Staged Excision: The treatment of choice for lentiginous melanomas
The "staged excision" technique is a specialized procedure for the removal of certain melanomas and allows for the highest cure rate available. The staged excision procedure involves a thorough examination of the entire border of the melanoma, which minimizes chance of tumor recurrence.
Lentigo maligna, a subtype of melanoma, is found most commonly on sun-exposed skin and is the most frequent type of melanoma to be treated with the staged excision technique. Lentigo maligna, also known as melanoma in situ, occurs in the the epidermis, or most-outer layer of skin. The majority of lentigo maligna cancers have a prolonged phase of surface growth and generally have a low risk of invasion into the middle layer of skin (the dermis). However, this risk increases with time.
Although lentigo maligna can be treated with destructive modalities such as cryotherapy (“freezing”) or radiation, surgical treatments are often preferred because they allow for microscopic assessment by a dermatopathologist. These studies can determine if the cancer cells remain at the borders of the tissue or if there is an invasive component within the tumor. One of the main challenges in treating lentigo maligna is that tumor cells may be present in the neighboring, “normal” appearing skin. In fact, the tumor often has subtle pigment and/or textural changes. The staged excision approach takes this into consideration and is therefore the preferred treatment method for lentigo maligna.
The procedure is performed under local anesthesia. Our experience has shown that most people require 2 surgery visits in order to completely “clear” or remove the tumor. Depending on the pathology results, you may require only 1 surgery date for tumor removal or possibly 3 or more dates if the tumor is more extensive than initially expected. You should ideally keep your calendar free for two weeks from the start of the surgery.
What to expect on the day of surgery:
The tumor is examined using a special UV light and a magnifying lens.
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The border of the tumor is noted with a surgical marker.
Next, a surrounding margin of “normal” appearing skin is outlined 5 millimeters from the border. This is the standard recommended margin for treating this type of skin cancer. This outlined area is fashioned into a geometric shape such as a square, diamond, or triangle using a surgical marker. This aids in tissue processing.
The entire area is numbed with local anesthetic. Using a scalpel, the outlined area is removed. The bleeding spots are treated with an electric cautery machine. A bandage is applied. The removed tissue is prepared for processing and a special map is made that correlates with the tissue.
This tissue is sent to a dermatopathologist for examination. Special stains may be ordered to help in making the final diagnosis. It usually takes 24-48 hours to receive the results. If the pathologist identifies residual melanoma cells at the border, you will need to return for additional surgery/tissue removal. Again, the areas noted to have residual tumor will be outlined with a surgical marker and will include an additional 5 millimeter margin. Again, the tissue will be processed and submitted for pathology examination. The results are available in another 24-48 hours. The process repeats until no further melanoma cells are identified.
Once the lentigo maligna has been entirely removed, you will need to follow-up to determine reconstruction options. Sometimes these wounds are allowed to heal on their own. Other times, a graft of skin or a flap of tissue from the surrounding skin are better options. In some circumstances, we may refer you to a plastic surgeon for the repair.
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