to the WLE. With MMS, this workflow is not possible. The SLNB would have to be done in a separate operative encounter prior to MMS. Post-MMS reconstruction may then require an additional operative encounter of course.  Alternatively, SLNB may be performed after MMS, but this would require injection of the tracer into the margin of the excised lesion, or the resultant scar. The concern here is the alteration of dermal lymphatic drainage after MMS which may alter the reliability of the SLNB procedure.  Though the details are out of the scope of this blog post, the importance of properly performed SLNB has been clearly established in multiple studies, both from a prognostic and therapeutic standpoint. To alter or degrade the prognostic and therapeutic effect of SLNB when performing MMS in lieu of WLE may actually be detrimental to some patients at high risk of occult nodal disease at presentation. In addition, the potential need for multiple operative encounters and anesthetic episodes can lead to increased costs and time for the patient.

The Evidence

High quality evidence addressing the use of MMS for melanoma is a bit lacking. Studies largely consist of retrospective, non-randomized, or single arm prospective observational trials.

Most data report results with treatment of melanoma in-situ (MIS), specifically lentigo maligna (LM).

  • De Vries et al, have demonstrated 100% local control rates in a retrospective cohort of LM patients treated with MMS. Average follow-up was 60 months6.
  • Hou et al demonstrated similar rates of local control for MMS compared to WLE in a non-randomized prospective trial of LM patients. Larger lesions of the head and neck, with indistinct borders, were preferentially treated with MMS, and demonstrated 1.9% rate of recurrence7.
  • Nosrati et al report retrospective analysis of 277 patients with MIS treated with MMS and 385 patients treated with conventional WLE, demonstrating no significant differences in local recurrence rates, overall survival, or melanoma-specific survival. Median follow-up was 8.6 years8.

Some studies report the use of MMS in invasive disease as well.

  • Bricca and colleagues report favorable local recurrence rates for invasive melanoma treated with MMS compared to WLE. This data even suggests superior local control with MMS rather than WLE, for MIS and thin melanoma. Local recurrence was noted to be 0.3 and 0% for MIS and melanoma <0.76 mm respectively, when treated with MMS, versus recurrence rates of 20 and 7.3% when treated with WLE9. This study is severely limited by use of historical control rates for patients undergoing WLE.
  • A prospective study by Ellison and colleagues demonstrated excellent local control rates in a cohort of 562 tumors, including invasive disease, mostly involving the head and neck10. However, the authors report the need for 10 to 12 mm margins for optimal local control, even if MMS technique is used.

The Guidelines

Institutional guidance is provided regarding the use of MMS in melanoma. The NCCN cutaneous melanoma guidelines (2.2021) state:

Mohs micrographic surgery (MMS) is not recommended for primary treatment of invasive cutaneous melanoma. It may be considered selectively for minimally invasive melanomas when standard margins cannot be achieved in anatomically constrained areas, along with other surgical methods that provide comprehensive histologic assessment, such as staged excision with permanent sections for dermatopathology review.

In the “Guidelines of care for the management of primary cutaneous melanoma”, a working group of the American Academy of Dermatology (AAD) acknowledges the recommendation to maintain at least 1 cm margins for invasive disease when possible11. MMS may be used for clearance of melanoma-in-situ, specifically of the lentigo maligna subtype (as distinguished from acral lentiginous).

In Conclusion

Take home points:

  • MMS is not recommended for invasive melanoma, and not supported by the NCCN or AAD guidelines.
  • Data regarding long term outcomes of MMS are evolving and the guidelines are under revision.
  • Regarding MIS specifically, complete circumferential and peripheral margin assessment (CCPMA) is ideal, and this can be accomplished with either en face rush permanent section analysis of margins, as well as MMS.

In practice, the current data and institutional guidelines recommend against the use of MMS for melanoma which is known or suspected to be invasive. This is due to a lack of clear oncologic equipoise when compared to WLE. Also, MMS may confound and complicate the performance and validity of SLNB, which is a critical component of treating certain invasive lesions. If purely in-situ disease is known or suspected, MMS seems to have a role here. In addition, a common scenario is the presence of residual in-situ disease at the margins of invasive disease cleared by WLE. MMS may be helpful to address this when WLE re-resection to clear the in-situ finding is not feasible or accepted by the patient. In many cases where MMS may play a role, these decisions are optimally made after consultation with both an oncologic head and neck melanoma surgeon and MMS surgeon, who can recommend the appropriate approach after weighing risks and benefits in select cases on an individualized basis.

References:

  1. Mansouri B, Bicknell LM, Hill D, Walker GD, Fiala K, Housewright C. Mohs Micrographic Surgery for the Management of Cutaneous Malignancies. Facial Plast Surg Clin North Am. 2017 Aug;25(3):291-301.
  2. Prickett KA, Ramsey ML. Mohs Micrographic Surgery. [Updated 2021 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441833/
  3. Siscos SM, Neill BC, Seger EW, Hooton TA, Hocker TLH. The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons. Dermatol Surg. 2020 Oct;46(10):1267-1271.
  4. NCCN Clinical Practice Guidelines in Oncology. Melanoma: Cutaneous. Version 2.2021 — February 19, 2021.
  5. Beaulieu D, et al. Current perspectives on Mohs micrographic surgery for melanoma. Clin Cosmet Investig Dermatol. 2018; 11: 309–320.
  6. de Vries K, Greveling K, Prens LM, et al. Recurrence rate of lentigo maligna after micrographically controlled staged surgical excision. Br J Dermatol 2016;174:588-593.
  7. Hou JL, Reed KB, Knudson RM, et al. Five-year outcomes of wide excision and Mohs micrographic surgery for primary lentigo maligna in an academic practice cohort. Dermatol Surg 2015;41:211-218.
  8. Nosrati A, Berliner JG, Goel S, McGuire J, Morhenn V, de Souza JR, Yeniay Y, Singh R, Lee K, Nakamura M, Wu RR, Griffin A, Grimes B, Linos E, Chren MM, Grekin R, Wei ML. Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision. JAMA Dermatol. 2017 May 1;153(5):436-441.
  9. Bricca GM, et al. Cutaneous head and neck melanoma treated with Mohs micrographic surgery. J Am Acad Dematol. 2005 Dec;52(1):92-100.
  10. Ellison PM, Zitelli JA, Brodland DG. Mohs micrographic surgery for melanoma: A prospective multicenter study. J Am Acad Dermatol. 2019 Sep;81(3):767-774.
  11. Melanoma Work Group. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019 Jan;80(1):208-250.
  • Bio
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Bharat Yarlagadda

Bharat Yarlagadda

Dr. Bharat Yarlagadda is a head and neck surgeon at the Lahey Hospital and Medical Center in Burlington, MA and an assistant professor in the Department of Otolaryngology - Head and Neck Surgery at Boston University School of Medicine. He completed Otolaryngology residency at the Boston Medical Center, and head and neck fellowship at the Massachusetts Eye and Ear Infirmary. His research is focused on surgical simulation as well as quality improvement and outcomes.
Bharat Yarlagadda

Latest posts by Bharat Yarlagadda (see all)

  • The Role of Moh’s Surgery in the Treatment of Melanoma - April 8, 2021

Published on April 7, 2021 by AHNS Webmaster

AHNS/COSM Meeting This Week – April 7th and 8th

Starting today, AHNS Symposium at COSM 2021

“Coming Together in Crisis- The Conversations We Need to Have: COVID, Disparity, Ethics, Education, our Future”

Please click here to view the program.

Virtual Meeting Platform link is here.

Register using this link here.

@AHNSinfo

@__COSM

Published on March 26, 2021 by AHNS Webmaster

Coming Together in Crisis: The Conversations We Need to Have – Learn More at COSM 2021

Join the American Head & Neck Society at this year’s virtual COSM as we focus on “Coming Together in Crisis – The Conversations We Need to Have: COVID, Disparity, Ethics, Education, our Future”.

The virtual COSM meeting is taking place April 7-11, 2021 with AHNS sessions taking place on Wednesday, April 7th and Thursday, April 8th.

We hope you can join our live sessions and be a part of the conversation as these important topics are discussed.

Wednesday, April 7, 2021

  • COVID 19: The Approaching Storm with Ehab Hanna, MD
  • COVID Recap with Maie St. John, MD, PhD
  • COVID-19 and the Effects on Cancer Surgery: The Tsunami after the Earthquake with Jonathan Irish, MD, MSc, FRCSC
  • COVID Caused Clinic and OR Challenges: Strategies, Successes and Failures
  • Multidisciplinary Care Post COVID: Did We Evolve or Simply Pivot?
  • Enhanced Challenges of Global Medicine During and After COVID
  • Research and Clinical Trials: Coping, Evolving and Succeeding during the Pandemic
  • Publishing in the COVID Era: Did We Over or Under Compensate?
  • A Personal Experience with Bevan Yueh, MD
  • Open Forum: A Time to Share – Be a part of the conversation!

Thursday, April 8, 2021

  • Diversity, Equity, and Inclusion: Facts, Challenges and Actions
  • Providing ‘Truly’ Equitable Care Across Diverse Populations, Cultural Competency, Financial Toxicity
  • Core Ethical Principles: Explanations and Applications
  • Should There Be More Surgeons in Palliative Care Fellowships or More Palliative Care in Surgical Fellowships? A Round Table Discussion
  • Head and Neck Fellowships: Have We Evolved?
  • What is the Future of Educational Activities: Virtual or In-Person and Out-of-Date?
  • Inspiring and Educating Medical Students and Residents: More Than Just Replacing Ourselves
  • How Do We Crash the Ceiling for Woman in Head and Neck Surgery? An Action Plan is Needed, Faculty Development, and Retention

All-Access Registration Fees:
*A $35 administration fee will be added to all categories, excluding Residents and Medical Students

Category
Member – $150*
Non-Member – $200*
Allied Health $125*
International – $125*
International (Low/Middle Income) – $75*
Active Military (Non-Member) – $175*
Resident – $100
Medical Student – $75

COSM is offering one fee for access to all 9 Societies’ presentations, panels, and posters, in addition to the virtual COSM Exhibit Hall. Up to 118.75 AMA PRA Category 1 Credits™ and MOC points will be offered.

Following the live virtual meeting, content will also be available for on-demand viewing to all registrants.

Questions?

  • For any COSM registration questions, please contact [email protected].
  • For any AHNS program questions, please contact [email protected].

SAVE THE DATE!
Mark your calendars for the AHNS International Conference on Head & Neck Cancer taking place July 22-25, 2021 at the Hyatt Regency in Chicago, IL. For more information, please visit https://www.ahns2021.org/.

Published on March 19, 2021 by Jeffrey Myers

A Giant of Head and Neck Surgery has Passed

It is with great sadness that I write to you about the passing of one of the true giants of the field of Head and Neck Surgical Oncology, Dr. Robert Byers passed away Saturday, March 6, 2021 at 3 AM.  There will be no funeral, but there will be a Memorial Service which will be announced later this month.

Robert Maxwell Byers, M.D. was born in Union Hospital, Baltimore Maryland on September 24, 1937. He grew up on the Eastern Shore of Maryland in the small town of Elkton. Very active in the varsity sports of baseball, basketball and track during his high school years, he continued his athletic participation at Duke University along with his pre-med studies. He entered the University of Maryland Medical School in Baltimore in 1959 where he excelled in his medical studies and received membership in AOA and the Rush Honor Medical Society. The highlight of his sophomore year was his 1961 marriage to Marcia Davis, a high school sweetheart. During his junior year, he was commissioned an Ensign in the United States Naval Reserve and later rose to the rank of Captain in 1986.

In 1963, Dr. Byers begin his general surgical residency with Dr. Robert Buxton at the University Hospital in Baltimore. Five years later, as a fully trained general surgeon, he went to the Republic of Vietnam with the 1st Marine Division where he received a unit commendation medal and a combat action ribbon. On return to the United States, he spent a year at Quonset Point, Rhode Island Naval Hospital as Chief of Surgery. In 1969, the American Board of Surgery certified him. After discharge from the Navy in 1970, he and his family moved to Houston, Texas where he began a fellowship in Surgical Oncology at the University of Texas M.D. Anderson Cancer Center under the guidance of Drs. R. Lee Clark, Richard Martin, Ed White, William MacComb, Richard Jesse and Alando J. Ballantyne. This move proved to be a decisive event, as he never left. His career in Head and Neck Surgical Oncology was born nurtured and matured during the 31 years of his academic/clinical practice at the University of Texas M.D. Anderson Cancer Center. In 1974, his fourth son, MacGregor was born.

During his tenure at M.D. Anderson Cancer Center he rose through the ranks from Assistant Professor in 1972 to Associate Professor in 1976 and, finally, Professor and Surgeon in 1981. In 1998, he was honored with the Distinguished Alando J. Ballantyne Chair of Head and Neck Surgery. He was the author or co-author of over 200 published papers, book chapters and monographs. He gave invited lectures all over the world. In 1999, he was selected to give the Hayes Martin Memorial Lecture at the 5th International Conference on Head and Neck Cancer (A copy of this lecture can viewed by clicking here). He was President of the American Radium Society and President of the Society of Head and Neck Surgeons both in 1995 – 1996. His research interests and his expertise were focused on cancer of the oral cavity, head and neck cancer in young people and treatment of the neck involved with metastatic cancer with a particular interest in various neck dissections. Dr. Byers was a member of many prestigious societies of which the Southern Surgical Association, the Texas Surgical Society, the American College of Surgeons and the Society of Surgical Oncologists are but a few. He was a peer reviewer for many medical journals and on the Editorial Board of three. During his 31 years at the University of Texas M.D. Anderson Cancer Center he participated in the surgical education of over 300 residents and fellows, many of who have gone on to become prominent members of the specialty.

As a former trainee, I can honestly say that he greatly shaped my thinking about oncologic problems and attention to technical precision and hemostasis in the operating room.  Almost every time I operate, I hear his voice saying, “cut on the patient side”.  He was always on the patient’s side!  I know that he has impacted many other past trainees and colleagues in the same positive way, and we will all miss him.

  • Bio
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Jeffrey Myers

Jeffrey N. Myers is a head and neck surgeon, Chair, Department of Head and Neck Surgery, Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery, and translational scientist at the University of Texas MD Anderson Cancer Center. President of the American Head and Neck Society from 2016-2018. Dr. Jeffrey N. Myers received his medical (MD) and doctoral (PhD) degrees from the University of Pennsylvania School of Medicine and he then completed his residency training in Otolaryngology-Head and Neck Surgery at the University of Pittsburgh. He subsequently completed fellowship training in Head and Neck Surgical Oncology at the University of Texas MD Anderson Cancer Center, where he has been on the faculty ever since. Dr. Myers leads a basic and translational research program and his primary research interests are in the role of p53 mutation in oral cancer progression, metastasis and response to treatment.

Latest posts by Jeffrey Myers (see all)

  • A Giant of Head and Neck Surgery has Passed - March 19, 2021

Published on March 12, 2021 by AHNS Webmaster

Myers’ Family Summer Travel Fellowship in Otolaryngology Application is Open

Diversity Summer Travel Fellowship in Otolaryngology for under-represented minority medical students 

This program is sponsored by the American Head and Neck Society Research and Education Foundation, thanks to the very generous contributions of Dr. Eugene Myers and Dr. Jeffrey Myers, as well as other AHNS donors.  It is intended to expose an under-represented minority medical student to the field of Head and Neck surgery specifically and Otolaryngology in general. Please click the link here to watch the RFA video to disseminate to your URM M1 and M2 candidates of the AHNS Myers’ Family Summer Travel Fellowship in Otolaryngology.

 

A grant of $5,000 will be awarded to a medical student to cover travel, lodging and food expenses for the summer experience.  This summer program offers the interested candidate the opportunity to work in a Department of Academic Excellence in Head and Neck Surgical Oncology that has an approved Fellowship Training Program from the Advanced Training Council of the AHNS.  Participants will be assigned to a clinical faculty mentor and will rotate on his or her clinical service and have the chance to participate in the care of Head and Neck Cancer patients in the outpatient setting, inpatient environment, as well as the operating room.  Summer fellows will also have the opportunity to perform basic, translational, clinical, or population based research under the guidance of a chosen/assigned research mentor.

 

The grant of $5,000 includes the recipients roundtrip airfare, cost to travel to the meeting, transportation to and from, food and hotel stay expenses at the AHNS Annual/International Meetings. At the AHNS Annual/International Meeting the student will share their Summer experience via PowerPoint presentation and can network with AHNS members.

 

Ideally the candidate is between year 1 and 2 of medical school. Some applicants between year 2 and 3 may have the ability to participate as a fellow award winner but this depends upon their medical school year academic calendar. Our Myers’ Family Summer Travel Fellowship in Otolaryngology FAQ page can be found by clicking here.

Please click this link to apply to the 2021 Myers’ Summer Travel Fellowship

 The application closes March 31, 2021 5PM PST.

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News and Announcements

  • AHNS Webinar Tomorrow! Genomics in Head and Neck Surgery June 24, 2025
  • KN689 Infographic June 9, 2025
  • Immunotherapy in Mucosal HNSCC: Key Takeaways from the AHNS Webinar June 4, 2025
  • World No Tobacco Day May 31, 2025
  • Journal Club May 2025 hosted by the Cutaneous Cancer Section for Skin Cancer Awareness Month May 23, 2025

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