TITLE:
The Emergence of Rapid Counter Immunostaining in the Controlled Narrow Excision of Malignant Melanoma—How We Do It
AUTHORS:
Jordan Troxel, Grace Brummer, Kristin Cox, S. Ray Peterson
KEYWORDS:
Moh’s Surgery; Malignant Melanoma; Rapid MART-1
JOURNAL NAME:
Journal of Cancer Therapy,
Vol.4 No.6,
July
22,
2013
ABSTRACT:
Mohs Micrographic Surgery (MMS) is
widely employed in the treatment of non-melanoma skin cancer and is a preferred treatment for many cutaneous
malignancies, particularly in high risk locations and tumors [1,2]. It has also been used in the
narrow excision of malignant melanoma with local control rates equivalent to
standard margins [3]. It has gained acceptance in the treatment of noninvasive
melanoma where standard 0.5 cm margins may be inadequate for local control [4].
The frozen section processing used in MMS has been assumed by some to be
inadequate in assessing melanocyte populations or residual melanoma within
excision margins. This difficulty has likely led to a majority of surgeons with
fellowship training to process margins with slow, permanent hematoxylin and
eosin sections (“slowmohs”)
or to simply resort to standard 0.5, 1.0, or 2.0 cm margins with traditional
excision and outside pathology confirmation of clear margins. A recent survey of practicing
fellowship-trained Mohs surgeons revealed roughly one-third (35.9%) of Mohs
surgeons felt comfortable interpreting MART-1 immunostains, and far fewer were
actually performing
immunostains in their labs [5]. Some Mohs surgeons currently refer melanoma to
a colleague experienced in processing and reading melanoma with available rapid immunostaining. The
development of rapid immunohistochemistry, which can be implemented into a traditional
frozen section laboratory, has greatly improved the ease of interpreting
margins in the excision of melanoma. Although the process is considerably more
complicated than staining with H&E or Toluidine Blue (T-Blue), it easily
falls within the skill-set and equipment of most busy frozen section laboratories.
The additional cost of biologic reagents may be fully recovered by proper
billing of immunohistochemical laboratory work and interpretation of slides.