Treatment of lentigo maligna and lentigo maligna melanoma.

The results of treatment of 42 cases of lentigo maligna and 16 of lentigo maligna melanoma at the New York University Medical Center was reviewed. The recurrence rate after surgical excision of 22 lesions of lentigo maligna was 9% (2/22), but after treatment of 20 such lesions with destructive techniques (X rays, curettage-electrodesiccation, cryosurgery), it was 35% (7/20). Of 11 cases of lentigo maligna melanoma that were excised, none recurred locally, but fatal metastases ensued in one case. Five patients who were eventually classified as having lentigo maligna melanomas had been treated by destructive techniques. In four of them there were local recurrences and in two, metastases as well; the fifth patient had metastases without local recurrence. On the basis of this review of these 58 cases, we conclude that surgical excision and careful histologic study of step sections through the entire lesion insure accurate diagnosis and provide the highest cure rates for lentigo maligna and lentigo maligna melanoma.     

Metastatic lentigo maligna melanoma

An elderly woman presented with an advanced and ultimately lethal lentigo maligna melanoma after ignoring a precursor lesion present for several decades. Lentigo maligna melanoma can be lethal in the elderly. Early detection and treatment are warranted.     

Management of lentigo maligna and lentigo maligna melanoma: seminars in surgical oncology

Lentigo maligna (LM) and lentigo maligna melanoma (LMM) represent a character, histogenetic subclass of melanocytic malignancies. They often present with a prolonged phase of slow growth but once invasion has occurred, the prognostic features are identical to all other melanomas. These lesions occur primarily on the head and neck where they evolve from areas of pigmented staining to the more typical features identifiable with malignant melanomas on other skin surfaces. The treatment options and recent advances in management are reviewed.     

Conventional fractionated radiotherapy for 51 patients with lentigo maligna and lentigo maligna melanoma

Lentigo maligna (LM) and lentigo maligna melanoma (LMM) are distinct entities from other forms of melanoma, occurring predominantly on the skin of the head and neck in elderly people, having a slow growth rate and a low metastatic potential (10%). Twenty-three patients with LM were treated with conventional fractionated irradiation, 18 were locally controlled and two failed locally both of whom, however, were salvaged with further treatment. Three patients are not evaluable because of short follow-up time. Median time to complete regression of the lesion is seven months. Twenty-eight patients with LMM have been irradiated, 23 are locally controlled, two locally recurred (both retrieved with subsequent treatment), and three are inevaluable because of short follow-up time. One patient with a level 5 LMM has developed regional and distant metastases. It is concluded that irradiation is a simple effective method of treatment for this form of melanoma.     

Struma ovarii associated with Meigs syndrome

A 67-year-old female was referred to our hospital for furtherevaluation and treatment of progressively increasing abdominaldistention and     

Mohs micrographic surgery in the treatment of lentigo maligna and melanoma

BACKGROUND AND OBJECTIVES: The treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM) is challenging due to lesion location, size, patient age, and potential for recurrence and spread. The largest studies to date confirm that for melanocytic tumours, MMS provides high local control rates while minimizing tissue loss. Herein we report our local control rate for melanoma treated by MMS over a decade. METHODS: Charts were reviewed on all patients with melanocytic tumors treated by a single physician (JPA) using MMS over the time period of 1993-2002. Demographic, surgical and pathological details were recorded. Patients were followed for local, regional and distant recurrences. RESULTS: The patient population was comprised of 199 patients with 202 melanomas. There were 69 invasive lesions, with a mean Breslow depth of 0.92 mm (0.2-3.6 mm). The mean number of levels required to clear the lesions was 2.7 (1-7), resulting in a mean defect size of 11.8 cm2 (0.9-70.7 cm2). Patients with LMM were significantly older (73.2 vs. 66.5 yrs, p = 0.012) and had larger defects after MMS (16.74 cm2 vs. 10.27 cm2) than patients with LM. At a mean follow-up of 29.8 months, there were no local recurrences, four regional recurrences, and two distant recurrences. CONCLUSION: MMS is an effective modality for the clearance of melanocytic tumors.     

The perimeter technique for lentigo maligna: an alternative to Mohs micrographic surgery

BACKGROUND: Lentigo maligna (LM) presents a challenge for complete surgical excision because of its extensive subclinical spread and predilection for the face. OBJECTIVE: To report our experience using the staged perimeter technique as an alternative to Mohs micrographic surgery for treatment of LM. METHODS: The perimeter procedure was performed on 11 patients with LM between March 2003 and June 2004. Data on patient and lesion characteristics, number of stages required to obtain clear margins, and follow-up was obtained by chart review. RESULTS: A mean of 1.9 stages were required to achieve clear margins. A mean of 7 tissue specimens were sent to pathology per patient for evaluation. After a mean follow-up of 4.7 months, all patients were free of recurrence. CONCLUSIONS: The perimeter technique is a simple method of margin-controlled excision of LM. The main advantage is that all margins are examined with permanent sections. The main drawback is that multiple operative sessions are required to complete the procedure. This technique does not require specific Mohs training and is therefore applicable to non-Mohs surgeons.     

Clinical outcomes following surgical treatment of lentigo maligna of the head and neck

Introduction: Lentigo maligna (LM), a subtype of melanoma in-situ commonly occurring in the head and neck region, often presents a treatment challenge due to anatomical constraints, particularly on the face of mostly elderly patients. This study sought to assess the clinical outcomes of wide local excision of head and neck LM, identify predictors of recurrence and define optimal excision margins.Materials and Methods: Patients with LM treated between January 1997 and December 2012 were identified from the large institutional database of a tertiary center and their data were analyzed.Results: In 379 patients, 382 lesions were eligible for analysis. Median maximal lesion diameter was 10.5 mm. The mean surgical excision and histopathological clearance margins were 6.2 mm and 4.0 mm, respectively. Median follow-up was 32 months. The LM recurrence rate was 9.9%, and subsequent invasive melanoma developed in 2.3% of cases (mean Breslow thickness 0.7 mm). The recurrence rate was 27.2% if the histological margin was <3.0 mm (median time to recurrence 46.5 months) compared with 2.6% if the margin was ≥3.0 mm. The mean surgical margin required to achieve a histological clearance of ≥3.0 mm was 6.5 mm.Conclusions: Our data suggest that to minimize recurrence, a histological margin of ≥3.0 mm is required. To achieve this, a surgical margin of ≥6.5 mm was required. This is greater than the 5 mm margin recommended in some national guidelines. Careful long-term follow-up is required for all patients because of the risk of recurrence.     

Paliación de la disfagia maligna con endoprótesis metálica autoexpandible

Aims. Evaluate the results of esophageal cancer palliation with expandable metal stents. Patients and methods. A set of patients with esophageal cancer and/or malignat dysphagia were included; the charts were reviewed to obtain clinical data; an upper endoscopy and esophagogram were perfomed to evaluate the stenosis. Expandable metal stents were inserted, with previous dilation when necessary and under fluroscopic and anesthesic support. Results. Twelve patients with esophageal cancer and one patient with lung cancer were included; dysphagia was present in all cases, and all of them were out of any curative treatment. Five adenocarcinomas and 7 squamous carcinomas, two of them with respiratory-digestive fistulas. Mean age 74.1 years, luminal obstruction 73% length of lesion 6.3. Previous dilations: 2.5 per patient. Thirteen expandable metal stents were inserted: dysphagia diminishes in all patients. There was a case of prosthesis migration and four cases with grown tumoral. Morbidity was of 15% and 0% of mortality. Seven patients with previous chemotherapy and/or radiotherapy didn’t increased morbidity. Conclusions. Expandable metal prosthesis have a good palliative effect on malignant dysphagia, sealing respiratory-digestive fistulas successfully; and they are safe for patients with previous radiotherapy and/or chemotherapy.     

Comparison between lentigo maligna melanoma and other histogenetic types of malignant melanoma of the head and neck. Scottish Melanoma Group.

A study of 953 invasive cutaneous malignant melanomas of the head and neck was performed to determine differences between lentigo maligna melanoma and other histogenetic types with regard to patients and sites affected; prognosis was analysed in 595 of these cases. The cases studied comprised all head and neck melanomas registered with the Scottish Melanoma Group between 1979 and 1992, apart from the 3% of cases that were unclassifiable or rare histogenetic types. The histogenetic types of melanoma were 498 (52%) lentigo maligna melanoma (LMM), 237 (25%) superficial spreading melanoma (SSM) and 218 (23%) nodular melanoma (NM). All types increased in incidence throughout the study period. Patients with LMM (mean age 73 years) and NM (mean 68 years) were significantly older than those with SSM (mean 57 years). There were significant anatomical subsite differences related to sex of patients and histogenetic type of melanoma; melanomas on the face were more frequent in females and 90% of LMM occurred at this site, whereas melanomas on the scalp, neck and ears were more frequent in men. Kaplan-Meier estimates of the probability of survival were produced for the 595 of these 953 patients with 5 year follow-up details. In this group of patients the prognostic significance of tumour thickness, Clark level of invasion, ulceration, histogenetic type of melanoma and number of mitoses were studied using stepwise variable selection of procedures. Each of these possible prognostic factors attained individual significance but the tumour thickness was the dominant risk factor in the proportional hazards analysis. When patients were divided into four sex/ulceration subgroups (male/ulcerated, female/ulcerated, male/non-ulcerated, female/non-ulcerated) and analysed by proportional hazards analysis, no variable other than the tumour thickness had any further prognostic effect. Histogenetic type did not remain an independent prognostic variable at this stage. Despite sex and subsite differences, the prognosis for invasive lentigo maligna melanoma does not differ from that for other histogenetic types after controlling for tumour thickness.     

Utility of teledermatopathology for intraoperative margin assessment of melanoma in situ,lentigo maligna type: A 6 year community practice experience

BackgroundAchieving negative margins for melanoma in situ, lentigo maligna type can be challenging, particularly on cosmetically sensitive areas.ObjectiveTo assess the utility of intraoperative frozen section margin assessment using a teledermatopathology system in the treatment of head and neck lentigo maligna.Methods and materialsOver a 6 year period, 96 patients with lentigo maligna had surgical excisions. The margins were assessed intraoperatively with frozen sections prepared in the manner used in Mohs surgery. The surgeon guided the frozen section slides around the margin while a dermatopathologist assessed the margin remotely.ResultsIn 2/96 (2.1%) cases, the safety margin was positive (frozen sections were false negative). In 1 further case (1%) there was a recurrence of the melanoma 13 months following the excision.ConclusionThe described method is effective in treating melanoma in situ, lentigo maligna type with clearance rates similar to previous studies for Mohs surgery.     

Papillary Thyroid Cancer in Struma Testis with Malignant Transformation in the Lung Associated with Trisomy 17 Successfully Treated with Total Thyroidectomy and Radioiodine Ablation

Background

Struma testis is a rare entity, and there are only few reports on the malignant transformation of a testicular teratoma to papillary thyroid carcinoma in the literature. In this report, we describe the malignant transformation of struma testis with distant lung metastasis associated with trisomy 17 and a coexisting papillary microcarcinoma in the thyroid.

Case Report

A 56-year-old man presented after a left orchiectomy for an undescended left testicle. Pathologic examination identified a monodermal teratoma composed of thyroid parenchyma and associated with a 1.7-cm papillary thyroid carcinoma. Further evaluation showed a pulmonary mass on a chest CT scan. Total thyroidectomy revealed a 0.5-mm focus of papillary thyroid cancer, and removal of the lung mass confirmed metastatic papillary thyroid cancer. Array-comparative genomic hybridization of both tumors showed trisomy 17 in the struma testes and the lung metastasis. The patient responded well to radioactive iodine ablation and has no evidence of cancer 3 years later.

Conclusion

To our knowledge, this is the first case of papillary thyroid cancer in struma testes metastatic to the lung. It highlights the difficulties in treating these patients. Surgery to remove cancer foci, followed by radioactive iodine ablation, resulted in an excellent response in our patient. Interestingly, trisomy 17, which has so far been observed only in noninvasive thyroid nodules, was associated with pulmonary metastasis in our patient.Key words: Trisomy 17, Struma testis, Papillary thyroid cancer, Comparative genomic hybridization     

A cohort analysis of surgically treated primary head and neck lentigo maligna (melanoma): Prognostic value of melanoma subtype and new insights in the clinical value of guideline adherence

BackgroundKnowledge about lentigo maligna (melanoma) (LM/LMM) and its associated prognostic clinicopathological characteristics are limited compared to that of non-LM/LMM subtypes. The current study aimed to determine the clinical relevance of the LM/LMM subtype and its influence on recurrence and survival outcomes.MethodsAll consecutive cases of primary cutaneous head and neck LM/LMM treated by wide local excision over a ten-year period were retrospectively reviewed and compared to non-LM/LMM. Clinical outcome and prognostic factors were assessed by cumulative incidence and competing risk analyses.ResultsA total of 345 patients were identified. Specific clinicopathological characteristics such as lower median Breslow thickness (1.6 mm versus 2.1 mm; P = 0.013), association with diagnostic sampling errors (17.3% versus 5.2%; P = 0.01), and increased risk of local recurrences due to incomplete resection (18.7% versus 2.3%; P < 0.001), were significantly associated with LM/LMM. Guideline adherence was similar between the two study groups. The positive nodal status at baseline for LMM was low compared to non-LM/LMM (4.2% vs 17.9%; P = 0.037). The LMM subtype, facial localization, and reduced surgical margins (i.e., guideline non-adherence) were not shown to be independent prognostic factors for disease-free, melanoma-specific, or overall survival after correction for competing risks such as patient age and Breslow thickness.ConclusionsThe LMM subtype was not shown to be prognostically different from non-LM/LMM when corrected for other variables of influence such as patient age and Breslow thickness. Reduced resection margins did not seem to affect disease-free, and melanoma-specific survival and warrant LM/LMM-specific guidelines. Further research is needed to evaluate the value of SLNB in LMM patients.