Cases and Research Letters
The Perimeter Technique in the Surgical Treatment of Lentigo Maligna and Lentigo Maligna Melanoma
Técnica de delimitación del perímetro en el tratamiento quirúrgico del lentigo maligno y el lentigo maligno melanoma
B. García Bracamonte
, S.I. Palencia-Pérez, G. Petiti, F. Vanaclocha-Sebastián
Corresponding author
Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain
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García Bracamonte, S.I. Palencia-Pérez, G. Petiti, F. Vanaclocha-Sebastián" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "García Bracamonte" "email" => array:1 [ 0 => "beagarcia50@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "S.I." "apellidos" => "Palencia-Pérez" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Petiti" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Vanaclocha-Sebastián" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Técnica de delimitación del perímetro en el tratamiento quirúrgico del lentigo maligno y el lentigo maligno melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1637 "Ancho" => 1500 "Tamanyo" => 365747 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A-D, Excision of a strip of skin around the lesion, by sectors, and suture of the defect.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The treatment of choice for lentigo maligna (LM) and for lentigo maligna melanoma (LMM) is still complete excision of the tumor with adequate surgical margins. Conventionally, surgical margins of 0.5<span class="elsevierStyleHsp" style=""></span>cm for LM and of 1<span class="elsevierStyleHsp" style=""></span>cm for thin LMM with a Breslow depth<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm have been recommended. However, numerous reports have demonstrated the need for wider margins, as the subclinical extension of the melanocytic dysplasia in LM can be greater than predicted.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1-4</span></a> Techniques with 3-dimensional histological control of the margins have been found to be better than conventional surgery as they are followed by fewer recurrences.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Since 2008, the National Comprehensive Cancer Network recommends the use of these techniques whenever possible.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our first patient was an 84-year-old woman who presented an irregularly pigmented lesion of 2.5<span class="elsevierStyleHsp" style=""></span>cm that had been present for 4 years on her left cheek; biopsy confirmed LM. The so-called spaghetti technique (initial delimitation of the perimeter of the lesion) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) was chosen. This technique consists of the excision of a strip of tissue with a breadth of about 3<span class="elsevierStyleHsp" style=""></span>mm around the perimeter of the lesion; the wound is then sutured and the patient can go home with a closed wound to await the histology report (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The specimen is fixed in formol by sectors and marked so that the pathologist can process it as usual and take vertical sections after embedding the tissue in paraffin. If necessary, based on findings, the surgical margins can be enlarged until free margins are achieved. Complete excision of the lesion is then performed, with closure of the defect using a flap if indicated. In this patient, free margins were achieved with excision of the first strip of tissue and complete excision of the lesion could be performed the following week.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Our second patient was a 69-year-old man with a 2-cm LM on the forehead. In this case, a polygonal excision was designed to match the outline of the lesion and the skinfolds of the forehead (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). It was necessary to extend the margin in the superior zone in a second operation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). Complete excision of the lesion and closure of the defect was performed 20 days after the first operation.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The spaghetti technique is not new, but rather the further development of an idea proposed by Johnson in 1997 and that envisaged a different strategy in the treatment of LM. First the surgical margins of the LM are established, as if the lesion was a picture and we are drawing its frame. Next, the lesion is then removed with full assurance that excision is complete.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The initial proposal involved a square or polygonal excision to facilitate the cutting and orientation of the surgical specimen, but depending on the site of the lesion, rounded or polygonal forms are now possible with the use of photographs or marker sutures to indicate the orientation of the specimen.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7-9</span></a> It is a simple technique that can be performed by any dermatologist.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Mohs micrographic surgery and other techniques of sequential (stepped) excision with the examination of sections taken from the fresh or paraffin-embedded specimen are of proven efficacy<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4,10</span></a> but are only performed in specialized centers. In Mohs micrographic surgery, the interpretation of the frozen sections by the pathologist can be very difficult and occasionally the wound must be left open while waiting for the results of examining paraffin-embedded sections.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The technique described in this paper, in which the initial step is to locate the margins, can be very useful in treatment centers where Mohs micrographic surgery is not available or in certain circumstances, such as recurrent tumors with poorly defined borders, older patients or patients living at a distance from the hospital, and lesions whose size means that a flap will be required to close the defect, thereby distorting the margins. The spaghetti technique has several advantages. Routine pathology processing systems can be used and the dermatologist needs no special training. No wounds are left open (meaning that the patient can be discharged without the need for special measures), and there is time to design the reconstruction technique according to the histological findings and the size of the defect, both of which will be known before the final procedure. One of the limitations of this technique is that foci of invasive malignant melanoma cells may be present within the LM, and the excision must therefore reach a deep plane. Another problem is that the complete excision of the lesion will be delayed by days or weeks, and the reason for this must be explained to the patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: García Bracamonte B, Palencia-Pérez SI, Petiti G, Vanaclocha-Sebastián F. Técnica de delimitación del perímetro en el tratamiento quirúrgico del lentigo maligno y el lentigo maligno melanoma. Actas Dermosifiliogr.2012;103:748-750.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 915 "Tamanyo" => 72816 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Technique to establish the perimeter of the lesion and allow histological study of the specimen by sectors.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1637 "Ancho" => 1500 "Tamanyo" => 365747 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A-D, Excision of a strip of skin around the lesion, by sectors, and suture of the defect.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 581 "Ancho" => 1401 "Tamanyo" => 128279 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Design of a pentagonal strip of skin to be excised and analyzed. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 10 | 26 |
| 2024 October | 128 | 42 | 170 |
| 2024 September | 156 | 22 | 178 |
| 2024 August | 185 | 53 | 238 |
| 2024 July | 178 | 41 | 219 |
| 2024 June | 143 | 53 | 196 |
| 2024 May | 155 | 37 | 192 |
| 2024 April | 119 | 23 | 142 |
| 2024 March | 165 | 29 | 194 |
| 2024 February | 127 | 43 | 170 |
| 2024 January | 127 | 37 | 164 |
| 2023 December | 175 | 28 | 203 |
| 2023 November | 161 | 32 | 193 |
| 2023 October | 140 | 41 | 181 |
| 2023 September | 114 | 26 | 140 |
| 2023 August | 131 | 21 | 152 |
| 2023 July | 82 | 35 | 117 |
| 2023 June | 97 | 29 | 126 |
| 2023 May | 136 | 28 | 164 |
| 2023 April | 107 | 25 | 132 |
| 2023 March | 98 | 29 | 127 |
| 2023 February | 104 | 25 | 129 |
| 2023 January | 74 | 33 | 107 |
| 2022 December | 60 | 38 | 98 |
| 2022 November | 39 | 28 | 67 |
| 2022 October | 27 | 23 | 50 |
| 2022 September | 34 | 35 | 69 |
| 2022 August | 30 | 34 | 64 |
| 2022 July | 29 | 39 | 68 |
| 2022 June | 33 | 38 | 71 |
| 2022 May | 60 | 52 | 112 |
| 2022 April | 85 | 45 | 130 |
| 2022 March | 64 | 47 | 111 |
| 2022 February | 61 | 22 | 83 |
| 2022 January | 58 | 35 | 93 |
| 2021 December | 51 | 41 | 92 |
| 2021 November | 59 | 58 | 117 |
| 2021 October | 91 | 62 | 153 |
| 2021 September | 60 | 53 | 113 |
| 2021 August | 41 | 35 | 76 |
| 2021 July | 34 | 36 | 70 |
| 2021 June | 43 | 32 | 75 |
| 2021 May | 41 | 32 | 73 |
| 2021 April | 86 | 62 | 148 |
| 2021 March | 86 | 30 | 116 |
| 2021 February | 63 | 28 | 91 |
| 2021 January | 38 | 15 | 53 |
| 2020 December | 34 | 14 | 48 |
| 2020 November | 23 | 32 | 55 |
| 2020 October | 18 | 11 | 29 |
| 2020 September | 35 | 22 | 57 |
| 2020 August | 22 | 17 | 39 |
| 2020 July | 40 | 17 | 57 |
| 2020 June | 35 | 29 | 64 |
| 2020 May | 21 | 27 | 48 |
| 2020 April | 44 | 26 | 70 |
| 2020 March | 34 | 18 | 52 |
| 2020 February | 5 | 1 | 6 |
| 2020 January | 4 | 3 | 7 |
| 2019 December | 8 | 8 | 16 |
| 2019 November | 4 | 3 | 7 |
| 2019 October | 0 | 7 | 7 |
| 2019 September | 8 | 10 | 18 |
| 2019 August | 4 | 8 | 12 |
| 2019 July | 2 | 11 | 13 |
| 2019 June | 6 | 34 | 40 |
| 2019 May | 1 | 31 | 32 |
| 2019 April | 0 | 25 | 25 |
| 2019 March | 2 | 9 | 11 |
| 2019 February | 0 | 4 | 4 |
| 2019 January | 2 | 2 | 4 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 2 | 1 | 3 |
| 2018 September | 8 | 0 | 8 |
| 2018 August | 0 | 4 | 4 |
| 2018 July | 0 | 3 | 3 |
| 2018 June | 0 | 3 | 3 |
| 2018 May | 0 | 3 | 3 |
| 2018 March | 4 | 10 | 14 |
| 2018 February | 84 | 3 | 87 |
| 2018 January | 91 | 10 | 101 |
| 2017 December | 92 | 9 | 101 |
| 2017 November | 64 | 11 | 75 |
| 2017 October | 55 | 7 | 62 |
| 2017 September | 74 | 18 | 92 |
| 2017 August | 70 | 16 | 86 |
| 2017 July | 65 | 22 | 87 |
| 2017 June | 81 | 20 | 101 |
| 2017 May | 65 | 17 | 82 |
| 2017 April | 64 | 18 | 82 |
| 2017 March | 72 | 8 | 80 |
| 2017 February | 40 | 10 | 50 |
| 2017 January | 33 | 13 | 46 |
| 2016 December | 66 | 13 | 79 |
| 2016 November | 106 | 17 | 123 |
| 2016 October | 112 | 27 | 139 |
| 2016 September | 142 | 14 | 156 |
| 2016 August | 102 | 19 | 121 |
| 2016 July | 51 | 15 | 66 |
| 2016 June | 14 | 10 | 24 |
| 2016 May | 7 | 14 | 21 |
| 2016 April | 7 | 25 | 32 |
| 2016 March | 7 | 18 | 25 |
| 2016 February | 10 | 17 | 27 |
| 2016 January | 9 | 14 | 23 |
| 2015 December | 10 | 10 | 20 |
| 2015 November | 14 | 16 | 30 |
| 2015 October | 15 | 9 | 24 |
| 2015 September | 9 | 8 | 17 |
| 2015 August | 11 | 1 | 12 |
| 2015 July | 132 | 13 | 145 |
| 2015 June | 81 | 22 | 103 |
| 2015 May | 89 | 10 | 99 |
| 2015 April | 98 | 12 | 110 |
| 2015 March | 66 | 8 | 74 |
| 2015 February | 60 | 15 | 75 |
| 2015 January | 65 | 12 | 77 |
| 2014 December | 54 | 18 | 72 |
| 2014 November | 54 | 6 | 60 |
| 2014 October | 78 | 27 | 105 |
| 2014 September | 32 | 6 | 38 |
| 2014 August | 32 | 7 | 39 |
| 2014 July | 20 | 9 | 29 |
| 2014 June | 53 | 7 | 60 |
| 2014 May | 53 | 6 | 59 |
| 2014 April | 45 | 4 | 49 |
| 2014 March | 34 | 10 | 44 |
| 2014 February | 31 | 16 | 47 |
| 2014 January | 35 | 4 | 39 |
| 2013 December | 33 | 11 | 44 |
| 2013 November | 31 | 6 | 37 |
| 2013 October | 29 | 4 | 33 |
| 2013 September | 23 | 13 | 36 |
| 2013 August | 13 | 7 | 20 |
| 2013 July | 11 | 20 | 31 |
| 2013 June | 5 | 11 | 16 |
| 2013 May | 8 | 11 | 19 |
| 2013 April | 9 | 18 | 27 |
| 2013 March | 13 | 6 | 19 |
| 2013 February | 28 | 6 | 34 |
| 2013 January | 28 | 5 | 33 |
| 2012 December | 35 | 9 | 44 |
| 2012 November | 2 | 0 | 2 |
| 2012 October | 2 | 4 | 6 |
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