I Had a Melanoma in Situ on my Face Removed. Can Mohs Be Used?

Mohs micrographic surgery is a tissue sparing technique that can achieve up to 99% cure rate for non-melanoma skin cancers such as basal cell carcinoma or squamous cell carcinoma and thus should be the gold standard for these skin cancer lesions on face, neck, and hands. However, when it comes to melanoma or melanoma in situ, getting the highest cure rate is the foremost priority given the dangerous nature of the disease and thus most Mohs micrographic surgeonsnmay not favor utilizing Mohs surgery in the setting of melanoma because adequate margins cannot be absolutely be guaranteed given the challenge of interpreting atypical melanocytic proliferation under microscope with frozen section. Melanoma in situ around the eyelids presents a unique medical and cosmetic challenge. I personally would seek an academic center where availability of special staining for melanoma cells as well as an experienced Mohs surgeon who is comfortable in performing Mohs surgery in this setting.

MOHS surgery is a special procedure where the surgeon (usually a dermatologist) removes the skin cancer slice by slice, ensuring complete removal of the cancer while preserving the most amount of normal tissue possible.  Then, the appropriate reconstructive surgeon (that would be oculoplastic surgeon for eyelid reconstruction) puts everything back together.  MOHS surgery is best for certain types of skin cancers including basal cell carcinoma and squamous cell carcinoma.  It is NOT ideal for pigmented skin cancer including melanoma and melanoma in situe.  For pigmented lesions, primary resection with adequate margins (with or without frozen sections) are appropriate.

Mohs surgery is an excellent choice for treatment of a melanoma near the eyelid. These types of melanomas in situ (frequently called lentigo malignas) have poorly defined margins and are located in areas where preservation of healthy tissue is very important and where other types of surgery have a higher risk of recurrence.

The key is to see a Mohs surgeon with extensive experience with this type of malignancy and treatment with Mohs. These types of tumors require that the tissue be cut properly and not overfrozen, and interpretation of melanoma frozend-section slides requires that the surgeon have a great deal of experience (in other words, it is not as straight forward as some basal cell and squamous cell carcinomas). A number of Mohs surgeons use immunostains to highlight the melanoma cells more clearly. In my opinion your best option is to see a Mohs surgeon who has completed a fellowship (after residency) in Mohs surgery and is a fellow of the American College of Mohs Surgery. Talk to your potential surgeon about how they would perform Mohs surgery for melanoma and what their experience is.

Regarding cure rates, the recurrence rate for lentigo maligna (melanoma in situ on chronically sun damaged skin) through standard surgical excision (i.e. not Mohs) is historically 6-20%. That is because a standard 5 mm margin is inadequate to clear the tumor 50% of the time. The recurrence rates for this type of tumor with Mohs surgery (and the author from that particular study) is 0.3% (Greg Bricca MD, Journal of the American Academy of Dermatology, 2005) and 0% (CL Temple MD and JP Arlette MD, Journal of Surgical Oncology, 2006). There are other articles as well that look at recurrence rates for Mohs and melanoma. If you're interested and have access to the scientific literature, you could also look up articles by John A Zitelli MD on other articles regarding Mohs surgery and melanoma.

Good luck

Being a board-certified facial plastic surgeon (15 years) as well as a board certified dermatologist (10 years), I have had discussions with Moh's surgeons about using Moh's for melanoma.  Understand that Moh's surgery allows the surgeon to remove a tumor with taking the least amount of normal tissue and insuring that all of the margins are clear.  They do a great job and it certainly has its place.  It is my belief that I do not want to be "close" when I resect a melanoma.  I want to have very clear margins and this requires taking more "normal" skin and going deeper then I might with another type of tumor.  So the answer is "yes" Moh's surgery can be used for resecting a melanoma, but I do not see the value over having it resected with "close" margins.  I always ask the pathologist "how clear were my margins".  This is an on-going discussion.  To date there has been no definitive study that proves that Moh's surgery has any greater success in treating melanoma then frozen sections or a wide resection.

I agree with Dr. Ramsdell. I have performed a lot of Mohs for Melanoma in situ and all have been successful. However, after doing the in-office Mohs, I do send my slides and materials into another local lab for further review and assessment on the clarity of the margins.

  Mohs can certainly be used for melanoma but when the tissue is frozen for processing, the pigment cells can be distorted making interpretation difficult. There are dermatologists who feel comfortable with this but most use what is termed "Slow Mohs". The tissue is excised, divided and color coded as with traditional Mohs. Then the specimen is sent to a lab to be paraffin embedded before examination. This means that the surgery will take more than one day but assures both the dermatologist and the patient that the margins are truly clear.