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Original Article

No Recurrence in Primary Invasive Stage 1a and 1b Melanoma and Melanoma in Situ Treated With Serial Disk Staged Excision

Ahn, Grace Sora BS; Pousti, Bobak MD; Singh, Gaurav MD, MPH; Elsensohn, Ashley MD; Jiang, Shang I Brian MD*

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doi: 10.1097/DSS.0000000000003357
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The surgical treatment of invasive melanoma (IM) and melanoma in situ (MIS) has been debated, with ongoing discussion regarding the various treatment modalities and ideal margins needed for optimal outcomes. The incidence of melanoma continues to rise, with an estimated 100,350 new cases of IM diagnosed in the United States in 2020.1 Lentigo maligna (LM), in particular, needs treatment clarification. Previously labeled a relatively benign melanoma subtype, LM has been shown to hold similar prognosis as other melanoma forms with a lifetime risk up to 4.7% of progressing to invasive disease.2,3

The 5-mm margin has been well-studied for MIS.4–9 The American Academy of Dermatology (AAD), National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) recommend 5-mm to 1-cm margins for MIS with the wider surgical margin suggested particularly for the LM subtype.4,10,11 There are multiple surgical techniques currently recommended for both IM and MIS. Among those are serial staged excision (SSE), Mohs micrographic surgery (MMS), and standard wide local excision (WLE). Mohs micrographic surgery and SSE have recently demonstrated better margin control compared with WLE.12–15 Much recent literature has come out to highlight the benefit of MMS in the treatment of melanoma, particularly at academic centers and with the use of immunohistochemistry—there are also retrospective studies demonstrating the superiority of MMS not only regarding recurrence rates but also regarding survival in large cohorts of patients.16–21 There has been some recent critique on the retrospective and heterogeneous nature of these MMS studies.22 Overall, however, there seems to be benefit of complete margin control using the MMS technique. Here, SSE is considered as an alternative to Mohs, allowing another modality for margin assessment prior to wound closure.

One SSE technique is the serial disk staged technique, which has shown low recurrence rates.5 The decision to use vertical “bread loafing” sectioning allows for the examination of the evolution of cell changes as they progress to the margins, especially important when considering the difficulties in interpreting LM in the background of sun-damaged skin.23,24 This technique was previously studied as part of a case series and was concluded to be a simple, accessible, alternative to WLE and MMS while comparable in efficacy to other SSE techniques.

The purpose of this study is to identify the recurrence rates and optimal surgical margin of MIS and invasive stage 1 melanoma using a serial disk staged excision technique with rush permanent processing and “bread loafing” microscopic analysis.

Materials and Methods

Data Collection

Two hundred seventy patients at the University of California San Diego Dermatologic Surgery Unit with MIS and Stage 1a or 1b IM treated with SSE between March 2010 and December 2019 were included. The primary outcome was clinical recurrence at the original surgical site. Age at diagnosis, age at excision, sex, skin type, pathology reports, tumor location, tumor dimensions, excision and repair dimensions, number of required stages, complications, recurrences, follow-up duration, preoperative size, postoperative size, and adverse outcomes were collected. Adverse outcomes were identified as any complication requiring additional medical or surgical intervention and included skin infections, postoperative bleeding, flap necrosis, graft loss, and wound dehiscence. The surgical margins were determined by taking the difference between the preoperative and postoperative excision dimensions. Continuous data were analyzed with t-test distributions. Institutional review board approved this study.

Surgical Technique

The staged excision utilizes a simple disk staged excision with 90° angles. A notch is marked at 12 o'clock for the initial stage and a three-suture marking technique for subsequent stages. Initial margins are 5 mm to the superficial/mid-fat for MIS and 10 mm to the muscular fascia for IM (stage T1a or T1b). Pathology is sent for rush permanent sections with 24-hour turnaround. The excision specimen is bread-loafed with 3-mm intervals with 1 or 2 slides per interval segment. All slides are reviewed by the board-certified dematopathologist. En-face margin assessment was not utilized.

Histopathologic Definition

Diagnoses were rendered by a board-certified dermatopathologist. Dermatopathologists of the University of California examined all the specimens, to include internal and externally referred cases.


From March 1, 2010, to December 31, 2019, 321 patients underwent SSE of either superficially IM (Stage 1a or 1b) or MIS. Two patients with MIS were excluded from this study due to previous primary excisions at outside institutions. Forty-nine patients were excluded due to inadequate follow-up duration, determined to be less than 10 months. Ultimately, 270 patients were included, including 63 with IM and 207 with MIS (Tables 1 and 2).

TABLE 1. - Patient Demographics and Lesion Characteristics of MIS Cohort
Serial Staged Excision for MIS
Variable n (SD or %)
No. of MIS cases 207
 Male 138 (67%)
 Female 69 (33%)
 I 2 (1%)
 II 202 (98%)
 III 3 (1%)
Lesion location
 Head and neck 133 (64%)
  Cheek 41 (20%)
  Chin/jawline 6 (3%)
  Forehead 8 (4%)
  Nose 5 (2%)
  Neck 22 (11%)
  Scalp 21 (10%)
  Ear 10 (5%)
  Eyelid 5 (2%)
  Temple 11 (5%)
  Lip 4 (2%)
 Torso and extremities 74 (36%)
  Back 9 (4%)
  Leg 20 (10%)
  Foot/ankle 6 (3%)
  Arm 20 (10%)
  Shoulder 7 (3%)
  Hand 1 (1%)
  Chest 11 (5%)
Age at excision (yrs) Mean 68.7, median 70 (range 22–96)
Preoperative size (mm) Mean 14.7 (SD 16.5) 
Postoperative size (mm) Mean 25.8 (SD 23.1) 
Final surgical margin (mm) Mean 12.1 (SD 12.2) 
Stages needed for histologically clear margin Mean 1.28 (range 1–3) 
Follow-up duration (mo) Mean 36.5, median 33 (range 10–92) 
Complications 5
Recurrences 0
MIS, melanoma in situ.

TABLE 2. - Patient Demographics and Lesion Characteristics of IM cohort
Serial Staged Excision for IM
Variable n (SD or %)
No. of IM cases 63
 Male 43 (68%)
 Female 20 (32%)
 I 2 (3%)
 II 61 (97%)
 III 0
Lesion location
 Head and neck 35 (56%)
  Cheek 8 (13%)
  Chin/jawline 1 (2%)
  Forehead 2 (3%)
  Nose 1 (2%)
  Neck 9 (14%)
  Scalp 6 (10%)
  Ear 4 (6%)
  Eyelid 1 (2%)
  Temple 3 (5%)
 Torso and extremities 28 (44%)
  Back 10 (16%)
  Leg 8 (13%)
  Foot/ankle 3 (5%)
  Arm 1 (2%)
  Shoulder 2 (3%)
  Hand 2 (3%)
  Chest 2 (3%)
Age at excision (yrs) Mean 43, median 68 (range 22–89)
Preoperative size (mm) Mean 14.8 (SD 18.2) 
Postoperative size (mm) Mean 33.5 (SD 23.0) 
Final surgical margin (mm) Mean 19.8 (SD 9.7) 
Stages needed for histologically clear margin Mean 1.16 (range 1–2) 
Follow-up duration (mo) Mean 33.7, median 26 (range 10–90) 
Complications 2
Recurrences 0
IM, invasive melanoma.

Invasive Melanoma (n = 63)

Average Breslow depth was 0.41 mm (SD 0.14). All lesions were staged as T1a except one T1b with a Breslow depth of 0.8 mm. Approximately 24% (15/63) of lesions were classified as LM melanoma with the average Breslow depth of these lesions being 0.34 mm (SD 0.12) compared with 0.43 (SD 0.14) for non-LM lesions (p = .0386). The difference between LM type and non-LM type, as they relate to preoperative size, number of stages, and margin size for histopathologic clearance, were not statistically significant.

The average preoperative size for IM was 14.8 mm (SD 18.2), margin size for histopathologic clearance was 19.8 mm (SD 9.7), and number stages needed for margin clearance was 1.16 (range, 1–2) with 12.7% (8/63) requiring more than 1 stage. Reasons for reexcision were pathology upstaging (n = 1), atypical junctional melanocytic proliferation at lateral margin (n = 3), residual IM at margin (n = 1), and residual MIS at margin (n = 3). Three percent (2/63) experienced complications, comprising 2 superficial infections requiring oral antibiotics. No recurrences were identified within this cohort.

Melanoma in Situ (n = 207)

The average preoperative size for MIS was 14.7 mm (SD 16.5), the margin size for histopathologic clearance was 12.1 mm (SD 12.2), and the number of stages needed for histologically clear margins was 1.29 (range, 1–3). Although 24% (50/207) of lesions required more than 1 stage, 3 stages were the maximum and required for only 4% (9/207) of patients. There was no correlation between preoperative lesion size and the number of stages. Five (2.4%) experienced complications; the most common (4/5) being superficial infection requiring oral antibiotics, with one patient requiring surgical intervention for primary graft loss. No recurrences were identified within this cohort.


There were no recurrences within this series of 270 melanoma in situ or superficial (Stage T1a or T1b) IM with the variant of serial disk staged excision. This assuring lack of recurrence is similar to previously reported ranges for such staged techniques, between 0% and 12%, as summarized in Table 3.5,6,15,29,36–50 Likewise, the mean follow-up duration between 34 and 36 months for MIS and IM, respectively, provides a good window in identifying potential recurrence, similar to previously reported duration of 4.7 to 96 months.5,6,15,29,36–50

TABLE 3. - Prior Studies Summarizing Recurrence Rates of Serial Staged Excision for IM and MIS
Staged Excision Study Recurrence Rate Time to Recurrence (mo) Follow-up Duration (mo)
Walling 3 of 41 (7.3%) 24 96 ± 43.6
Bub 2 of 55 (3.6%) n/a 57
Huilgol 2 of 125 (1.6%) 12 38 ± 25
Johnson 0 of 35 (0%) n/a n/a
Hill and Gramp 1 of 38 (2.6%) 10 25
Anderson 1 of 150 (0.67%) <60 undefined n/a
Agarwal-Antal 0 of 93 (0%) n/a n/a
Malhotra 4 of 109 (3.7%) 12–40 32 ± 26
Mahoney 0 of 11 (0%) n/a 4.7
Jejurikar 0 of 51 (0%) n/a 31
Bosbous 1 of 59 (1.7%) n/a 26.4
Lee and Ryman 3 of 31 (9.7%) 48 42
Joyce 9 of 410 (2.2%) 29.6 23
de Vries 4 of 100 (4%) 37–77 60
Patel 1 of 21 (4.8%) 24 n/a
Lawrence 4 of 56 (12%) 52.8 60 minimum
Gaudy-Marqueste 0 of 20 (0%) 48 25.36
Möller 0 of 49 (0%) n/a 14
Garcia and Jiang 0 of 29 (0%) n/a 31.5
IM, invasive melanoma; MIS, melanoma in situ.

Histopathologic clearance in this series of 207 MIS lesions required an average margin of 12.1 mm with 79% of lesions cleared utilizing a margin of 10 mm or less. This is similar to prior studies showing a clearance rate of 74.5% and 97% utilizing a 10- and 12-mm margin, respectively.25,26 Additionally, shown through multiple prior studies as well as results of the current study, oftentimes, these margins are not adequate for margin control and disease clearance.7,25,27–29 Lack of recurrence with the above margins suggests that the current recommendations for MIS excision may be too conservative, leading to a higher than desired recurrence rate. Alternatively, larger margins than standard recommendations may also support the use of margin control techniques such as SSE and MMS.

A unique aspect of this study is its assessment of SSE for superficially IM (T1a and T1b). The NCCN, AAD, and ESMO guidelines recommend clinical margins based on Breslow depth (BD). All of the excised IM lesions were <1 mm in BD and thus correlate with recommended clinical margins of at least 1.0 cm and a maximum excision margin of 2 cm recommended in Europe.30 As stated previously, a margin of 1.0 cm has shown to be insufficient in acquiring margin control for a significant portion of MIS lesions. Notably, the average margin size for IM was just less than 2 cm, roughly 1 cm larger than the aforementioned guidelines. Prior studies have confirmed that a 10-mm margin for invasive disease is often insufficient. One study including more than 260 IMs with an average BD of 0.46 mm demonstrated that only approximately half of their excisions were clear of disease after 10 mm or less margins.29 Invasive melanoma in Europe has also shown favorable survival outcomes associated with 3-cm excision margins compared with 1 cm.31 Such results may advocate caution when following minimum margin recommendations because many lesions may need advanced sections and further excision for adequate disease management.

The LM variants of both MIS and IM provide additional challenges given their pattern of growth and subclinical spread, with prior literature suggesting the need for wider margins than what are currently recommended.26,32–36 In patient sample of this study, no significant difference in initial lesion size was identified between LM and non-LM type MIS lesions. Invasive LM type melanoma lesions on average had a decreased Breslow depth when compared with non-LM IM (p = .038). Even so, there was no clinical difference in the number of stages or margin size for disease clearance between the 2.

Although WLE was long believed to be standard of care treatment for both MIS and IM, an ever-growing body of literature has suggested benefits with either MMS or SSE surgical technique.5,6,15,29,36–50 Current literature affirms these comparisons. A recent 10-year retrospective study demonstrated that MMS for MIS or thin IM decreased local recurrence rate compared with WLE.51 An additional 10-year retrospective review of “modified” MMS with permanent sectioning identified a 0% to 2% recurrence rate in those with MIS as well as an estimated 99% (95% confidence interval, 97.7%–99.6%) melanoma-specific survival.52 A recent cohort study of more than 70,000 patients treated for thin (T1) melanoma echoed this sentiment, demonstrating a modest survival benefit (Hazard Ratio, HR 0.86) for MMS compared with WLE.53 Such benefits become even more evident on anatomically complex locations, such as the head, neck, and acral surfaces. A recent study addressing acral melanoma found just that, illustrating a local recurrence of 3.7% using MMS with permanent processing compared with 10.7% with WLE.54 These results, in addition to the results of the present study, demonstrate how both MMS and SSE provide effective treatment alternatives to WLE, particularly on anatomically complex locations.

Critics of SSE reference the multiday nature of the staged treatment course and the potential complications associated with maintaining open wounds between stages and subsequent delayed repair. Only a minority of patients in this study, 28% with MIS and 15% with IM, required an additional stage after their primary excision. As such, the majority of patients did not require lengthy, recurrent surgical sessions and were able to proceed with closure shortly after their primary excision. Additionally, this study found that even with an extended, multiday course requiring patients to address an open wound, the complication rate demanding additional intervention remained low. Only 2.4% (5/207) of MIS and 3.2% (2/63) of IM patients experienced complications—the most common being a superficial infection requiring oral antibiotics (6/7). These results are similar to prior analyses of dermatologic surgery complications, with identified rates between 1.6% and 6%.55–57 As such, this study demonstrates how SSE remains not only an effective but also a safe and logistically viable surgical method for the treatment of melanoma and its variants.

Comparison of the 2 tissue sparing modalities, SSE and MMS, is a more nuanced conversation, with multiple iterations of both modalities—MMS with traditional frozen sections, modified MMS in combination with permanent sections, and SSE with permanent sections. Logistically, MMS could offer a faster, single-day procedural experience when compared with SSE if the wound closure is not delayed due to processing of the permanent sections of the debulked central specimen. The counterargument to such claim is that the benefit SSE delay could result in better quality slides for histological evaluation with permanent sections compared with the frozen sections utilized during MMS. Concerns remain that utilizing frozen sections alone with Hematoxylin & Eosin (H&E) may make accurately identifying melanocytes more difficult, particularly in a background of sun-damaged skin or inflammatory infiltrate. This is often deemed a function of frozen processing's “freeze artifact” with H&E staining, leading to the alteration of melanocytes and vacuolization of keratinocytes.58,59 Prieto and colleagues identified the potential impact of such changes by confirming 66 discrepancies in IM cases between frozen and permanent sections. The majority of changed diagnoses in these cases led to negative frozen margins becoming positive in the permanent sections.60 Even so, other studies found that with experienced technicians, the sensitivity and specificity of frozen sections for MIS and LM may still be as high as 97% to 100% and 90% to 100%, respectively.61,62 Of further note, Mohs surgeons are using rapid immunohistochemical stains more often to accurately identify melanocytes with data demonstrating low local recurrence rates with immunostaining. The discrepancy in prior studies, in combination with the known underestimating of Breslow's depth by frozen processing, complicates the use of sole frozen sections, particularly if concerned for invasive disease.62

This study consists of a large single-institutional report on an SSE technique with a significant recurrence rate of 0% for both T1 melanomas and MIS. The following limitations are worth noting, namely, the cohort involved only a single institution review, and the patient population and physician skill set cannot fully translate to represent the recurrence rates achievable with a different patient population, surgeon, and dermatopathologist. Additionally, the academic center does not routinely biopsy prior surgical scar sites unless there is a suspicion for tumor recurrence. Clinical and histologic recurrence alongside longer follow-up are highly recommended in future studies. The conclusions of this study regarding the significant recurrence rate of serial disk staged SSE could benefit from the data that a prospective study involving a comparison group with either WLE or MMS could better illustrate the direct comparison of each technique for both melanoma and MIS lesions.


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