Reactive lentiginous hyperpigmentation after cryosurgery for lentigo maligna.

BACKGROUND: Twenty patients treated for lentigo maligna of the face with cryosurgery developed benign lentiginous hyperpigmentation mimicking a recurrence. OBJECTIVE: When cryosurgery is used in the treatment of lentigo maligna, it is important to know whether repigmentation of the scar represents true recurrence or a benign process. METHODS: Twenty patients were treated with cryosurgery for lentigo maligna of the face. Within a follow-up period of 7 to 80 months, frequent clinical observations were made. RESULTS: Lentiginous hyperpigmentation developed within the treatment area in eight patients. Histologic investigation revealed recurrence of lentigo maligna in three and benign hyperpigmentation in five. CONCLUSION: Genetic factors and UV exposure after cryosurgery may favor the development of benign lentiginous hyperpigmentation. Because recurrence of lentigo maligna must be considered, histologic evaluation of repigmentation is mandatory.     

Wachsende Pigmentl?sion der linken Wange

A 75-year-old man presented after recurrence of a pigmented macule on his left cheek. Approximately 8 month before a seborrheic keratosis had been diagnosed clinically and treated with cryosurgery and curettage. Dermatoscopy of the recurrent lesion revealed a number of criteria associated with lentigo maligna including asymmetric pigmented follicular openings, streaks, rhomboidal structures, and homogeneous slate-gray areas. Histopathology confirmed a lentigo maligna melanoma with a Breslow tumor thickness of 0.3 mm.     

Recurrent lentigo maligna as amelanotic lentigo maligna melanoma

Amelanotic lentigo maligna and lentigo maligna melanoma are extremely rare tumours. Even rarer is a recurrent amelanotic lentigo maligna or amelanotic lentigo maligna melanoma at the site of a previously removed pigmented lentigo maligna. We describe two cases of recurrent amelanotic lentigo maligna melanoma manifesting as erythematous plaques evolved from previously excised pigmented lentigo maligna.     

Immunocryosurgery as monotherapy for lentigo maligna or combined with surgical excision for lentigo maligna melanoma

The incidence of lentigo maligna (LM), in situ (LM) or invasive (lentigo maligna melanoma, LMM), has increased during the last decades. Due to functional or cosmetic outcomes, optimal treatment with surgical excision may not be appropriate in some cases. We tried less invasive therapy, immunocryosurgery, as a single treatment for LM or combined with surgery for LMM, with better aesthetic results. Three patients with LM or LMM not amenable to complete surgical excision were selected. LMM patients underwent limited surgical resection of the invasive area. Subsequently, a combined treatment with topical imiquimod and cryosurgery was performed. The LM patient received immunocryosurgery directly. All of them were free of local and systemic disease at 48, 42 and 41 months after discontinuation of therapy. We consider that immunocryosurgery is an alternative option for LM or even for LMM (after removal of the invasive tissue with narrow margins) in poor surgical candidates, with good therapeutic, functional and cosmetic results.     

Following lentigo maligna may not prevent the development of life-threatening melanoma.

BACKGROUND--Management of lentigo maligna (Hutchinson's melanotic freckle, in situ lentigo maligna melanoma) by regular observation relies on the detection of invasive melanoma before it has developed significant life-threatening potential. Recent studies indicate that lentigo maligna melanoma does not have a better prognosis than other forms of melanoma. OBSERVATIONS--A case is reported of an amelanotic lentigo maligna that evolved from a macular lesion to a deeply invasive, amelanotic, lentigo maligna melanoma within 6 months. The melanoma was Clark level IV and measured 3.0 mm in maximum tumor thickness. CONCLUSIONS--Observation of lentigo maligna at 6-month intervals would not seem to be sufficiently reliable in detecting the development of invasive lentigo maligna melanoma before it becomes a life-threatening disease. Early surgical excision is the treatment of choice.     

Treatment of lentigo maligna

Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM) and, if left untreated, 30-50% of cases will progress to LMM, which is now thought to behave as aggressively as any other melanoma. Literature on the of treatment of LM including conventional surgery, micrographic Mohs surgery, cryosurgery, radiotherapy, electrodesiccation and curettage, 5-fluorouracil (5-FU), azelaic acid, retinoic acid and lasers are reviewed. It is concluded that micro-graphic Mohs surgery has the lowest recurrence rates and that conventional surgery, cryosurgery and radiotherapy all have recurrence rates in the order of 7-10%. Therefore, on the basis of the current literature available, all three of these methods could be recommended as primary treatment of LM. It is extremely important when choosing one of the above treatments that the physician is adequately trained in the appropriate technique and understands the limitation of the method used and the need for close follow up of the patient     

A clinically invisible melanoma

We report a case of an amelanotic lentigo maligna incidentally found on a shave biopsy in an 87‐year‐old woman. Amelanotic lentigo maligna is a rare variant of lentigo maligna. It is often reported as presenting as erythematous scaly macules and is usually confused as benign dermatoses. Here were present a case of amelanotic lentigo maligna with no visible or palpable features.     

Series of Fourteen Cases of Topical Imiquimod 5% in Lentigo Maligna: Treatment Modalities and Clues for Detecting Recurrences

Topical imiquimod has been used off-label as monotherapy or adjuvant treatment for lentigo maligna. Our aim is to describe treatment modalities, clinical outcomes, and management of recurrence in patients receiving imiquimod for lentigo maligna.Patients from our unit with lentigo maligna or lentigo maligna melanoma treated with imiquimod 5% as monotherapy or in combination with surgery were included in this study.Fourteen cases were recruited (85.7% lentigo maligna and 14.3% lentigo maligna melanoma). Eight patients (57.1%) received imiquimod without surgery, and six (42.9%) underwent narrow excision before beginning treatment. During the follow-up period, pigmentation reappeared in 6 patients (4 postinflammatory hyperpigmentation and 2 relapses). Relapses were managed with very narrow excision (1 mm margin) and retreatment with imiquimod 5%.All imiquimod modalities showed well-tolerated side effects and low recurrence rates, with long periods of follow-up. Imiquimod appears to be a versatile option for treating LM in suitable candidates.     

[Artículo traducido] Serie de 14 casos de tratamiento con imiquimod tópico al 5% en lentigo maligno: modalidades terapéuticas y claves para detectar recidivas

Topical imiquimod has been used off-label as monotherapy or adjuvant treatment for lentigo maligna. Our aim is to describe treatment modalities, clinical outcomes, and management of recurrence in patients receiving imiquimod for lentigo maligna.Patients from our unit with lentigo maligna or lentigo maligna melanoma treated with imiquimod 5% as monotherapy or in combination with surgery were included in this study.Fourteen cases were recruited (85.7% lentigo maligna and 14.3% lentigo maligna melanoma). Eight patients (57.1%) received imiquimod without surgery, and six (42.9%) underwent narrow excision before beginning treatment. During the follow-up period, pigmentation reappeared in 6 patients (4 postinflammatory hyperpigmentation and 2 relapses). Relapses were managed with very narrow excision (1 mm margin) and retreatment with imiquimod 5%.All imiquimod modalities showed well-tolerated side effects and low recurrence rates, with long periods of follow-up. Imiquimod appears to be a versatile option for treating LM in suitable candidates.     

Amelanotic lentigo maligna managed with topical imiquimod as immunotherapy

Clinically amelanotic lentigo maligna often resembles an inflammatory lesion rather than a melanoma in situ. We present two cases of extensive amelanotic lentigo maligna presenting as gradually enlarging erythematous patches on the faces of women following incomplete excisions of lentigo maligna. Because of their site and size, therapeutic options were limited; the lesions have, however, resolved (clinically and histologically) following the topical application of 5% imiquimod cream. We discuss the rationale for the use of imiquimod in the treatment of lentigo maligna.     

Unstable solar lentigo: A defined separate entity

An unstable solar lentigo is a solar lentigo with areas of melanocytic hyperplasia not extending past the margin of the lesion. They are discrete, macular, pigmented lesions arising on sun‐damaged skin and a subset of typical solar lentigos. Clinically they differ from usual solar lentigines in often being solitary or larger and darker than adjacent solar lentigines. These lesions are of clinical importance as they can arise in close proximity to lentigo maligna and in a single lesion there can be demonstrated changes of solar lentigo, unstable solar lentigo and lentigo maligna. These observations led us to conjecture that unstable solar lentigos could be a precursor lesion to lentigo maligna. In this article we examine the possibility that lentigo maligna can arise within a solar lentigo through an intermediate lesion, the unstable solar lentigo. We propose that the histopathological recognition of this entity will allow for future research into its behaviour and thus management. We review difficulties in the diagnosis of single cell predominant melanocytic proliferations and the concept of unstable lentigo in view of the literature and clinical experience supporting the proposal of its recognition as a separate entity.     

Key points in dermoscopic differentiation between lentigo maligna and solar lentigo

A clinical diagnosis of lentigo maligna at an early stage is often difficult even for experienced dermatologists. Differential diagnoses would include solar lentigo, early lesions of seborrheic keratosis, lichen planus-like keratosis, pigmented actinic keratosis and melanocytic nevus. Dermoscopy has been shown to have higher diagnostic accuracy, especially in the diagnosis of pigmented skin lesions, in the past two decades. To aim of the present study was to review the diagnostic key points on dermoscopy in the published work to differentiate lentigo maligna from other differential diagnoses and reassess these important features on dermoscopy for specificity by describing the findings in detail. Diagnostic key points for lentigo maligna/lentigo maligna melanoma on dermoscopy are asymmetrical pigmented follicular openings, rhomboidal structures, annular-granular structures and gray pseudo-network. Lentigo maligna, at first, seems to occur as asymmetrical pigmented follicular openings and/or annular-granular structures, then expand and develop into the rhomboidal structures. Annular-granular structures and gray pseudo-network seem to be observed also in regressive areas of solar lentigo/initial seborrheic keratosis, lichen planus-like keratosis and pigmented actinic keratosis. The four important criteria on dermoscopy for the diagnosis of lentigo maligna have been reviewed, and the former two criteria seem to be more specific, but it might be difficult to recognize these findings without misinterpretation. The latter two seem to be not so specific as they would also be demonstrated in other pigmented epidermal lesions, although the distribution of the structures in these disorders would be inclined to be more homogeneous than that of lentigo maligna.     

Cryosurgical treatment of lentigo maligna

Background: Lentigo maligna (LM) is a common melanocytic malignancy which requires therapy because of the risk of progression to invasive lentigo maligna melanoma which a much worse prognosis. Patients and Methods: 18 patients with clinical and histopathological diagnosis of LM were treated with cryosurgery.The patients were older Caucasians (mean age 59.5 years) and 11 were male. They were chosen for cryosurgery because the lesion posed a surgical challenge or the patient was not a good surgical candidate. They were treated with two freeze-thaw cycles of liquid nitrogen under local anesthesia in a single sitting. Lesions larger than 2 cm² were divided into smaller segments for freezing. Results: The lesions resolved clinically in all cases, with no recurrence or metas-tasis detected during a mean follow-up of 75.5 months. Some patients developed hypopigmented scars. Conclusions: Cryosurgery with liquid nitrogen is an efficient, safe and in most cases aesthetically acceptable alternative method to treat LM.     

Lentigo Maligna: Review of Salient Characteristics and Management

Lentigo maligna is a melanocytic neoplasm, often regarded as ‘melanoma in situ,’ which may progress to lentigo maligna melanoma. Lentigo maligna clinically presents as a pigmented, asymmetric macule that originates on the head and neck and spreads slowly. The preferred method for diagnosing lentigo maligna is excisional biopsy. Histology shows proliferation of atypical melanocytes at the epidermal–dermal junction in small nests or single cells. The differential diagnosis includes solar lentigo, seborrheic keratosis, lichen planus-like keratosis, pigmented actinic keratosis, and melanocytic nevus. Stains used in diagnosis include hematoxylin and eosin, HMB-45, MART-1/Melan-A, Mel-5, and S-100. Surgical excision is the preferred treatment for lentigo maligna. Second-line techniques include medical (topical imiquimod) and destructive therapy.     

Lentigo maligno

Lentigo maligna is a type of in situ melanoma. It develops mainly in middle-aged and elderly individuals on areas of the skin chronically exposed to sunlight. It progresses to its invasive form, lentigo maligna melanoma, in 5% to 50% of cases. Management of lentigo maligna is open to debate, with a notable lack of randomized trials and specific guidelines and protocols. Early diagnosis and treatment is necessary to achieve cure if possible and prevent progression to invasive melanoma with the corresponding risk of metastasis. The treatment of choice for lentigo maligna is surgery. When surgery is not possible, other alternatives are available although outcomes and rates of recurrence are variable. The objective of this study was to review the diagnostic methods and criteria for lentigo maligna, as well as the different surgical options and alternatives to surgery, in order to provide information on the best approach in each case.     

Utilidad clínica de la microscopia confocal de reflectancia en el manejo del lentigo maligno melanoma

Facial lentigo maligna melanoma can be a diagnostic challenge in daily clinical practice as it has similar clinical and morphological features to other lesions such as solar lentigines and pigmented actinic keratoses. Confocal microscopy is a noninvasive technique that provides real-time images of the epidermis and superficial dermis with cellular-level resolution. We describe 3 cases of suspected facial lentigo maligna that were assessed using dermoscopy and confocal microscopy before histopathology study. In the first case, diagnosed as lentigo maligna melanoma, presurgical mapping by confocal microscopy was performed to define the margins more accurately. In the second and third cases, with a clinical and dermoscopic suspicion of lentigo maligna melanoma, confocal microscopy was used to identify the optimal site for biopsy.     

Apparent progression of lentigo maligna to invasive melanoma during treatment with topical azelaic acid

Nine patients with lentigo maligna were treated with topical azelaic acid. Clinical improvement was observed in four, with complete clearing in one. Two patients developed invasive lentigo maligna melanoma while on treatment. Caution should be exercised in the use of topical azelaic acid in the treatment of lentigo maligna.     

In vivo examination of lentigo maligna and malignant melanoma in situ, lentigo maligna type by near-infrared reflectance confocal microscopy: comparison of in vivo confocal images with histologic sections.

In vivo confocal microscopy can noninvasively image thin en face sections within living intact human tissue with high resolution and contrast. This evolving technique may provide clinicians with tools to help detect lentigo maligna lesion progression in vivo and may be important in defining tumor margins, thus providing a more definitive surgical eradication of lentigo maligna and malignant melanoma in situ, lentigo maligna type. We present a case of malignant melanoma in situ, lentigo maligna type, and we describe the images seen with confocal microscopy in correlation with routine histopathology.     

Rapid progression of lentigo maligna to deeply invasive lentigo maligna melanoma. Report of two cases

Two patients had lesions of lentigo maligna that evolved into deeply invasive (level 4-5) lentigo maligna melanoma during a relatively short period (two years and four years, respectively). In both patients, the clinical impression of lentigo maligna had been difficult to confirm by histopathologic analysis until the invasive tumor had developed. Both patients were actively followed up during this period of evolution, with our intention of detecting any early changes suggestive of invasive melanoma. Since deep invasion developed despite close clinical supervision, a more aggressive approach to the treatment of lentigo maligna may be warranted.     

Dubreuilh melanoma: and epidemiologic and prognostic study

BACKGROUND: Lentigo maligna melanoma is a specific histoclinical type of melanoma. We studied the epidemiologic features of lentigo maligna melanoma (Dubreuilh's melanoma) and compared prognosis with other types of melanoma. PATIENTS AND METHODS: A retrospective review of 516 cases of cutaneous melanomas, seen from 1985 to 1997, identified 29 cases of lentigo maligna melanoma. Epidemiologic, clinical and prognostic data were collected using a common scoring system for all patients. The chi-squared test, univariate log rank analysis, Cox multiple regression model for multivariate analysis, and actuarial survival curves were applied. RESULTS: The 29 cases of lentigo maligna melanoma (16 women, 13 men) accounted for 5.9 p. 100 of all melanomas. Mean age at diagnosis was 73 years compared with 54 years for others melanomas. Predominant localization was head and neck. There was no prior history of nevi compared with 50 p. 100. Mean delay to diagnosis was 4 years versus 1 year. All patients have had an occupation with to sun exposure. Mean tumoral thickness was 2 mm. Survival was the same as for extensive superficial melanomas and better than for nodular melanomas. Multivariate analysis showed that prognosis was not better in case of lentigo maligna melanoma. Tumoral thickness was the main prognosis factor. DISCUSSION: Our findings confirmed the specific nature of lentigo maligna melanoma and suggested that sun exposure plays an important role. Multivariate analysis did not show that prognosis was any better in case of lentigo maligna melanoma than in other types of melanoma. The thickness of the tumor must be taken into account as for other melanomas.