Practice habits of Mohs surgeons treating melanoma with Mohs surgery: A cross-sectional survey

To the Editor: Mohs micrographic surgery (MMS) is increasingly used to treat melanoma in United States.1Lee M.P. Sobanko J.F. Shin T.M. et al.Evolution of excisional practices for States.JAMA Dermatol. 2019; 155: 1244-1251Crossref Scopus (10) Google Scholar Recent studies have shown lower recurrence rates and improved survival outcomes treated with MMS compared wide local excision.2Cheraghlou S. Christensen S.R. Agogo G.O. Girardi M. Comparison after vs margin excision early-stage invasive melanoma.JAMA 1252-1259Crossref (12) Scholar,3Hanson J. Demer A. Liszewski W. Foman N. Maher I. Improved overall head neck versus excision.J Am Acad 2020; 82: 149-155Abstract Full Text PDF PubMed (13) Given variations practice patterns combined a lack best guidelines,1Lee this survey surgeons sought elucidate habits by who situ MMS. This study was nationwide cross-sectional membership American College Surgery (ACMS). An anonymous developed distributed all ACMS members (N = 1630) during March 2020 through May using mailing lists. defined as intraoperative frozen section analysis. Excisional en face permanent analysis (“slow Mohs”) not considered Fellowship exposure treating at least 1 case sections fellowship. The inquired about subtypes (primary tumor [T], Joint Committee on Cancer, 8th Edition), anatomic locations treated, number cases per year, processing debulked specimens, initial sizes (the total distance beyond clinically apparent first stage), depth stage, immunohistochemical (IHC) staining. approved institutional review board University Kansas. Chi-square, Fisher exact tests, 1-way variance were compare differences between groups, P < .05 statistically significant. A 1002 participants completed (61.5% response rate; average age, 46 ± 11 years; 632 [64.1%] male; 715 [71.4%] private practice; 174 [17.4%] Midwest, 185 [18.5%] Northeast, 246 [24.6%] Southeast, 131 [13.1%] Southwest, 219 [21.9%] West, 47 [4.7%] other/unspecified location). Half (n 499; 50.0%) received fellowship melanoma. Among 363 (36.2% overall) (MMS-M), 216 (59.5%) (T1) melanoma, 76 (20.9%) (T≥2) (Table I). MMS-M more likely debulk (MIS) (93.2% T≥1 85.4% MIS; .002). MIS, T1, T≥2 melanomas 4.99 mm, 6.60 7.52 respectively (P .001) II). excise down fascia stage MIS (22.6% 3.0% .001). submit an additional layer around negative (16.0% 7.2% melanoma; majority 273; 75.2%) use IHC stains nearly 267; 97.8%) antigen recognized T cells (MART-1) their primary stain.Table IPractice 363)CharacteristicMohs MMS, n (%)Subtypes treated∗Based Edition staging criteria. LM348 (95.9) (subtypes excluding LM)332 (91.5) T1216 (59.5) T2 and/or greater76 (20.9)Anatomic location Head neck360 (99.2) Trunk extremities (excluding hands feet)174 (47.9) Hands, feet, genitalia259 (71.3)Number year ≤40204 (56.2) 41-120118 (32.5) 121-20021 (5.8) >20020 (5.5)IHC staining Yes273 (75.2) No90 (24.8)IHC MART-1261 (95.6) MITF11 (4.0) S-10011 HMB-453 (1.1)IHC, Immunohistochemical; LM, lentigo maligna; situ; surgery.∗ Based Open table new tab Table IIMelanoma surgeryCharacteristicsMohs subtypes∗Based (%)P value†Comparisons groups conducted chi-square, test, variance.MIS 363)T1 216)T≥2 76)Debulk.005 Yes310 (85.4)199 (92.1)73 (96.1) No53 (14.6)17 (7.9)3 (3.9)Debulk technique.94 Debulk scalpel305 (98.4)212 (98.1)76 (100.0) curette5 (1.6)4 (1.9)0 (0.0)Debulked specimen processing.15 Permanent vertical sectioning184 (60.3)126 (59.4)42 (55.3) Frozen sectioning31 (10.3)11 (5.2)3 (3.9) Both87 (28.5)72 (34.0)29 (38.2) Discard3 (0.9)3 (1.4)2 (2.6)Initial margins (debulk + 1st mm<.001 Mean (SD)4.99 (1.66)6.60 (2.69)7.52 (2.24)Depth stage<.001 Deep dermis17 (4.7)3 (2.6) Subcutaneous fat335 (92.3)173 (80.1)48 (63.2) Fascia11 (3.0)40 (18.5)26 (34.2)Additional margin<.001 No305 (84.0)195 (90.3)76 Yes, analysis56 (15.4)13 (6.0)0 (0.0) analysis0 (0.0)0 both frozen2 (0.6)8 (3.7)0 (0.0)MIS, Melanoma surgery; SD, standard deviation.∗ criteria.† Comparisons variance. IHC, surgery. deviation. our knowledge, largest date investigate findings suggest that are early MART-1 In addition, wider when