10.5826/dpc.1303a193
Introduction: Lentigo maligna is a subtype of melanoma in situ that typically affects the head and neck region with an increasing incidence. Margin-controlled techniques, such as spaghetti technique (ST), have gained popularity over wide local excision (WLE) with a margin of 5 mm.
Objectives: To evaluate the outcomes of lentigo maligna cases in the head and neck area treated by either WLE or ST in a tertiary referral hospital. The secondary goal was to describe the demographic and clinical characteristics of our series.
Methods: Cohort study of patients diagnosed with lentigo maligna on the head and neck region between January 2014 and February 2022 in a tertiary hospital.
Results: In total, 79 lentigo maligna were studied, corresponding to 77 patients. Fifty-three lesions (67%) were treated with WLE and 26 (33%) with ST. The mean age of the patients was 73 years and 58% were men. Most of the tumors were located on the cheek (50%) and mean lesion diameter was 2.2 cm for the ST group and 1.2 cm for the WLE group. Mean duration follow-up was 44 months. There were two local recurrences in the WLE group (2/53; 3.7%) and none in the ST group.
Conclusions: Both WLE and ST are appropriate surgical approaches for lentigo maligna. ST offers an efficient alternative to Mohs surgery for treating lentigo maligna in the head and neck area, especially when guided by reflectance confocal microscopy.
text/xml
2160-9381
3082
en
Aram Boada
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Melanoma
Spaghetti Technique Versus Wide Local Excision for Lentigo Maligna Affecting the Head and Neck Regions: Surgical Outcome and Descriptive Analysis of 79 Cases From a Single Practice Cohort
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-12-13
2023-07-31
2023-08-24
e2023193
Dermatol Pract Concept
Introduction: Lentigo maligna is a subtype of melanoma in situ that typically affects the head and neck region with an increasing incidence. Margin-controlled techniques, such as spaghetti technique (ST), have gained popularity over wide local excision (WLE) with a margin of 5 mm.
Objectives: To evaluate the outcomes of lentigo maligna cases in the head and neck area treated by either WLE or ST in a tertiary referral hospital. The secondary goal was to describe the demographic and clinical characteristics of our series.
Methods: Cohort study of patients diagnosed with lentigo maligna on the head and neck region between January 2014 and February 2022 in a tertiary hospital.
Results: In total, 79 lentigo maligna were studied, corresponding to 77 patients. Fifty-three lesions (67%) were treated with WLE and 26 (33%) with ST. The mean age of the patients was 73 years and 58% were men. Most of the tumors were located on the cheek (50%) and mean lesion diameter was 2.2 cm for the ST group and 1.2 cm for the WLE group. Mean duration follow-up was 44 months. There were two local recurrences in the WLE group (2/53; 3.7%) and none in the ST group.
Conclusions: Both WLE and ST are appropriate surgical approaches for lentigo maligna. ST offers an efficient alternative to Mohs surgery for treating lentigo maligna in the head and neck area, especially when guided by reflectance confocal microscopy.
Aram Boada
2023/07/31
10.5826/dpc.1303a193
e2023193
Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain. 
2160-9381
Melanoma
en
e2023193
Kassi K, Vanwijck R, Kanga JM. The "collerette" technique for skin excision and biopsy: an efficient method for managing lentigo maligna of the head and neck. Int J Dermatol. 2014;53(7):899-903. doi:10.1111/ijd.12430. PMID: 24372370.
Spaghetti Technique Versus Wide Local Excision for Lentigo Maligna Affecting the Head and Neck Regions: Surgical Outcome and Descriptive Analysis of 79 Cases From a Single Practice Cohort
https://dpcj.org/index.php/dpc/article/download/3082/2196
  Spaghetti Technique Versus Wide Local Excision
 for Lentigo Maligna Affecting the Head and Neck
Regions: Surgical Outcome and Descriptive Analysis
     of 79 Cases from a Single Practice Cohort
               Manel Martinez-Molina1, Nina Richarz1, Ane Jaka1, Juli Bassas-Vila1,
            Verónica Mora-Fernández1, Ariadna Quer Pi-Sunyer 2, Sebastian Podlipnik3,
                            José Manuel Carrascosa1, Aram Boada1


1 Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
2 Department of Pathology, Hospital University Germans Trias i Pujol, Badalona, Barcelona, Spain
3 Department of Dermatology, Melanoma Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain



Key words: Lentigo maligna, Spaghetti technique, Wide local excision, Melanoma
Citation: Martinez-Molina M, Richarz N, Jaka A, et al. Spaghetti Technique Versus Wide Local Excision for Lentigo Maligna Affecting the
Head and Neck Regions: Surgical Outcome and Descriptive Analysis of 79 Cases From a Single Practice Cohort. Dermatol Pract Concept.
2023;13(3):e2023193. DOI: https://doi.org/10.5826/dpc.1303a193
Accepted: March 2, 2023; Published: July 2023
Copyright: ©2023 Martinez-Molina et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Manel Martinez Molina, Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona.
Autonomous University of Barcelona, Carretera de Canyet, w/n, PC: 08916, Badalona, Barcelona, Spain.
Email: manel.martmol@gmail.com




  ABSTRACT             Introduction: Lentigo maligna is a subtype of melanoma in situ that typically affects the head and
                       neck region with an increasing incidence. Margin-controlled techniques, such as spaghetti technique
                       (ST), have gained popularity over wide local excision (WLE) with a margin of 5 mm.
                       Objectives: To evaluate the outcomes of lentigo maligna cases in the head and neck area treated by
                       either WLE or ST in a tertiary referral hospital. The secondary goal was to describe the demographic
                       and clinical characteristics of our series.
                       Methods: Cohort study of patients diagnosed with lentigo maligna on the head and neck region
                       between January 2014 and February 2022 in a tertiary hospital.
                       Results: In total, 79 lentigo maligna were studied, corresponding to 77 patients. Fifty-three lesions
                       (67%) were treated with WLE and 26 (33%) with ST. The mean age of the patients was 73 years and
                       58% were men. Most of the tumors were located on the cheek (50%) and mean lesion diameter was
                       2.2 cm for the ST group and 1.2 cm for the WLE group. Mean duration follow-up was 44 months.
                       There were two local recurrences in the WLE group (2/53; 3.7%) and none in the ST group.


Original Article | Dermatol Pract Concept. 2023;13(3):e2023193                                                                           1
                     Conclusions: Both WLE and ST are appropriate surgical approaches for lentigo maligna. ST offers an
                     efficient alternative to Mohs surgery for treating lentigo maligna in the head and neck area, especially
                     when guided by reflectance confocal microscopy.




Introduction                                                      sensitive sites. Owing to the difficulty of assessing atypical
                                                                  melanocytes in frozen sections in MMS, even with immu-
Lentigo maligna (LM) is a subtype of melanoma in situ that        nohistochemical staining, variations of MMS, such as slow
typically appears on the sun-damaged skin of elderly patients     Mohs (SM) and staged excision (SE) have gained popularity
[1]. The estimated risk of progression of LM to LM mel-           among surgeons [12]. SM and SE rely on permanent sec-
anoma (LMM) is 3.5 % per year [2]. In recent years, the           tions and deferred histological examination. SM uses the
incidence of LM/LMM has increased in comparison to other          same horizontal sectioning technique as MMS, but relies on
melanoma subtypes [3,4]. A study of 8626 melanoma cases           formalin-fixed paraffin-embedded sections, instead of fro-
in Catalonia (Spain), showed a rise in the incidence of LMM,      zen sections. Following the intervention, the patient returns
from 13.9% in 2008 to 22.6% in 2017 [5]. A 25-year study          home. A few days later, depending on whether the margins
in the Netherlands mirrored this trend, with a rise in the        are positive or not, an additional resection or a defect re-
incidence rate from 0.72 LM/100.000 person years in 1989          construction is performed. In SE, narrow margins are exam-
to 3.84 LM/100.000 patient years [6]. The estimated an-           ined in formalin-fixed permanent sections, without tumour
nual incidence in another recent study was 12 LM/100.000          debulking in the first stage. Debulking is performed in the
persons. Surgical excision remains the treatment of choice        final stage when all margins are clear. Among staged exci-
for LM. Wide local excision (WLE) with 5-mm to 10-mm              sions, in both square technique and perimeter technique, a
margins is the standard surgical management [8,9]. How-           preoperative geometric-shaped excision is outlined adding
ever, 5-mm margins may be inadequate in some cases, with          safety margins to the clinically identified limits of the tumor,
recurrence ranging from 6% to 20% [10,11], owing to               to check the periphery of this geometric figure before resec-
subclinical peripheral spread and poor histological margin        tion [13,14]. In contrast, in the spaghetti technique (ST), a
assessment. LM primarily affects the head and neck region         variation of SE first described by Gaudy-Marqueste et al, the
and these margins are more difficult to achieve in areas          intention is to define, step by step, as closely as possible the
with aesthetic and functional implications, such as the face.     real - pathologically identified - shape of the LM, that will
Margin-controlled techniques like Mohs micrographic sur-          enable later its resection and reconstruction [15] (Table 1).
gery (MMS) evaluate 100% of the surgical margin, reducing             Although MMS has been controversial for melanoma,
the risk of recurrence, while preserving tissue in cosmetically   because of concerns about the accuracy of detecting atypical



                       Table 1. Staged excisions techniques: differences and similitudes.
                Square
                technique          Perimeter technique            Spaghetti technique               Collarette technique
 Differences    Excision of a      A variation of the square      Curved lines and rounded          It is identical to spaghetti
                2-mm strip of      technique.                     edges are used instead of         technique. The only
                skin in a square   Excision of a 2-mm strip       straight lines, in order to       difference with ST is the
                pattern.           of skin in a variety of        define as closely as possible,    use of dermoscopy to
                                   geometric shapes (triangles,   the real pathologically shape     delineate tumor edges, in its
                                   rectangles, or pentagons)      of the tumor.                     original description by Kassi
                                   to facilitate posterior                                          et al [37].
                                   reconstruction.
 Similitudes    • A double-bladed scalpel is used to remove a 2–4-mm strip surrounding the lesion.
                • The resulting linear defect is sutured.
                • The specimen is paraffin embedded and en face vertical sections containing 100 % of the peripheral
                  margins are assessed.
                • If positive margins are identified, a procedure is repeated 5 mm beyond the corresponding involved
                  segment and again sutured, until a tumor-free perimeter is achieved.
                • Resection of the central tumor and reconstruction is performed.



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(3):e2023193
melanocytes on frozen sections, a recent study showed a high              greatest diameter (< or ≥ 2 cm), type of surgery (WLE or
diagnostic accuracy on frozen sections compared with perma-               ST), number of stages required in ST (2 or ≥ 3) and in WLE
nent sections [16]. Another limitation of MMS is that immuno-             (1 or 2), local and distant recurrence, and follow-up du-
histochemical staining is time-consuming for histotechnicians             ration (months). We included patients with recurrent LM.
and can impair the flow of a Mohs practice [17]. In contrast, an          These included LM that had reappeared after a prior cura-
advantage of ST over MMS is that it does not require specially            tive therapy, whether surgical or non-surgical (cryosurgery,
trained MMS technicians, thus making it more accessible.                  laser therapy), performed in our hospital or elsewhere. Pa-
                                                                          tients with invasive melanoma (LMM) were excluded from
                                                                          the study. We also excluded cases in which the management
Objectives                                                                chosen was therapeutic abstention.
                                                                              Histological diagnosis of LM was obtained by incisional
The primary goal of the present study was to retrospectively
                                                                          biopsy prior to treatment. The surgical technique was chosen
evaluate the outcomes of LM cases in the head and neck area
                                                                          according to current guidelines, with ST being the preferred
treated by either WLE or ST in a tertiary referral hospital.
                                                                          option in most LM cases in the recent years. When WLE was
The secondary goal was to describe the demographic and
                                                                          used, the margin of excision around the clinically apparent
clinical characteristics of our series.
                                                                          tumor was 5 mm. In the case of ST, a 2-mm strip of skin
                                                                          was resected, 2 mm to 3 mm beyond the clinically and der-

Methods                                                                   moscopically defined outline of the lesion. The linear defect
                                                                          was sutured, and the patients discharged pending the results
This retrospective study included data from all the patients              of histology. The narrow strip of resected skin was divided
diagnosed with LM on the head or neck between January                     into appropriately sized segments, which were then pinned
2014 and February 2022 at a tertiary hospital in Spain                    in a circular pattern reflecting their anatomic orientation.
(Germans Trias i Pujol Universitary Hospital in Badalona,                 The number of segments varied depending on the size and
Barcelona). The database included age at diagnosis, gender,               morphology of the resected specimen (Figure 1). Each seg-
phototype (I-II, III-IV, V-VI), tumor site (cheek, nose, perio-           ment was fixed in formol and analyzed in vertical in-face sec-
cular, perioral, scalp, forehead, ear, neck), clinical tumor              tions by dermatopathologists. If a segment was positive for




Figure 1. Spaghetti technique. (A) Lentigo maligna on the cheek area. (B) Skin markings prior to the first excision. (C) Resected “spaghetti”
strip divided into segments and arranged in a circle before being sent for pathological study. (D) Suture of the resulting linear defect, leaving
the tumor on site pending the results of histopathological study. (E) Tumor resection followed by flap reconstruction was performed when
all “spaghetti” segments were tumor-free.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023193                                                                                3
malignant cells, an additional strip excision was performed          lesion as reported by the patient ranged from 2 months to 25
beyond the corresponding area. This step was repeated until          years, and only 8 patients claimed a history of more than 10
all the segments of the ‘spaghetti’ were tumor free. In the last     years. Mean follow-up duration was 44 months (range 2 –
stage, resection of the tumor and reconstruction of the final        90 months). Local recurrence was diagnosed in 2 of 53 cases
defect (skin graft, flap, or primary closure) were performed         treated with WLE, at 12 and 39 months, respectively, (a mean
at the same time. A major disadvantage of the ST is that the         interval of 25 months). Both cases were subsequently treated
central tumor is not excised until the time of closure, so an        with ST. No local recurrences were observed in the ST group.
unsuspected invasive melanoma would not be identified un-            Local recurrence-free survival at 30 and 60 months after di-
til after closure is complete [18]. This risk could be reduced       agnosis was 98% and 95%, respectively, for the WLE group
by correlating the dermoscopy findings with the Breslow              and 100% for lesions treated with ST (Figure 2). The differ-
index and by performing a punch biopsy of the most sus-              ence in local recurrence-free survival between WLE and ST
picious area of depth [19]. From 2019 onwards, reflectance           groups was not significant (P = 0.33). Progression to LMM,
confocal microscopy (RCM) was used to delineate excision             distant metastases or death attributable to melanoma were
margins before surgery in all cases of LM, whether the surgi-        not observed in any group. Ten patients died from other
cal approach was WLE or ST.                                          causes during the follow-up period.
    A descriptive analysis was carried out of the demo-
graphic and clinical data. We compared the LM characteris-
                                                                     Conclusions
tics of the two groups (WLE and ST). The Student t test was
used to analyze continuous variables and the Mann-Whitney            In this study, we present a cohort of patients with LM on the
U test when the data were not normally distributed. Com-             head and neck treated with either WLE or ST, contributing the
parative variables were analyzed with the Chi2 test. A P value       experience of one hospital to the literature on LM manage-
less than 0.05 was considered statistically significant. Local       ment. We found no significant difference in the frequency of
recurrence-free survival was assessed using Kaplan Meier             local recurrence between WLE and ST. Two non-randomized
analysis. For local recurrence-free survival, the time to an         studies have compared long-term outcomes for different sur-
event (date of recurrence or last follow-up) was calculated          gical treatment modalities in LM, like the present study. Wall-
from the date of histological diagnosis. Statistical analysis        ing et al reported a higher recurrence rate for MMS (36%)
was performed using SPSS software version 28.0. The study            than for SE (8%) [20]. Walling et al attributed this significant
was approved by the local Ethics Committee and patients              local recurrence rate to the long follow-up period (mean al-
gave written informed consent.                                       most 10 years), arguing that most recurrences occur 3 to 5
                                                                     years after treatment. Another possible explanation for the

Results                                                              high recurrence rate in that study may be the small number (N
                                                                     = 14) of lesions treated with MMS. Hou et al reported a lower
Between January 2014 and February 2022, 81 lesions diag-             risk of recurrence with MMS (1.9%) than with WLE (5.9%),
nosed as LM affecting the head and neck region were iden-            although the difference was not statistically significant [12].
tified in 79 patients. Therapeutic abstention was the strategy          Notably, in our series the recurrence rate for both sur-
chosen for two patients due to their advanced age (99 and            gical techniques was lower than that previously reported in
100 years-old respectively). In total, 79 LM corresponding           the literature [10-12, 20-29]. Other studies have reported
to 77 patients were included in the study; 53 lesions were           recurrence rates for WLE of between 6% and 20%, with a
treated with WLE and 26 with ST. The characteristics of the          follow-up period of 36 to 90 months. Recurrence rates re-
study population are summarized in Table 2. The mean age             ported for MMS range from 0% to 6% with a follow-up pe-
of the patients was 73 years (range 43 – 95). Forty-two per-         riod of 38 to 95 months, excluding the outlier of 36% in the
cent were women and 58% men. More than half of the pa-               study mentioned above. In the case of SE, recurrence rates
tients had skin phototype III-IV (52/79; 65.8%). Most of the         were 2% to 10% with follow-up periods of between 32 and
tumors (75/79; 95%) were primary. At the time of diagnosis,          95 months (Table 3). However, comparison with previous
three lesions in the ST group and one in the WLE group were          studies may be inaccurate because, the follow-up methods
recurrent. The most frequent site was the cheek (50%), fol-          were not described in some cases and in others follow up was
lowed by the forehead (12%), scalp (10%) and nose (10%).             performed by general practitioners or was based on telephone
In the ST group, 54% of the lesions measured ≥ 2 cm. In              reports by family members [30]. In our study, follow-up con-
contrast, only 17% of the LM treated with WLE measured               sisted of a physical examination carried out by one of the
≥ 2 cm. Mean lesion size was 2.2 cm for the ST group and             authors and local recurrence was confirmed by skin biopsy.
1.2 cm for the WLE group. These differences were statisti-              Even though the recurrence rate was lower in the ST
cally significant (P <0.05). The interval since first onset of the   group than the WLE group, the difference was not statistically



4                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023193
  Table 2. Demographic and clinical characteristics of patients with lentigo maligna in the head and
                                    neck region by surgery type.
           Variable                Spaghetti Technique           Wide Lesion Excision          Overall, N (%)        P value
 No. of cases                             26 (33%)                     53 (67%)                  79 (100%)
 Sex                                                                                                                 P>0.05
  Female                                 12 (36.4%)                   21 (63.6%)                 33 (41.8%)
  Male                                   14 (30.4%)                   32 (69.6%)                 46 (58.2%)
 Average age                                 72.2                        73.6                         73             P>0.05
  <70 years                               9 (32.1%)                   19 (67.9%)                 28 (35.4%)          P>0.05
  ≥70 years                              17 (33.3%)                   34 (66.7%)                 51 (64.5%)          P>0.05
 Skin phototype                                                                                                      P>0.05
  I-II                                    10 (40%)                     15 (60%)                  25 (31.6%)
  III-IV                                 15 (28.8%)                   37 (71.2%)                 52 (65.8%)
  V-VI                                     1 (50%)                     1 (50%)                    2 (2.5%)
 Site                                                                                                                P>0.05
 Centrofacial
   Cheek                                  16 (40%)                     24 (60%)                  40 (50.6%)
   Nose                                   3 (37.5%)                   5 (62.5%)                   8 (10.1%)
   Periocular                              1 (50%)                     1 (50%)                    2 (2.5%)
   Perioral                               1 (100%)                         0                      1 (1.3%)
 Peripheral
  Scalp                                   3 (37.5%)                   5 (62.5%)                   8 (10.1%)
  Forehead                                 2 (20%)                     8 (80%)                   10 (12.7%)
  Ear                                       0 (0%)                     9 (100%)                   9 (11.4%)
  Neck                                      0 (0%)                     1 (100%)                   1 (1.3%)
 Size                                                                                                                P<0.05
  <2 cm                                  12 (21.4%)                   44 (78.6%)                 56 (70.9%)
  ≥2 cm                                  14 (60.9%)                   9 (39.1%)                  23 (29.2%)
 Duration                                                                                                            P<0.05
  <5 years                               15 (38.5%)                   24 (61.5%)                 39 (49.4%)
  ≥5 years                                6 (27.3%)                   16 (72.7%)                 22 (27.8%)
  Unknown                                 5 (27.8%)                   13 (72.2%)                 18 (22.8%)
 Primary vs recurrent                                                                                                P<0.05
  Primary                                23 (30.7%)                   52 (69.3%)                 75 (94.9%)
  Recurrent                                3 (75%)                     1 (25%)                    4 (5.1%)
 No. of stages                                ST                         WLE                                         P<0.05
  1                                         0 (0%)                     51 (96%)                   51 (65%)
  2                                       21 (81%)                      2 (4%)                    23 (29%)
  ≥3                                          5 (19%)                    0 (0%)                      5 (6%)




significant. Since the outcomes of both surgical techniques          Some authors have shown that the standard 5-mm mar-
were similar in our study, we believe that additional factors     gins are often not sufficiently wide to ensure clear margins
should be considered before choosing the surgical approach,       [31]. However, wide excisions margins (10 mm) are not al-
such as patient preference, tumor size, reconstruction options    ways acceptable because they can lead to morbidity in func-
and the accessibility of margin-controlled techniques. In our     tional and cosmetically sensitive areas. Consequently, the
hospital, collaboration with experienced dermatopatholo-          site of the lesion, patient age and comorbidities must also be
gists with experience in ST and the use of paraffin-embedded      taken into account. The lower local recurrence rate observed
sections has proved to be a fruitful strategy.                    in our WLE patients may be explained by the introduction



Original Article | Dermatol Pract Concept. 2023;13(3):e2023193                                                                 5
         Table 3. Summary of studies reporting surgically treated lentigo maligna, by surgery typea.
                                                                                     Mean follow-up               Mean time
          Treatment                     Study              Recurrence rate (%)         (months)             to recurrence (months)
    Wide local excision         Pittman (1979)            9% (2/22)                           38                            -
                                Tsang (1994)              6% (1/18)                           36                            -
                                Osborne (2002)            20% (16/81)                         43                            -
                                Hou (2015)                6% (16/269)                         95                            -
    Mohs micrographic           Robinson (1994)           6% (1/16)                           60                          96
    surgery                     Cohen (1998)              0% (0/26)                           57                            -
                                Bhardwaj (2006)           1% (1/158)                          38                            -
                                Walling (2007)            36% (5/14)                         117                          50
                                Bene (2008)               1% (1/116)                          63                          48
                                Gambichler (2014)         2% (3/124)                          55                            -
                                Hou (2015)                2% (3/154)                          95                            -
    Staged excision             Bub (2004)                4% (2/55)                           57                          54
                                Walling (2007)            8% (3/36)                           95                          24
                                Lee (2008)                10% (3/31)                          42                          48
                                Abdelmalek (2012)         2% (4/225)                          32                          15
                                De Vries (2016)           4% (4/100)                          60                          62
a
Lentigo maligna melanoma cases were excluded



                                                                        between the WLE and ST groups cannot be precise. We
                                                                        nonetheless consider it to be of interest to report the out-
                                                                        comes for these 2 surgical techniques to reflect a real-world
                                                                        practice scenario.
                                                                           In terms of descriptive findings, our cohort is in line with
                                                                        those previously reported [32,35]. A predominance of male
                                                                        patients (58%) was observed in our registry, as previously
                                                                        widely described [34]. Interestingly, mean tumor size was
                                                                        16 mm, which is not especially large for slow-growing and
Figure 2. Local recurrence-free survival after wide local excision vs   ill-defined lesions. The clinical findings and tumor character-
spaghetti technique.                                                    istics did not differ significantly between the two groups. It
                                                                        is noteworthy that the tumors treated by ST were larger in
of RCM in our hospital, which allowed preoperative identi-              diameter than those treated with WLE and that this differ-
fication of surgical margins in vivo. Moreover, RCM guid-               ence was statistically significant. ST was the preferred treat-
ance contributed to the low number of stages (‘spaghetti’)              ment for recurrent LM. Both larger diameter tumours and
needed to achieve clearance in the ST group (2 stages in 21             recurrent tumours were considered high risk by Hou et al
patients vs >3 stages in 5 patients). Advantages of RCM                 [12], and MMS was the surgical approach chosen for those
guided ST for LM, especially in functional and aesthetic                LM. Even though treatment was individualized in our study
areas, has also been reported by Couty et al [32]. A major              group in accordance with current guidelines and patient
drawback of RCM is that is limited to few centers. In addi-             preference, larger and recurrent LM were more likely to be
tion, RCM adds further cost (device, maintenance, specific              treated by ST.
training) in the diagnostic performance of melanoma. It is                 The results of this study provide real-world insight into
also a time-consuming procedure.                                        the surgical treatment of LM in the head and neck area, com-
      Finally, our low recurrence rate could also be attribut-          paring WLE and ST. While some authors have concluded that
able to the short mean follow-up duration (44 months), since            margin-controlled techniques are the preferred treatment for
some authors have suggested that recurrence occurs later in             LM, to our knowledge, none of them have compared the
LM than other melanoma subtypes [33,34].                                outcomes of WLE and ST. To date, in the absence of data
      A major limitation of this study is its retrospective and         from randomized clinical trials and comparative studies on
non-randomized design, which means that the comparison                  the preferred surgical approach in different cases of LM, this



6                                                                           Original Article | Dermatol Pract Concept. 2023;13(3):e2023193
data from a consecutive cohort treated at a tertiary referral             11. Tsang RW, Liu FF, Wells W, Payne DG. Lentigo maligna of the
hospital guarantees consistency in the reported outcomes.                     head and neck. Results of treatment by radiotherapy. Arch Der-
                                                                              matol. 1994;130(8):1008-1102. PMID: 8053696.
      This study shows that both WLE and ST are appropri-
                                                                          12. Hou JL, Reed KB, Knudson RM, et al. Five-year outcomes of
ate surgical approaches for LM on the head and neck re-
                                                                              wide excision and Mohs micrographic surgery for primary len-
gion. The optimum treatment should, therefore, decide on a                    tigo maligna in an academic practice cohort. Dermatol Surg.
case-by-case basis. Based on our experience, ST is an efficient               2015;41(2):211-218. DOI: 10.1097/DSS.0000000000000248.
alternative to MMS for the treatment of LM on the head                        PMID: 25590473.
and neck. ST guided by RCM may be of special interest for                 13. Johnson TM, Headington JT, Baker SR, Lowe L. Usefulness of
                                                                              the staged excision for lentigo maligna and lentigo maligna mel-
large, recurrent, and ill-defined lesions. Careful long-term
                                                                              anoma: the “square” procedure. J Am Acad Dermatol. 1997;37
follow-up after treatment is mandatory as recurrence ap-
                                                                              (5 Pt 1):758-764. DOI:10.1016/s0190-9622(97)70114-2. PMID:
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                                                                          14. Mahoney MH, Joseph M, Temple CL. The perimeter tech-
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