Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study

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Kristen K. Curtis Case Western Reserve University School of Medicine, Cleveland, OH

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Nathan J. Fakult Case Western Reserve University School of Medicine, Cleveland, OH

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Jennifer L. Strunck Department of Dermatology, Oregon Health & Science University, Portland, OR

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Sumaira Z. Aasi Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA

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Christine S. Ahn Department of Dermatology and Pathology, Wake Forest School of Medicine, Winston-Salem, NC

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Murad Alam Departments of Dermatology and Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, IL

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Anna A. Bar Department of Dermatology, Oregon Health & Science University, Portland, OR

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Ramona Behshad Department of Dermatology, SLUCare, SSM Health, St. Louis, MS

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Christopher K. Bichakjian Department of Dermatology, University of Michigan, Ann Arbor, MI

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Diana Bolotin Section of Dermatology, Department of Medicine, University of Chicago, Chicago, IL

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Susan L. Boone Department of Dermatology, University of California, Davis School of Medicine, Sacramento, CA

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Jeremy S. Bordeaux Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH
Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, OH

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Jerry D. Brewer Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic, Rochester, MN

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David R. Carr Department of Dermatology, The Ohio State University Medical Center, Columbus, OH

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John A. Carucci The Ronald O. Perelman Department of Dermatology, NYU Langone, New York, NY

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Jason R. Castillo Division of Dermatology, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA

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Sean R. Christensen Department of Dermatology, Yale School of Medicine, New Haven, CT

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Melanie A. Clark Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI

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Lindsey K. Collins Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK

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Addison M. Demer Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic, Rochester, MN

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Daniel B. Eisen Department of Dermatology, University of California, Davis School of Medicine, Sacramento, CA

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Hao Feng Department of Dermatology, University of Connecticut, Farmington, CT

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Bahar F. Firoz Department of Dermatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

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Roy C. Grekin Department of Dermatology, University of California, San Francisco, San Francisco, CA

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Jason M. Hirshburg Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK

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Todd E. Holmes Division of Dermatology, University of Vermont Medical Center, Burlington, VT

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Conway C. Huang Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL

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Thomas A. Jennings Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AK

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Shang I. Brian Jiang Department of Dermatology, University of California, San Diego, CA

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Sailesh Konda Department of Dermatology, University of Florida College of Medicine, Gainesville, FL

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Justin J. Leitenberger Department of Dermatology, Oregon Health & Science University, Portland, OR

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Jesse M. Lewin The Kimberly and Eric J. Waldman Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, NY

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Ian A. Maher Department of Dermatology, University of Minnesota, Minneapolis, MN

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Elise Ng Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD

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Ida F. Orengo Department of Dermatology, Baylor College of Medicine, Houston, TX

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Faramarz H. Samie Department of Dermatology, Columbia University Irving Medical Center, New York, NY

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Drew K. Saylor Department of Dermatology, University of California, San Francisco, San Francisco, CA

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Victoria Rose Sharon Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY

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Teo Soleymani Division of Dermatologic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA

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Susan M. Swetter Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA

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Jesalyn A. Tate Division of Dermatology, Kansas University Medical Center, Kansas City, KS

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Marta J. Van Beek Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, IO

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Nahid Y. Vidal Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic, Rochester, MN

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Alok Vij Department of Dermatology, Cleveland Clinic, Cleveland, OH

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Ashley Wysong Department of Dermatology, University of Nebraska, Omaha, NE

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Yaohui Gloria Xu Department of Dermatology, University of Wisconsin, Madison, WI

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Bryan T. Carroll Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH
Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, OH

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Wesley Y. Yu Department of Dermatology, Oregon Health & Science University, Portland, OR
Operative Care Division, VA Portland Health Care System, Portland, OR

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Background: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. Methods: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. Results: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood’s lamp, dermatoscope, and negative tissue controls was established in Round 2. Conclusions: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Submitted September 18, 2023; final revision received March 16, 2024; accepted for publication April 22, 2024. Published online July 30, 2024.

K.K. Curtis and N.J. Fakult contributed equally.

B.T. Carroll and W.Y. Yu shared responsibility for supervision of this work.

Author contributions: Conceptualization: Carroll, Yu. Methodology: Curtis, Fakult, Carroll, Yu. Data collection: All authors. Analysis: Curtis, Fakult, Carroll, Yu. Supervision: Carroll, Yu. Writing—original draft: Curtis, Fakult. Writing—review & editing: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: W.Y. Yu is supported by a VA Career Development Award (1IK2CX002642-01A1), a US Department of Defense CDMRP Award (W81XWH-21-1-0818), and a Kuni Foundation Cancer Discovery Grant.

Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2024.7036. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: Wesley Y. Yu, MD, Oregon Health & Science University, Department of Dermatology, Center for Health & Healing, Building 1, 3303 South Bond Avenue, 16th Floor, Portland, OR 97239. Email: yuwe@ohsu.edu

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  • 1.

    Friedman EB, Scolyer RA, Williams GJ, et al. Melanoma in situ: a critical review and re-evaluation of current excision margin recommendations. Adv Ther 2021;38:35063530.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Sharma AN, Foulad DP, Doan L, et al. Mohs surgery for the treatment of lentigo maligna and lentigo maligna melanoma – a systematic review. J Dermatolog Treat 2021;32:157163.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Etzkorn JR, Sobanko JF, Elenitsas R, et al. Low recurrence rates for in situ and invasive melanomas using Mohs micrographic surgery with melanoma antigen recognized by T cells 1 (MART-1) immunostaining: tissue processing methodology to optimize pathologic staging and margin assessment. J Am Acad Dermatol 2015;72:840850.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Swetter SM, Johnson D, Albertini MR, et al. NCCN Clinical Practice Guidelines in Oncology: Melanoma: Cutaneous. Version 1.2024. Accessed March 15, 2024. To view the most recent version, visit https://www.nccn.org

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Krausz AE, Higgins HW II, Etzkorn J, et al. Systematic review of technical variations for Mohs micrographic surgery for melanoma. Dermatol Surg 2021;47:15391544.

  • 6.

    Jünger S, Payne SA, Brine J, et al. Guidance on conducting and reporting Delphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review. Palliat Med 2017;31:684706.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Rowe G, Wright G. The Delphi technique as a forecasting tool: issues and analysis. Int J Forecast 1999;15:353375.

  • 8.

    Oxford University. Oxford Centre for Evidence-Based Medicine: levels of evidence (March 2009). Accessed February 4, 2024. Available at: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377381.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019;95:103208.

  • 11.

    Robinson JK. Use of digital epiluminescence microscopy to help define the edge of lentigo maligna. Arch Dermatol 2004;140:10951100.

  • 12.

    Walsh SB, Varma R, Raimer D, et al. Utility of Wood’s light in margin determination of melanoma in situ after excisional biopsy. Dermatol Surg 2015;41:572578.

  • 13.

    Suzuki HS, Serafini SZ, Sato MS. Utility of dermoscopy for demarcation of surgical margins in Mohs micrographic surgery. An Bras Dermatol 2014;89:3843.

  • 14.

    Beaulieu D, Fathi R, Srivastava D, et al. Current perspectives on Mohs micrographic surgery for melanoma. Clin Cosmet Investig Dermatol 2018;11:309320.

  • 15.

    Chang KH, Finn DT, Lee D, et al. Novel 16-minute technique for evaluating melanoma resection margins during Mohs surgery. J Am Acad Dermatol 2011;64:107112.

  • 16.

    Albertini JG, Elston DM, Libow LF, et al. Mohs micrographic surgery for melanoma: a case series, a comparative study of immunostains, an informative case report, and a unique mapping technique. Dermatol Surg 2002;28:656665.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Iorizzo LJ III, Chocron I, Lumbang W, et al. Importance of vertical pathology of debulking specimens during Mohs micrographic surgery for lentigo maligna and melanoma in situ. Dermatol Surg 2013;39:365371.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Siscos SM, Neill BC, Seger EW, et al. The current state of Mohs surgery for the treatment of melanoma: a nationwide cross-sectional survey of Mohs surgeons. Dermatol Surg 2020;46:12671271.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Cherpelis BS, Moore R, Ladd S, et al. Comparison of MART-1 frozen sections to permanent sections using a rapid 19-minute protocol. Dermatol Surg 2009;35:207213.

  • 20.

    Morton DL. Sentinel lymphadenectomy for patients with clinical stage I melanoma. J Surg Oncol 1997;66:267269.

  • 21.

    Foxton GC, Elliott TG, Litterick KA. Treating melanoma in situ and lentigo maligna with Mohs micrographic surgery in Australia. Australas J Dermatol 2019;60:3337.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol 2012;66:438444.

  • 23.

    Bhatt MD, Perz AM, Moioli E, et al. The accuracy of detecting melanoma on frozen section melanoma antigen recognized by T cells 1 (MART-1) stains and on permanent sections of previously frozen tissue: a prospective cohort study. J Am Acad Dermatol 2021;84:17641766.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Young JN, Nguyen TA, Freeman SC, et al. Permanent section margin concordance after Mohs micrographic surgery with immunohistochemistry for invasive melanoma and melanoma in situ: a retrospective dual-center analysis. J Am Acad Dermatol 2023;88:10601065.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Lee MP, Sobanko JF, Shin TM, et al. Evolution of excisional surgery practices for melanoma in the United States. JAMA Dermatol 2019;155:12441251.

  • 26.

    Abrantes T, Robbins A, Kahn B, et al. Understanding melanoma in situ: lentigo maligna surgical treatment terminology and guideline adherence, a targeted review. J Am Acad Dermatol 2023;89:734744.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Miller CJ, Shin TM, Sobanko JF, et al. Risk factors for positive or equivocal margins after wide local excision of 1345 cutaneous melanomas. J Am Acad Dermatol 2017;77:333340.e1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Longo C, Navarrete-Dechent C, Tschandl P, et al. Delphi consensus among international experts on the diagnosis, management, and surveillance for lentigo maligna. Dermatol Pract Concept 2023;13:e2023244.

    • PubMed
    • Search Google Scholar
    • Export Citation

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