INTRODUCTION
Lentigo maligna (LM) is a melanoma in situ that commonly
presents as a macula with progressive and irregularly pigmented growth,
especially in the face of elderly people with sun-damaged skin1. The risk of progression to lentigo
maligna melanoma varies from 30-50% in this type of lesion2.
Treatment options for LM include surgical excision with oncologic margins or
non-surgical treatments such as cryotherapy, curettage, electrocautery, laser,
radiotherapy, fluorouracil, and imiquimod. However, these non-surgical methods
have high recurrence rates (20-100%)3.
Complete surgical excision of the melanoma in situ requires
circumferential margins of at least 5 mm4.
In cases of LM in areas with substantial aesthetic or functional implications
(face, neck, and soles of the feet), surgical margins are usually reduced to
preserve important anatomic structures. In addition, clinical margins of the LM
may be poorly defined and not always pigmented, and thus, such cases are
associated with underestimated extension, which increases the risk of inadequate
resection,5 and the appropriate
treatment is challenging.
The “spaghetti technique”, described by Gaudy Marqueste, is a surgical technique
based on the sampling of a narrow band of tissue just beyond the lesion to
determine the surgical margins before resection of the tumor lesion. This tissue
band is referred for conventional histopathological examination and, if the
margins are free of tumor tissue, the central lesion is then resected,
minimizing tissue loss; thus, being an alternative to Mohs micrographic
surgery5.
CASE REPORT
The medical records of patient M.B.M.C., a 54-year-old man with skin phototype
III on the Fitzpatrick scale, who presented with a pigmented lesion with
irregular edges and coloration and progressive growth located on the nasal tip
of approximately 1.5 cm in diameter, were reviewed (Figure 1).
Figure 1 - Lentigo maligna on the nasal tip.
Figure 1 - Lentigo maligna on the nasal tip.
The patient underwent incisional biopsy of the lesion in April 2018 with a
diagnosis of melanoma in situ type lentigo maligna.
The “spaghetti technique” was then used to determine the surgical margins before
complete resection of the lesion (Figure 2). Tumor limits were defined with the aid of confocal dermoscopy and
subsequently a band of skin beyond the tumor with a margin of 1 mm was resected
(Figures 3 and 4).
Figure 2 - Pre-operative marking of the margins of the lesion.
Figure 2 - Pre-operative marking of the margins of the lesion.
Figure 3 - First surgical stage with resection of the skin “spaghetti”
strip, circumferential to the tumor.
Figure 3 - First surgical stage with resection of the skin “spaghetti”
strip, circumferential to the tumor.
Figure 4 - Skin suture after resection of the circumferential margin
Figure 4 - Skin suture after resection of the circumferential margin
The surgical piece was marked with a nylon 5.0 suture at the 12 o’clock position
to guide the histopathological examination, which subdivided it into 4 quadrants
(12 - 3 hours, 3 - 6 hours, 6 - 9 hours, and 9 - 12 hours).
The result of the examination revealed neoplastic involvement in the margins of
the 3 to 6 o’clock quadrant. The margins were enlarged, and the material was
forwarded again for analysis (Figure 5).
Figure 5 - Widening of margins of the 3 to 6 o’clock quadrant.
Figure 5 - Widening of margins of the 3 to 6 o’clock quadrant.
The resection of the central lesion was performed after 15 days of expansion of
margins that proved to be free of neoplastic involvement by histopathological
examination. During the resection, the scar tissue peripheral to the central
lesion was encompassed and local reconstruction was performed with a Rintala
flap during the same surgery (Figures 6 to
8).
Figure 6 - Pre-operative marking of the resection of the central lesion with
immediate reconstruction with the Rintala flap.
Figure 6 - Pre-operative marking of the resection of the central lesion with
immediate reconstruction with the Rintala flap.
Figure 7 - Second surgical stage with resection of the central lesion and
reconstruction in the same procedure.
Figure 7 - Second surgical stage with resection of the central lesion and
reconstruction in the same procedure.
Figure 8 - Final appearance in the immediate postoperative period.
Figure 8 - Final appearance in the immediate postoperative period.
The patient recovered well, without any signs of recurrence during a six-month
follow-up period.
DISCUSSION
The “spaghetti technique” is an easy and safe method to control surgical margins
in the case of lentigo maligna, especially when the lesion is in an area where
there is a greater risk of impairment of vital structures.
One of the precautions that must be taken during the resection of the tumor
lesion is englobing the scar area from previous surgeries to prevent local
recurrence.
The skin suturing after resection of the circumferential margin in the
«spaghetti» technique should be done in a careful manner with minimal passage of
the needle to the healthy tissue.
Other techniques, such as the “square” technique and the “perimeter” technique,
have used the concept of pathological control of margins before total resection
of LM. In these techniques, a geometric resection shape (square, triangle, or
pentagon) is determined to facilitate the analysis of margins while maintaining
the central lesion intact. The objective is to verify the periphery of this
geometric figure before resection6,7.
The advantage of the «spaghetti» technique is the higher preservation of adjacent
tissues when compared to that with the other techniques mentioned.
Mohs micrographic surgery is also an option in these cases, but a trained team
must perform the operation. In addition, by using paraffin blocks, the
“spaghetti” technique is more reliable than those techniques using freezing5.
The disadvantages of the technique consist of the requirement of at least two
surgical operations, which may increase the risk of complications of the
surgical wound. Conversely, it may be more comfortable for the patient, since it
prevents the permanence of open wounds and allows the removal of the tumor with
immediate reconstruction. Confocal dermoscopy is a tool that can be used to
assist the delimitation of the tumor margins, but may not be accessible.
In this case, the “spaghetti” technique proved to be a good option in the
treatment of the LM as a simple and reproducible method, ensuring the control of
margins and lower morbidity for the patient.
COLLABORATIONS
GSS
|
Analysis and/or data interpretation, conception and design study,
data curation, writing - original draft preparation, writing -
review & editing.
|
FBH
|
Writing - review & editing.
|
CHSTS
|
Writing - review & editing.
|
LADS
|
Writing - review & editing.
|
FHSP
|
Supervision, writing - review & editing.
|
IDAOSF
|
Supervision, writing - review & editing.
|
CSS
|
Supervision, writing - review & editing.
|
ERB
|
Conception and design study, final manuscript approval, supervision,
writing - review & editing.
|
REFERENCES
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Surgical margins for lentigo maligna and lentigo maligna melanoma: the technique
of mapped serial excision. Arch Dermatol. 2004;140(9):1087-92. PMID: 15381549
DOI: https://doi.org/10.1001/archderm.140.9.1087
2. Weinstock MA, Sober AJ. The risk of progression of lentigo maligna
to lentigo maligna melanoma. Br J Dermatol. 1987;116(3):303-10. PMID: 3567069
DOI: https://doi.org/10.1111/j.1365-2133.1987.tb05843.x
3. Cohen LM. Lentigo maligna and lentigo maligna melanoma. J Am Acad
Dermatol. 1997;36(6 Pt 1):913.
4. Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision of
primary cutaneous melanoma. J Am Acad Dermatol. 1997;37(3 Pt 1):422-9. PMID:
9308558
5. Gaudy-Marqueste C, Perchenet AS, Taséi AM, Madjlessi N, Magalon G,
Richard MA, et al. The "spaghetti technique": an alternative to Mohs surgery or
staged surgery for problematic lentiginous melanoma (lentigo maligna and acral
lentiginous melanoma). J Am Acad Dermatol. 2011;64(1):113-8. PMID: 21167406 DOI:
https://doi.org/10.1016/j.jaad.2010.03.014
6. Johnson TM, Headington JT, Baker SR, Lowe L. Usefulness of the
staged excision for lentigo maligna and lentigo maligna melanoma: the "square"
procedure. J Am Acad Dermatol. 1997;37(5 Pt 1):758-64.
7. Mahoney MH, Joseph M, Temple CL. The perimeter technique for lentigo
maligna: an alternative to Mohs micrographic surgery. J Surg Oncol.
2005;91(2):120-5. PMID: 16028282 DOI: https://doi.org/10.1002/jso.20284
1. Hospital dos Defeitos da Face, Cruz Vermelha de
São Paulo, São Paulo, SP, Brazil
2. A.C. Camargo - Cancer Center, São Paulo, SP,
Brazil.
Corresponding author: Gabriela Suemi
Shimizu Rua Sabará, nº 210 - Higienópolis - São Paulo, SP, Brazil Zip
Code 01239-010 E-mail: gabrielashimizu@gmail.com
Article received: August 6, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.