J AM ACAD DERMATOL
834 Letters
OCTOBER 2014
occasion, some can develop worsening of facial erythema and/or rebound, which has been reported.1,2 This is also not surprising in that vascular reactivity may vary among patients. In summary, the majority of individuals treated with BT 0.33% gel seem to experience a favorable response in reducing the background erythema of rosacea. However, in others with rosacea, a worsening of facial erythema may occur. The most likely causes to consider diagnostically when there is exacerbation of facial erythema are rebound effect, atypical pattern of vascular reactivity and response, allergic contact dermatitis, and a flare of facial vasodilation of rosacea (flushing) induced by an exogenous trigger factor. James Q. Del Rosso, DO Touro University College of Osteopathic Medicine, Las Vegas, Nevada Funding sources: None.
Valeant, Promius, Obagi, and Ranbaxy; he has served as a consultant for Allergan, Dermira, Galderma, Bayer, Medicis, Valeant, Promius, Primus, Eisai, Unilever, Obagi, Ranbaxy, and Taro Pharma; he is a speaker for Allergan, Bayer, Galderma, Medicis, Valeant, Promius, Unilever, Warner-Chilcott, Obagi, and Ranbaxy; he has served as an investigator for Allergan, Galderma, and Medicis; and he has received honoraria as compensation. Correspondence to: James Q. Del Rosso, DO, 8644 Castle Hill Avenue, Las Vegas, NV 89129 E-mail: [email protected] REFERENCES 1. Ilkovitch D, Pomerantz RG. Brimonidine effective but may lead to significant rebound erythema. J Am Acad Dermatol 2014;70: e109-10. 2. Routt ET, Levitt JO. Rebound erythema and burning sensation from a new topical brimonidine tartrate gel 0.33%. J Am Acad Dermatol 2014;70(2):e37-8.
Disclosure: Dr Del Rosso has served on advisory boards for Allergan, Galderma, Bayer, Medicis,
RESEARCH Excision of melanoma in situ on nonchronically sun-exposed skin using 5-mm surgical margins To the Editor: Although melanoma in situ (MIS) has traditionally been treated by excision with 5-mm margins, recent guidelines have recommended 5- to 10-mm surgical margins, acknowledging that margins greater than 5 mm may be necessary for treatment of lentigo maligna.1 There is conflicting evidence regarding the necessary margin for excision of MIS on nonchronically sun-exposed skin (NCSES). One study found that conventional excision with 3-mm margins is sufficient to achieve negative histologic margins and very low rates of recurrence for MIS on sites other than the face.2 Recently, Kunishige et al3,4 recommended 9-mm clinical margins for the excision of MIS, regardless of site or type of MIS, based on a study in which MIS was removed using Mohs excision. Some have questioned the recommendation for 9-mm margins in the treatment of MIS on NCSES, citing experiences of low recurrence rates with 5-mm margins.5 We found no published data concerning histologic clearance rates for MIS on NCSES when treated with conventional excision using 5-mm excision
http://dx.doi.org/10.1016/j.jaad.2014.06.040
LETTERS margins; therefore, we conducted a retrospective study to address this question. Records from 1 academic and 1 private group practice were searched to identify clinic visits for which a melanoma diagnosis code (172.x) was paired with a procedural code for excision (11600-11606). Included cases had a biopsy diagnosis of MIS on NCSES (back, chest, abdomen, legs, and proximal arms), and were treated with conventional excision using 5-mm margins. Of 311 cases identified, 156 were excluded as a result of a biopsy specimen showing lentigo maligna, invasive melanoma, or location on chronically sun-exposed (head, neck, back of hands, back of arms) or acral (hand, foot) skin. A total of 155 cases were included (Table I). Negative histologic margins were achieved in all cases. Clinical follow-up information was available for 148 (95%) cases, with a mean follow-up duration of 4 years (range 0.25-13 years), during which no cases of recurrence or metastasis were noted. Clinical lesion size was available for 38 cases, with a mean lesion diameter of 8.7 mm (range 2-20 mm). In our practice, conventional excision with a 5mm margin appears sufficient for the treatment of MIS (other than lentigo maligna) on the trunk, legs,
J AM ACAD DERMATOL
Letters 835
VOLUME 71, NUMBER 4
Table I. Patient and tumor characteristics of 155 patients with melanoma in situ excised with 5-mm clinical margins Sex Male Female Age, y \40 40-65 [65 Tumor site Back Chest Arm Leg Abdomen Tumor diameter, mm* \5 5-10 10-20 Negative margins in biopsy specimeny Negative margins after 5-mm excision Clinical recurrencez
n
%
71 84
46 54
23 94 38
15 61 24
57 16 41 33 8
37 10 27 21 5
6 20 12 64 155 0
16 53 31 45 100 0
In summary, our study demonstrates that for MIS on NCSES and on nonacral sites, conventional excision with 5-mm clinical margins has a high rate of success in achieving negative histologic margins and a low rate of recurrence. We acknowledge that margins greater than 5 mm may be needed for lentigo maligna, as this variant of MIS is typically more poorly demarcated both clinically and histologically, making Mohs micrographic surgery and other forms of staged excision useful in its management. Arianna Welch, BS,a Taylor Reid, BA,a Judith Knox, MD,b and Morgan L. Wilson, MDa Southern Illinois University,a and Springfield Clinic,b Springfield, Illinois Funding sources: None.
*Data on tumor diameter were available for 38 cases. y Data concerning margin positivity in biopsy specimen were available for 142 cases. z Follow-up data were available for 148 patients; mean follow-up duration ¼ 4 years.
and proximal arms. Variations in biopsy technique may partly account for differences between our findings and those of Kunishige et al.3,4 When confronted with a relatively small, but highly atypical pigmented lesion on the trunk, some physicians routinely perform a biopsy that includes the entire visible lesion plus a 2- to 3-mm margin. When a subsequent excision is performed with 5-mm margins, this results in a total clinical margin of 7 to 8 mm, which approaches that advocated by Kunishige et al.3,4 This may have been a common scenario with lesions in our study, as the mean clinical diameter was only 8.7 mm, and in 45% of cases, MIS did not involve the margin of the biopsy specimen. In contrast, Kunishige et al3,4 reported a mean tumor size of 28 mm (not separately reported for lesions on NCSES), and it is likely that many of these were the subject of only a partial biopsy, such that no clinical margin had been taken before the excision. Although Kunishige et al3,4 might have been more successful in detecting positive margins because of evaluation of a larger proportion of the margin using the Mohs technique, the lack of any case of clinical recurrence in our patients suggests that clinically meaningful margin involvement was not missed.
Conflicts of interest: None declared. Correspondence to: Morgan L. Wilson, MD, Division of Dermatology, Southern Illinois University, PO Box 19644, Springfield, IL 62794-9644 E-mail: [email protected] REFERENCES 1. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Melanoma (Version 3. 2014). Available from: URL:http://www.nccn.org/professio nals/physician_gls/pdf/melanoma.pdf. Accessed February 11, 2014. 2. Bartoli C, Bono A, Clemente C, Del Prato I, Zurrida S, Cascinelli N. Clinical diagnosis and therapy of cutaneous melanoma in situ. Cancer 1996;77:888-92. 3. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012;66:438-44. 4. Kunishige JH, Brodland DG, Zitelli JA. Larger surgical margins are required for lentigo maligna and other melanoma in situ. J Am Acad Dermatol 2012;67:1070-1. 5. Grossman D, Duffy KL, Bowen GM. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012;67:1068-9. http://dx.doi.org/10.1016/j.jaad.2014.05.021
Adequacy of 5-mm surgical excision margins for non-lentiginous melanoma in situ To the Editor: The lentigo maligna (LM) subtype of melanoma in situ (MIS) develops on chronically sun-exposed skin, with indistinct clinical margins corresponding to single melanocytes trailing along the epidermal-dermal junction (Fig 1, A, C, E ). Alternatively, the less common non-lentiginous MIS (non-LM MIS) typically occurs in more sun-protected areas with distinct clinical margins corresponding to sharp transition from malignant to normal melanocytes histologically (see Fig 1, B, D, F ).
834 Letters
OCTOBER 2014
occasion, some can develop worsening of facial erythema and/or rebound, which has been reported.1,2 This is also not surprising in that vascular reactivity may vary among patients. In summary, the majority of individuals treated with BT 0.33% gel seem to experience a favorable response in reducing the background erythema of rosacea. However, in others with rosacea, a worsening of facial erythema may occur. The most likely causes to consider diagnostically when there is exacerbation of facial erythema are rebound effect, atypical pattern of vascular reactivity and response, allergic contact dermatitis, and a flare of facial vasodilation of rosacea (flushing) induced by an exogenous trigger factor. James Q. Del Rosso, DO Touro University College of Osteopathic Medicine, Las Vegas, Nevada Funding sources: None.
Valeant, Promius, Obagi, and Ranbaxy; he has served as a consultant for Allergan, Dermira, Galderma, Bayer, Medicis, Valeant, Promius, Primus, Eisai, Unilever, Obagi, Ranbaxy, and Taro Pharma; he is a speaker for Allergan, Bayer, Galderma, Medicis, Valeant, Promius, Unilever, Warner-Chilcott, Obagi, and Ranbaxy; he has served as an investigator for Allergan, Galderma, and Medicis; and he has received honoraria as compensation. Correspondence to: James Q. Del Rosso, DO, 8644 Castle Hill Avenue, Las Vegas, NV 89129 E-mail: [email protected] REFERENCES 1. Ilkovitch D, Pomerantz RG. Brimonidine effective but may lead to significant rebound erythema. J Am Acad Dermatol 2014;70: e109-10. 2. Routt ET, Levitt JO. Rebound erythema and burning sensation from a new topical brimonidine tartrate gel 0.33%. J Am Acad Dermatol 2014;70(2):e37-8.
Disclosure: Dr Del Rosso has served on advisory boards for Allergan, Galderma, Bayer, Medicis,
RESEARCH Excision of melanoma in situ on nonchronically sun-exposed skin using 5-mm surgical margins To the Editor: Although melanoma in situ (MIS) has traditionally been treated by excision with 5-mm margins, recent guidelines have recommended 5- to 10-mm surgical margins, acknowledging that margins greater than 5 mm may be necessary for treatment of lentigo maligna.1 There is conflicting evidence regarding the necessary margin for excision of MIS on nonchronically sun-exposed skin (NCSES). One study found that conventional excision with 3-mm margins is sufficient to achieve negative histologic margins and very low rates of recurrence for MIS on sites other than the face.2 Recently, Kunishige et al3,4 recommended 9-mm clinical margins for the excision of MIS, regardless of site or type of MIS, based on a study in which MIS was removed using Mohs excision. Some have questioned the recommendation for 9-mm margins in the treatment of MIS on NCSES, citing experiences of low recurrence rates with 5-mm margins.5 We found no published data concerning histologic clearance rates for MIS on NCSES when treated with conventional excision using 5-mm excision
http://dx.doi.org/10.1016/j.jaad.2014.06.040
LETTERS margins; therefore, we conducted a retrospective study to address this question. Records from 1 academic and 1 private group practice were searched to identify clinic visits for which a melanoma diagnosis code (172.x) was paired with a procedural code for excision (11600-11606). Included cases had a biopsy diagnosis of MIS on NCSES (back, chest, abdomen, legs, and proximal arms), and were treated with conventional excision using 5-mm margins. Of 311 cases identified, 156 were excluded as a result of a biopsy specimen showing lentigo maligna, invasive melanoma, or location on chronically sun-exposed (head, neck, back of hands, back of arms) or acral (hand, foot) skin. A total of 155 cases were included (Table I). Negative histologic margins were achieved in all cases. Clinical follow-up information was available for 148 (95%) cases, with a mean follow-up duration of 4 years (range 0.25-13 years), during which no cases of recurrence or metastasis were noted. Clinical lesion size was available for 38 cases, with a mean lesion diameter of 8.7 mm (range 2-20 mm). In our practice, conventional excision with a 5mm margin appears sufficient for the treatment of MIS (other than lentigo maligna) on the trunk, legs,
J AM ACAD DERMATOL
Letters 835
VOLUME 71, NUMBER 4
Table I. Patient and tumor characteristics of 155 patients with melanoma in situ excised with 5-mm clinical margins Sex Male Female Age, y \40 40-65 [65 Tumor site Back Chest Arm Leg Abdomen Tumor diameter, mm* \5 5-10 10-20 Negative margins in biopsy specimeny Negative margins after 5-mm excision Clinical recurrencez
n
%
71 84
46 54
23 94 38
15 61 24
57 16 41 33 8
37 10 27 21 5
6 20 12 64 155 0
16 53 31 45 100 0
In summary, our study demonstrates that for MIS on NCSES and on nonacral sites, conventional excision with 5-mm clinical margins has a high rate of success in achieving negative histologic margins and a low rate of recurrence. We acknowledge that margins greater than 5 mm may be needed for lentigo maligna, as this variant of MIS is typically more poorly demarcated both clinically and histologically, making Mohs micrographic surgery and other forms of staged excision useful in its management. Arianna Welch, BS,a Taylor Reid, BA,a Judith Knox, MD,b and Morgan L. Wilson, MDa Southern Illinois University,a and Springfield Clinic,b Springfield, Illinois Funding sources: None.
*Data on tumor diameter were available for 38 cases. y Data concerning margin positivity in biopsy specimen were available for 142 cases. z Follow-up data were available for 148 patients; mean follow-up duration ¼ 4 years.
and proximal arms. Variations in biopsy technique may partly account for differences between our findings and those of Kunishige et al.3,4 When confronted with a relatively small, but highly atypical pigmented lesion on the trunk, some physicians routinely perform a biopsy that includes the entire visible lesion plus a 2- to 3-mm margin. When a subsequent excision is performed with 5-mm margins, this results in a total clinical margin of 7 to 8 mm, which approaches that advocated by Kunishige et al.3,4 This may have been a common scenario with lesions in our study, as the mean clinical diameter was only 8.7 mm, and in 45% of cases, MIS did not involve the margin of the biopsy specimen. In contrast, Kunishige et al3,4 reported a mean tumor size of 28 mm (not separately reported for lesions on NCSES), and it is likely that many of these were the subject of only a partial biopsy, such that no clinical margin had been taken before the excision. Although Kunishige et al3,4 might have been more successful in detecting positive margins because of evaluation of a larger proportion of the margin using the Mohs technique, the lack of any case of clinical recurrence in our patients suggests that clinically meaningful margin involvement was not missed.
Conflicts of interest: None declared. Correspondence to: Morgan L. Wilson, MD, Division of Dermatology, Southern Illinois University, PO Box 19644, Springfield, IL 62794-9644 E-mail: [email protected] REFERENCES 1. National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Melanoma (Version 3. 2014). Available from: URL:http://www.nccn.org/professio nals/physician_gls/pdf/melanoma.pdf. Accessed February 11, 2014. 2. Bartoli C, Bono A, Clemente C, Del Prato I, Zurrida S, Cascinelli N. Clinical diagnosis and therapy of cutaneous melanoma in situ. Cancer 1996;77:888-92. 3. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012;66:438-44. 4. Kunishige JH, Brodland DG, Zitelli JA. Larger surgical margins are required for lentigo maligna and other melanoma in situ. J Am Acad Dermatol 2012;67:1070-1. 5. Grossman D, Duffy KL, Bowen GM. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012;67:1068-9. http://dx.doi.org/10.1016/j.jaad.2014.05.021
Adequacy of 5-mm surgical excision margins for non-lentiginous melanoma in situ To the Editor: The lentigo maligna (LM) subtype of melanoma in situ (MIS) develops on chronically sun-exposed skin, with indistinct clinical margins corresponding to single melanocytes trailing along the epidermal-dermal junction (Fig 1, A, C, E ). Alternatively, the less common non-lentiginous MIS (non-LM MIS) typically occurs in more sun-protected areas with distinct clinical margins corresponding to sharp transition from malignant to normal melanocytes histologically (see Fig 1, B, D, F ).
