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Staged Excisions

Mark A. Hurt MD



On or about 1999 I received a request from a Mohs surgeon to help perform staged excisions for patients with melanomas and melanomas in situ. These lesions usually were located in problematic areas on the face, especially on the nose and eyelids.

In those days, I wasn't using any immunostains to assist in defining the boundaries of the in situ component of the melanomas. I was using only the classical H&E stains to make the judgment.

Within a year, Melan-A became available commercially; I became an early adopter of its use. What I have learned about the periphery of melanomas from that time until now has simply been remarkable.

Here is a brief summary of what I have learned.

1. Don't depend on the H&E to help you find the margin limits. You will be fooled more often than not. In the periphery of melanomas in situ, they often take on subtle forms that look like negative results on the H&E. Melan-A brings out subtle patterns to help define the limits of the lesion.

2. You will need to stain the true margin with Melan-A, and it is a very good idea to stain the 5th section in (toward the tumor bed) with another Melan-A. By comparing the two levels, you will be able to determine the difference between regional variation of melanocytes versus the neoplasm.

3. Do your own embedding. You will have the best chance of seeing the margins intact if you embed the peripheral margins yourself. Yes, it is laborious, but it's time well spent, and it will save you time in the long run.

4. You will need controls. In every case, I have found that obtaining the previous biopsy and comparing it to the tumor bed of the staged excision are invaluable in establishing the pattern of the melanoma in situ. Although somewhat time consuming, it is worth doing in every case.

For the article of the technique with outcome data, this is the reference:

Abdelmalek M, Loosemore MP, Hurt MA, Hruza G. Geometric staged excision for the treatment of lentigo maligna and lentigo maligna melanoma: a long-term experience with literature review. Arch Dermatol. 2012 May;148(5):599-604. PubMed PMID: 22782151.

In our practice, we perform approximately 250 of these procedures per year. If any of the readers of this blog are performing staged excisions for melanoma, I would like very much to learn of your criticisms and agreements with the process as outlined in the article in the Archives of Dermatology. Please leave your comments below.


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Dr. Phillip McKee


Many thanks Mark for bringing this to our attention. When I was at Brigham and Women's Hospital we also received Mohs' specimens of in situ and lentigo maligna melanoma. At first I was very reluctant to accept this approach but after a while I found that it worked very well. We used to have weekly case conferences with the clinican to review all of the specimens. We also used immunohistochemistry to assess the margins and found it invaluable. Mind you, it was very time consuming along with the sentinel node specimens and never ending re-excisions. I don't think that pathologists in other specialities have any idea how much of a workload dermatopathologists actually have.
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Mark A. Hurt MD


I second you on the workload issue, Phillip. In my experience many dermatopathologists are reluctant to do these procedures because of the time required for turnover (usually a day), the close attention required at the grossing and embedding benches, and the industrial-like organization that ensures quality. I am convinced, however, that the effort is worth it, and the patients benefit greatly.
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