Skin section showing melanoma cells
Frozen skin section with MART-1 immunostain and traditional hematoxylin and eosin demonstrating microscopic residual melanocytes.

Surgeons in the Division of Dermatologic Surgery and Cutaneous Oncology at Penn Medicine are improving cure rates and helping to change the way difficult melanomas are treated. Up to ten percent of melanomas of the head and neck grow back after traditional methods of surgery. [1-2]

Using Mohs micrographic surgery with highly specialized microscopic stains, surgeons at Penn Medicine are able to detect and remove melanomas that evade traditional methods of excision and reduce cancer recurrence at the site of the surgery to less than two percent. Recent advances in microscopic techniques have made it possible to detect melanoma cells with a high degree of accuracy. During Mohs micrographic surgery, all visible melanoma and a margin of clinically normal skin are first excised.

All of the excised skin is then examined immediately under a microscope, during surgery. If cancer cells are detected at the margin, the Mohs surgeon performs another targeted excision to remove the precise areas where cancer still remains. This process of targeted cancer removal and microscopic examination continues until all the cancer has been excised. Once the cancer has been removed, Mohs surgeons at Penn typically reconstruct the wound on the same day.

The fellowship-trained Mohs surgeons and certified histotechnologists at Penn Medicine have developed careful protocols for rapid immunostaining, a specialized technique that permits surgeons to highlight and detect cancer cells under the microscope. These rapid immunostains are as accurate as slower methods of tissue processing, [3] and allow the Penn Mohs surgeons to perform multiple stages of surgery on the same day—and to eliminate the risk of having to perform multiple surgeries for incompletely excised melanomas.

Case Study

Mrs. K, is a fair skinned 68-year-old female with an extensive history of sun exposure and damage to her skin. Ten years previously, a non-Mohs procedure was performed to remove a superficial melanoma from her cheek. During this surgery, cancer was found at the margins after the first two excisions, so a third excision was performed before it appeared that all the cancer had been removed.

Ten years later, however, Mrs. K developed a subtle pink and tan spot around the scar from the previous surgery. A biopsy was performed, and revealed that the melanoma had grown back.

Side view of the face of a woman following extensive surgery to remove melanoma
Figure 1: Same-day reconstruction following Mohs micrographic surgery at Penn. Microscopic examination of initial excised tissue margin revealed residual melanoma; a second, expanded, margin was cancer-free.

Mrs. K and her dermatologist wanted to avoid the risk of multiple excisions and the chance that the cancer would grow back again, so she was referred to the Division of Dermatologic Surgery and Cutaneous Oncology for definitive excision with Mohs surgery and same day reconstructive surgery after obtaining clear microscopic margins. Mrs. K was seen in consultation in the Mohs surgery suite at the Perelman Center for Advanced Medicine. A large amount of background sun-damage was present on her face as well as the scar on her cheek from the prior excisions. The pink and tan areas at the site of the melanoma were very indistinct and hard to distinguish from the pink and tan spots on much of the rest of her cheek.

Because high quality frozen sections in the Mohs lab and the use of MART-1 immunostains permit accurate visualization of melanocytes, Mohs micrographic surgery was recommended to clear the incompletely excised melanoma. The Penn Mohs surgeons carefully outlined all areas suspicious for melanoma. The previous scar was then removed and examined with frozen sections stained with MART-1 immunostain and traditional hematoxylin and eosin to evaluate the microscopic residual disease.

Side view of the face of a woman demonstrating healing after extensive Moh's surgery for melanoma.
Figure 2: Post-operative recovery at five months following Mohs micrographic surgery at Penn Medicine.

Mrs. K’s skin had clear evidence of residual melanoma visible under the microscope. A peripheral and deep margin of normal skin beyond the edge of the cancer was excised and 100% of the surgical cut edge was immediately examined under the microscope. Twenty-five percent of the margin still contained melanoma in situ. Immediately, Mrs. K had another margin of skin excised around the residual cancer. Examination of the microscopic edge of this specimen was free of cancer.

The Mohs surgeons immediately reconstructed Mrs. K’s wound with a local tissue flap (Figure 1). Today, more than five years after her surgery, she is seen frequently for total skin and lymph node examinations to evaluate for melanoma recurrence and to monitor for newly arising skin cancers. She remains free of any evidence of cancer (Figure 2).

Access

Division of Dermatologic Surgery and Cutaneous Oncology

Perelman Center for Advanced Medicine
3400 Civic Center Boulevard
Suite 1-330
Philadelphia, PA 19104

Published on: June 23, 2017

References

1. Bricca GM, et al. J Am Acad Dermatol. 2005;52:92-100; 2. Clark GS, et al. Cancer Control. 2008;15:216-224; 3. Cherpelis BS, et al. Dermatol Surg 2009;25:207-213.

About the Division of Dermatologic Surgery and Cutaneous Oncology

Dedicated to delivering the most current and precise treatments for common and rare malignancies of the skin, the Division of Dermatologic Surgery and Cutaneous Oncology at Penn Medicine is the center for Mohs micrographic surgery and reconstructive surgery. Both procedures are performed in modern, comfortable outpatient facilities staffed by fellowship-trained Mohs surgeons, certified histotechnicians, and an expert support staff. A personalized skin care maintenance program is developed for each patient according to his or her individual risk of skin cancer. Preventive treatments and non-surgical treatments for precancerous and early cancerous lesions are also available.

Penn Faculty Team

Christopher J. Miller, MD

Director, Penn Dermatology Oncology Center

Associate Professor of Dermatology at the Hospital of the University of Pennsylvania

Joseph F. Sobanko, MD

Director, Dermatologic Surgery Education

Assistant Professor of Dermatology at the Hospital of the University of Pennsylvania

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