Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: a preliminary study

Background Facial lentigo maligna (LM) and lentigo maligna melanoma (LMM) may be difficult to diagnose clinically and dermoscopically. Reflectance confocal microscopy (RCM) enables the in vivo assessment of equivocal skin lesions at a cellular level. Objectives To assess cytomorphological and architectural RCM features of facial LM/LMM. Methods Four women and eight men aged 58–88 years presenting with facial skin lesions suspicious of LM/LMM were included. In total, 17 lesion areas were imaged by RCM before biopsy. The histopathological diagnosis of LM was made in 15 areas; the other two were diagnosed as early LMM. Results A focal increase of atypical melanocytes and nests surrounding adnexal openings, sheets of mainly dendritic melanocytes, cord‐like rete ridges at the dermoepidermal junction (DEJ) and an infiltration of adnexal structures by atypical melanocytes were found to be characteristic RCM features of facial LM/LMM. Areas with a focal increase of atypical melanocytes and nests surrounding adnexal openings were observed at the basal layer in three cases. The remaining cases displayed these changes at suprabasal layers above sheets of mainly dendritic melanocytes. Cord‐like rete ridges at the DEJ and an infiltration of adnexal structures by atypical melanocytes were observed in all cases. Previously described criteria for RCM diagnosis of melanoma, such as epidermal disarray, pleomorphism of melanocytes and pagetoid spreading of atypical melanocytes, were additionally observed. Conclusions We observed a reproducible set of RCM criteria in this case series of facial LM/LMM.     

Cryotherapy for lentigo maligna

Eleven patients, 10 with lentigo maligna (LM) and one with lentigo maligna melanoma (LMM), were treated with cryotherapy. The symptoms cleared in all patients except one with LM. There were recurrences in four patients and three cleared with further treatment.     

Imiquimod: a novel treatment for lentigo maligna

Lentigo maligna is the in situ phase of lentigo maligna melanoma, and if left untreated it may progress to invasive melanoma. It most commonly occurs on the exposed sites of the face and neck of middle-aged or elderly patients. Conventional surgery using a 5-10 mm margin is the recommended treatment; however, lesions can be quite large and surgical removal may involve extensive plastic repair. We report an elderly patient with a large lentigo maligna on the scalp who was reluctant to have surgery. We tried topical imiquimod 5% cream (Aldara), a local immunomodulator, which has recently become available for the treatment of external genital and perianal warts. Initially used over a test area and then over the whole of the lesion, for a total of 7 months, the imiquimod cream resulted in complete clinical and histological cure. The patient has been followed up for 9 months without evidence of recurrence.     

A pilot study of treatment of lentigo maligna with 5% imiquimod cream

BACKGROUND: Lentigo maligna (LM) is an in situ form of malignant melanoma, and surgical excision is often unsatisfactory. Imiquimod cream is an immune response modifier and induces a predominantly T-helper 1 type response. OBJECTIVES: Assessment of histological and clinical response of surgically resectable LM after treatment with 5% imiquimod cream. METHODS: Six patients with LM were treated with 5% imiquimod cream daily for 6 weeks. The whole site of the original lesion was then excised. Clinical and histological and appearances were measured using clinical response and histological grading scores. RESULTS: Complete or almost complete clearance of pigmentation with minimal residual histological evidence of LM was observed in four patients, one patient showed no clinical or histological improvement, and the remaining patient had almost no residual pigmentation clinically after treatment yet histopathological changes remained as severe as before treatment. CONCLUSIONS: Topical imiquimod cream merits further investigation as a new therapy for LM.     

Management of lentigo maligna and lentigo maligna melanoma with staged excision: a 5-year follow-up

OBJECTIVE: To assess the long-term cure rate for treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM) by means of a staged, margin-controlled, vertical-edged excision with rush permanent specimens and a radial sectioning technique. DESIGN: Retrospective follow-up study. SETTING: University-affiliated and private-practice dermatologic surgery clinics. PATIENTS: Fifty-nine patients treated for 55 LMs and 7 LMMs between January 1, 1990, and December 31, 2001. INTERVENTIONS: The technique included vertical excision with initial 2- to 3-mm margins examined by rush permanent sections (prepared and read within 24 hours). Further excision took place as guided by histologic findings. Data on patient and lesion characteristics were obtained via a medical chart review. Patients were then contacted and examined for local recurrence. Biopsies were performed on all patients with possible recurrence on clinical examination. MAIN OUTCOME MEASURES: Local recurrence of LM or LMM. RESULTS: After a mean follow-up of 57 months (median, 54 months; 293.8 person-years), 95% of patients were free of recurrence. Three patients had local recurrence and no patients had evidence of metastasis. Two of the 3 local recurrences were of previously excised LM, and 1 was of an LMM. Half (32) of all lesions required 2 or more stages. One required more than 4 stages. The average margin of excision was 0.55 cm. Three of the 58 lesions read as LM on biopsy were found to have invasive disease (LMM) at the time of definitive excision. CONCLUSIONS: The technique described herein for the treatment of LM and LMM provides a long-term disease-free survival of 95%. The cure rate is greater than that reported for standard excision and is similar to that for other margin-control techniques. To our knowledge, this is the largest reported study and has the longest follow-up for this excision method for LM and LMM.     

Surgical margins for lentigo maligna and lentigo maligna melanoma: the technique of mapped serial excision

OBJECTIVES: To assess the margins required for excision of lentigo maligna (LM) and lentigo maligna melanoma (LMM) by the technique of mapped serial excision (MSE), and to assess the efficacy of MSE. DESIGN: An interventional, prospective, noncontrolled case series. SETTING: Tertiary referral, dermatologic surgery unit. PATIENTS: Consecutive patients with head and neck LM or LMM who underwent MSE between March 1, 1993, and October 31, 2002. INTERVENTION: The MSE of LM or LMM. MAIN OUTCOME MEASURES: The number of 5-mm levels for excision of LM and LMM and recurrence. RESULTS: One hundred sixty-one LMs or LMMs in 155 patients were treated. Thirty percent (37 of 125) of LMs required more than 5-mm margins. For LMMs less than 1 mm in Breslow thickness, 12% (4/32) required more than 10-mm margins. For primary tumors, 20% of LMs (18 of 91) required more than 5-mm margins, while 10% of LMMs less than 1 mm in Breslow thickness (2 of 21) required more than a 10-mm margin. For recurrent tumors, 56% of LMs (19/34) required more than a 5-mm margin. Mean follow-up of 38 months (range, 5-100 months) showed 4 recurrences (2%) after MSE. The extrapolated recurrence at 5 years was 5.0%. CONCLUSIONS: The current recommendations of 5-mm margins for LM and 10-mm margins for LMM less than 1 mm in Breslow thickness are often insufficient. Our results demonstrate the importance of margin-controlled excision, particularly in recurrent lesions. The use of MSE offers a high cure rate, in conjunction with tissue conservation.     

Contoured technique for lentigo maligna

The surgical approach to lentigo maligna is a challenge to dermatologists, given the difficulty of clinical delimitation of borders. We report here a case of a 69-year-old female patient presenting with brownish macules on her face, since 10 years ago, with histopathological diagnosis of lentigo maligna. The surgical management employed was excision of visible borders with the contoured technique and immediate submission of these borders for histopathological analysis before complete excision of the tumor. This technique is a variant of staged excision, with lower rates of recurrence and acceptable aesthetic results.     

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.     

Prolonged evolution of a lentigo maligna

Lentigo maligna (LM) is a melanocytic lesion which is a potential precursor to melanoma and often has a prolonged intraepidermal growth phase before evolving into lentigo maligna melanoma (LMM). LM is also noted for its tendency to locally recur after treatment. We present a patient who had a persistent LM on her left cheek which, despite multiple excisions, persisted and transformed into a partially amelanotic LMM roughly three decades later. Our patient's course was also notable for this melanoma recurring at the edge of, and subsequently migrating into, a previously placed skin graft.     

Amelanotic lentigo maligna and amelanotic lentigo maligna melanoma: a report of three cases mimicking intraepidermal squamous carcinoma

The clinical diagnosis of amelanotic melanoma may pose diagnostic difficulties. We report three cases of amelanotic lentigo maligna, two of which developed an invasive component (lentigo maligna melanoma). The clinical appearances in each case mimicked intraepidermal squamous carcinoma.