Lentigo Maligna Lesions Research Articles

Lentigo maligna and lentigo maligna melanoma in-vivo differentiation with dermoscopy and reflectance confocal microscopy: a retrospective, multi-center study.

Dermoscopic predictors of lentigo maligna (LM) and lentigo maligna melanoma (LMM) have been recently reported, but these have not been reported in reflectance confocal microscopy (RCM). (i) To validate dermoscopic predictors for LM/LMM, (ii) to identify RCM patterns in LM and LMM and (iii) correlations between dermoscopic and RCM features in LM and LMM. A retrospective, multicenter study of consecutive lesions with histologically proven LM or LMM subtypes of the head and face, with complete sets of dermoscopic and RCM images. A total of 180 lesions were included (n=40 LMM). Previously reported differential dermoscopic features for LM subtypes were confirmed. Other features significantly associated with LMM diagnosis included irregular hyperpigmented areas, shiny white streaks, atypical vessels, and light brown color at dermoscopy and medusa head-like structures, dermal nests and nucleated cells within the papillae at RCM (p<0.05). Correlations among LM lesions between dermoscopic and RCM features included brown to-gray dots and atypical cells (epidermis), grey color and inflammation and obliterated follicles and medusa head-like structures. Among LMM lesions, significant correlations included obliterated follicles with folliculotropism, both irregular hyperpigmented areas and irregular blotches with widespread atypical cell distribution (epidermis), dermal nests and nucleated cells within the papillae (dermis). Irregular blotches were also associated with medusa head-like structures (dermal epidermal junction [DEJ]). Dermoscopic and RCM features can assist in the in-vivo identification of LM histopathological subtypes and many are correlated. RCM 3-dimensional analysis of skin layers allows the identification of invasive components in the DEJ and dermis.

Genomic Profiling of Lentigo Maligna within an Interim Registry Analysis​

Background: Pigmented lesion analysis remains a challenging aspect of dermatology. The DermTech Melanoma Test (‘the test’) is a non-invasive genomic test designed to rule-out melanoma. It consists of the pigmented lesion assay, which detects RNA products of Long Intergenic Non-Coding RNA 00518 (LINC00518) and Preferentially Expressed Antigen in Melanoma (PRAME), and an add-on assay for DNA promoter mutations in telomerase reverse transcriptase (TERT). In previous studies, the test was found to have a negative predictive value ≥99%. This interim analysis of a registry study examines the genomic patterns of the Lentigo Maligna (LM) subtype of melanoma. Methods: Between April 2021 and March 2022, multiple geographically diverse sites throughout the US submitted data to a registry to assess real-world use of the test. Approximately 8,000 clinically atypical lesions were tested. After receiving the test result, providers followed their clinical judgement for biopsy decision. Histopathologic diagnoses for biopsied lesions were correlated with test results and all melanomas were sorted into LM subtype vs non-LM subtype. In addition, lesions that were noted to be on sun exposed skin and/or noted to have solar elastosis and called atypical melanocytic hyperplasia were included. Results: At the 1-year mark of the registry, there were roughly 8000 unique entries. Of those, 1003 expressed one or more genomic markers from the DMT and had records available, and 134 (13.2%) were found to be melanoma or melanoma in-situ. More than a third (n=46, 34.3%) of the melanomas were of the Lentigo Maligna sub-type, with 7 of those being Lentigo Maligna Melanoma (LMM). Seven additional lesions were called atypical junctional melanocytic hyperplasia (AJMH) on sun-damaged skin. This group of 53 LM, LMM, and AJMH lesions were all evaluated for correlations to the DMT markers. LINC was the most commonly expressed genomic marker (n=45, 84.9%), with PRAME (n=36, 67.9%) and TERT (n=24, 45.3%) following. Most invasive tumors (LMM) expressed all three markers (n=4) and all 7 expressed LINC. Conclusion: While the original validation study included the LM subtype, this interim registry analysis demonstrates real-world use of the DMT in assessing pigmented macules concerning for LM. Over 1/3 of the melanomas reported in the registry were LM subtypes. LINC had a higher correlation with the lentigo maligna subtype of melanoma and was present in all invasive tumors. While AJMH is considered borderline, it may be worthwhile in the clinical context to group AJMH lesions with LM due to similarities in treatment.

795 Adequacy of Surgical Excision Margins in Lentigo Maligna: An Audit

Abstract Aim The optimal excision margin for Lentigo Maligna (LM) lesions has been a frequent topic of debate. An audit was carried out to compare the excision margins used for LM excisions with current NICE guidelines, and to assess the adequacy of these excision margins. Method A retrospective study was carried out to analyse all excisions of LM lesions in 2018. 33 patients were identified from the plastic surgery departmental database. Patient demographics, the site and distribution of LM lesions, and any history of previous skin cancer were analysed. Patient electronic records, operative notes, and histopathological reports were examined to determine the number of excisions done for each LM lesion along with the peripheral and deep surgical excision margins, and the histological clearance achieved. Complete histological clearance was determined by the Multidisciplinary team for each lesion. Results 60 cases were identified. 60% of cases were located on the head and neck. The average peripheral surgical excision margin at first excision was 2.3mm. 55% of patients had a 2nd excision. The average peripheral surgical excision margin at 2nd excision was 5.4mm. 70.6% of cases achieved complete histological clearance at 2nd excision. 72.7% of lesions excised at 2nd excision with a 5mm or less surgical excision margin achieved complete histological clearance. Conclusions Taking &amp;gt;5mm surgical excision margins did not increase the rate of complete histological clearance for Lentigo Maligna lesions.

Folliculotropism in head and neck lentigo maligna and lentigo maligna melanoma.

Lentigo maligna (LM) and lentigo maligna-melanoma (LMM) are histotypes of melanoma arising in skin with cumulative solar radiation damage. The extension of atypical melanocytes to the hair follicle (folliculotropism) is a histopathological feature of LM/LMM. Its role has not been totally clarified, but it may be correlated to treatment response in LM or to progression in LMM. This retrospective, multicentric study aims to identify dermatoscopic features associated with folliculotropism in LMs/LMMs. We analyzed cases of head and neck LMs/LMMs diagnosed between 2005-2014 at Melanoma Units, University of Bologna/Modena/Florence/Siena (Italy), Nice (France): 25 LMs and 73 LMMs were included. Grey circles (44%) indicated an isthmic/bulb level of involvement, which were completely absent in the infundibular LM lesions (P=0.041). In the group of LMMs, light/dark brown pseudonetwork and light brown structureless areas were an indicator of diffuse distribution of malignant melanocytes in the follicular units (P <0.001 and P=0.001, respectively), while grey circles indicated focal or diffuse distribution (P<0.001). A better understanding of the extension of malignant melanocytes is helpful, aiding clinicians in their decision to perform a radical excision or obtaining a biopsy in the most invasive area of the lesion, which includes potential folliculotropism.

Strategies for Reducing Final Surgical Defect Sizes in the Treatment of Lentigo Maligna.

Lentigo maligna (LM) is associated with disproportionately high surgical morbidity. The authors report on 2 strategies to reduce the surgical morbidity associated with LM. Forty LM lesions were removed with excisional biopsies without margins and closed with purse-string sutures. Invasive cases underwent staged excisions with 10-mm margins. Cases without invasion were treated with neoadjuvant topical imiquimod 5% cream (5 d/wk × 8 weeks) followed by conservative staged excisions with 2-mm margins using radial sections stained with hematoxylin and eosin and immunostaining with Mart-1, with or without SOX10. Invasion was detected in 12/40 (30%) of the excisional biopsy specimens (average depth 0.45 mm). No invasion was detected in 28/40 (70%). All 24 patients who completed neoadjuvant topical imiquimod 5% cream before staged excisions had negative first-stage margins at 2 mm. Compared with average published margins for LM, this represents a 71.4% reduction in the required margin and an average reduction in the final surgical defect by 74%. LM treatment by excisional biopsies with a purse-string closure enables accurate tumor staging and contracts the tumor footprint to its minimal size. Subsequent neoadjuvant imiquimod followed by a conservative staged excision with 2-mm margins allows for removal of LM with decreased surgical morbidity.

Histologic Features Associated With an Invasive Component in Lentigo Maligna Lesions

Lentigo maligna (LM) presents an invasive component in up to 20% of biopsied cases, but to date the histologic features useful in detecting this invasive component have not been described. Some histologic characteristics are hypothesized to contribute to the progression of LM invasion. To identify the histologic characteristics associated with lentigo maligna melanoma (LMM) in patients with LM diagnosed by a partial diagnostic biopsy. A retrospective cross-sectional study of patients treated between January 1, 2000, and December 31, 2017, was conducted in a referral oncology center in València, Spain. Data and specimens of patients (n = 96) with a diagnosis of primary cutaneous melanoma in the form of either LM or LMM who had undergone surgical treatment, a complete histologic examination of the whole tumor, and an initial diagnostic partial biopsy of LM were included in the study. Histologic assessment was blinded to the presence of an invasive component. All biopsy specimens were evaluated for the presence of certain histologic characteristics. Comparisons between invasive samples and samples without an invasive component were performed. The differences in the distribution of variables between the groups were assessed using the χ2 and Fisher exact tests, and the degree of association of the relevant variables was quantified by logistic regression models. A classification and regression tree analysis was performed to rank the variables by importance. In total, 96 patients had sufficient histologic material that could be evaluated. The patients were predominantly male (56 [58.3%]) and had a mean (SD) age at diagnosis of 72 (12) years. Of these patients, 63 (65.6%) had an LM diagnosis and 33 (34.4%) had an LMM diagnosis (an invasive component). The histologic variables associated with the presence of an invasive component were melanocytes forming rows (odds ratio [OR], 11.5; 95% CI, 1.4-94.1; P = .02), subepidermal clefts (OR, 2.8; 95% CI, 1.0-7.9; P = .049), nests (OR, 3.0; 95% CI, 1.1-8.6; P = .04), and a lesser degree of solar elastosis (OR, 0.4; 95% CI, 0.1-1.1; P = .07). A classification and regression tree analysis of the relevant histologic features was able to accurately identify lentigo maligna with an invasive component (LMM) in more than 60% of patients. These findings may be useful in classifying early LM specimens at higher risk of invasion, which may eventually be relevant in identifying the most appropriate management for LM.

Nine per cent of biopsy‐proven lentigo maligna lesions are reclassified as lentigo maligna melanoma after surgery

Nine per cent of biopsy‐proven lentigo maligna lesions are reclassified as lentigo maligna melanoma after surgery

The utility of confocal microscopy in lentigo maligna lesions

The diagnosis of pigmented facial lesions is considered challenging since benign and malignant lesions might have similar clinical and dermoscopic features – especially in the early stages of the lesion – entailing that it is often difficult to identify lentigo maligna lesions in the face. In this way, confocal reflectance microscopy has the potential to become a useful tool both in the diagnosis and surgical planning of lentigo maligna

Correlation of Handheld Reflectance Confocal Microscopy With Radial Video Mosaicing for Margin Mapping of Lentigo Maligna and Lentigo Maligna Melanoma

The management of lentigo maligna (LM) and LM melanoma (LMM) is challenging because of extensive subclinical spread and its occurrence on cosmetically sensitive areas. Reflectance confocal microscopy (RCM) improves diagnostic accuracy for LM and LMM and can be used to delineate their margins. To evaluate whether handheld RCM with radial video mosaicing (HRCM-RV) offers accurate presurgical assessment of LM and LMM margins. This prospective study included consecutive patients with biopsy-proven LM and LMM located on the head and neck area who sought consultation for surgical management from March 1, 2016, through March 31, 2017, at the Dermatology Service of the Memorial Sloan Kettering Cancer Center. Thirty-two patients underwent imaging using HRCM-RV, and 22 patients with 23 LM or LMM lesions underwent staged surgery and contributed to the analysis. Clinical lesion size and area, LM and LMM area based on HRCM-RV findings, surgical defect area estimated by HRCM-RV, and observed surgical defect area. In addition, the margins measured in millimeters estimated for tumor clearance in each quadrant based on HRCM-RV findings were calculated and compared with the surgical margins. Among the 22 patients (12 men and 10 women; mean [SD] age, 69.0 [8.6] years [range, 46-83 years]) with 23 lesions included in the final analysis, the mean (SD) surgical defect area estimated with HRCM-RV was 6.34 (4.02) cm2 and the mean (SD) area of surgical excision with clear margins was 7.74 (5.28) cm2. Overall, controlling for patient age and previous surgery, surgical margins were a mean of 0.76 mm (95% CI, 0.67-0.84 mm; P < .001) larger than the HRCM-RV estimate. Mapping of LM and LMM with HRCM-RV estimated defects that were similar to but slightly smaller than those found in staged excision. Thus, mapping of LM using HRCM-RV can help spare healthy tissue by reducing the number of biopsies needed in clinically uncertain areas and may be used to plan treatment of LM and LMM and counsel patients appropriately.

Correlation between digital epiluminescence microscopy parameters and histopathological changes in lentigo maligna and solar lentigo: A dermoscopic index for the diagnosis of lentigo maligna

The clinical and dermoscopic differentiation between lentigo maligna (LM) and solar lentigo (SL)/initial seborrheic keratosis (SK) may be difficult. Our aim was to identify digital epiluminescence microscopy (DELM)-specific criteria that can be helpful in distinguishing LM from SL/SK and to propose a new model of LM dermoscopic progression based on a study of DELM-histopathological correlation. A total of 167 consecutive doubtful pigmented lesions of the head (105 LM and 62 SL/SK) were studied. DELM assessment was based on the presence or absence of 15 DELM parameters that were subsequently examined histologically. Statistical analysis was performed to determine which DELM parameters were most strongly associated with LM. The finding of at least 1 of 4 parameters (ie, brown globules, a "necklace" pigment network, an atypical pigment network, and dark-brown/blue-gray ribbonlike structures) showed to be an extremely sensitive (99%) and specific (83.9%) DELM criterion to discriminate between LM and SL/SK. Our findings were obtained by examining medium-high magnification DELM images. The finding of 1 or more among the 4 above-mentioned DELM parameters allows for the correct identification of 99.0% of the LM lesions, and - when the score is 0 - the correct classification as non-LM, of 83.9% of the SL/SK lesions.

Five-year outcomes of wide excision and Mohs micrographic surgery for primary lentigo maligna in an academic practice cohort.

Wide local excision with 5-mm margins is the standard of care for lentigo maligna (LM). Mohs micrographic surgery (MMS) is used increasingly to treat this tumor. To study the authors' experience with these 2 approaches. Primary LM cases treated at the authors' institution from January 1, 1995, through December 31, 2005, were studied retrospectively. Main outcome measures were recurrence and outcomes after treatment for recurrence. In total, 423 LM lesions were treated in 407 patients: 269 (64%) with wide excision and 154 (36%) with MMS. In the MMS group (primarily larger head and neck lesions with indistinct clinical margins), recurrence rates were 3 of 154 (1.9%). In the wide excision group (primarily smaller, nonhead and neck, or more distinct lesions), recurrence rates were 16 of 269 (5.9%). Each of the 16 recurrences was biopsy proven and treated surgically: 6 by standard excision and 10 by MMS. This follow-up study of LM surgical treatments shows excellent outcomes for wide excision and MMS. Because this is a nonrandomized retrospective study, no direct comparisons between the 2 treatments can be made. When recurrences occurred, repeat surgery, either standard excision or MMS, was usually sufficient to provide definitive cure.

Interventions for melanoma in situ, including lentigo maligna.

Interventions for melanoma in situ, including lentigo maligna.

Evaluation of the Role of Routine Melan-A Immunohistochemistry for Exclusion of Microinvasion in 120 Cases of Lentigo Maligna

To assess the usefulness of routine melan-A immunohistochemistry (IHC) for exclusion of microinvasion in lentigo maligna (LM). One hundred and twenty cases of LM from our archives were reviewed by 2 authors with S100 protein and melan-A IHC using a red chromogen. Melan-A was useful to confirm the diagnosis of LM in early lesions and to differentiate these from chronically sun-damaged skin. The presence of scattered melan-A-positive cells was noted in the dermis in 72 of 120 cases (melanophages in 36 cases, nonspecific cells different to melanophages in 16 cases, and a dual cell population in 20 cases). The significance of these cells was uncertain. Only 3 cases suspicious for microinvasion were identified: 2 on haematoxylin and eosin and 1 on S100. We recommend use of melan-A to confirm the diagnosis in early lesions of LM and in the differential diagnosis from melanocytic hyperplasia in chronically sun-exposed skin. We do not recommend routine use of melan-A to identify or exclude microinvasion. However, it may have a role, in conjunction with S100, in cases with suspicious features for early invasion on haematoxylin and eosin sections.

Surgical excision margins for melanoma in situ

Melanoma in situ (MIS) is a non-invasive lesion accounting for up to 27% of all melanomas by Coory et al. (2006).(1) MIS may be a precursor to invasive disease. The Lentigo Maligna (LM) subgroup of MIS carries upto a 4.7% lifetime risk of developing an invasive component by Agarwal-Antal et al. (2002).(2) Surgical excision is recommended however other modalities of treatments are possible. In this study we aim to assess whether histological margins following excision of in situ melanoma has any bearing on recurrence or progression to malignancy. We retrospectively reviewed data accumulated on all melanomas referred to the hospital between the dates of February 2001 to February 2009. We identified all patients with melanoma in situ and for these patients recorded age, sex, anatomical site of lesion, histological type, histological excision margin, recurrence after excision and transformation to malignant melanoma. A total of 2121 patents were identified having been diagnosed and treated for melanoma of which 192 cases were identified with melanoma in situ representing 9.1% of all melanomas treated. 38% of all the lesions were of the LM subgroup. We noted a higher incomplete excision rate in this subgroup (p < 0.01) compared to the non-LM subgroup. We only noted two recurrences following complete excision (1.1%) and one recurrence in lesions completely excised with histological margins less than 2 mm (1.4%). Both of the lesions that recurred following complete excision were LM lesions. Recurrence following complete excision of LM was 2.9%. Our data suggests that MIS lesions that were not LM and adequately excised even with narrow margins are unlikely to recur therefore reducing the need for wider excision. LM however poses a more challenging clinical problem not only with the higher inadequate primary excision and higher recurrence rates following excision but also the fact that it occurs in much older patients who may be less able to tolerate more extensive surgery. In keeping with the literature we would suggest treating LM lesions more aggressively if possible.

Improving Management and Patient Care in Lentigo Maligna by Mapping With In Vivo Confocal Microscopy

Lentigo maligna (LM) is a clinical, pathologic, and therapeutic challenge with a higher risk of local recurrence than other types of melanoma correctly treated and also carries the cosmetically sensitive localization of head and neck. To determine whether in vivo reflectance confocal microscopy (RCM) mapping of difficult LM cases might alter patient care and management. Analysis of LM and LM melanoma (LMM) in a series of patients with large facial lesions requiring complex reconstructive surgery and/or recurrent or poorly delineated lesions at any body sites were investigated. Two tertiary referral melanoma centers in Sydney, Australia. Thirty-seven patients with LM (including 5 with LMM) were mapped with RCM. Fifteen patients had a recurrent LM, including 9 with multiple prior recurrences. The LM was classified amelanotic in 10 patients, lightly pigmented in 9, and partially pigmented in 18. The RCM images were obtained in 4 radial directions (allowing for anatomic barriers) for LM margin delineation using an RCM LM score previously described by our research team. Differences in the margin of LM as determined by RCM vs dermoscopy vs histopathologic analysis. Seventeen of 29 patients (59%) with dermoscopically visible lesions had subclinical (RCM-identified) disease evident more than 5 mm beyond the dermoscopy margin (ie, beyond the excision margin recommended in published guidelines). The RCM mapping changed the management in 27 patients (73%): 11 patients had a major change in their surgical procedure, and 16 were offered radiotherapy or imiquimod treatment as a consequence of the RCM findings. Treatment was surgical in 17 of 37 patients. Surgical excision margins (based on the RCM mapping) were histopathologically involved in only 2 patients, each of whom had an LM lesion larger than 6 cm. In vivo RCM can provide valuable information facilitating optimal patient care management.

Conventional Surgery Compared With Slow Mohs Micrographic Surgery in the Treatment of Lentigo Maligna: A Retrospective Study of 62 Cases

IntroductionSurgical excision with margins of 0.5cm is the standard treatment for lentigo maligna (LM). Excision, however, is often incomplete as many of these tumors have indistinct borders. ObjectiveTo identify clinical predictors of subclinical extension in primary and recurrent LM of the head and thereby determine which lesions might require wider surgical margins. Material and methodsWe reviewed the clinical records of patients with LM of the head treated definitively with conventional surgical excision or slow micrographic Mohs surgery (MMS) at the dermatology department of Instituto Valenciano de Oncología between January 1993 and April 2011. ResultsSurgical margins larger than 0.5cm were required in 69.2% of recurrent LM and 26.5% of primary LM. Factors associated with the need for wider margins were prior treatment that might have interfered with the clinical delineation of the border, lesions in the center of the face, and skin phototypes III to V. ConclusionsSurgical margins of 0.5cm are inadequate for the treatment of a considerable number of LM lesions located on the head, particularly if these are recurrent. Slow MMS using paraffin-embedded sections appears to be the treatment of choice in such cases, particularly for recurrent lesions or lesions with poorly defined borders or possible subclinical extension.

Tratamiento quirúrgico del lentigo maligno: cirugía convencional vs. Mohs diferida. Estudio retrospectivo de 62 casos

IntroductionSurgical excision with margins of 0.5cm is the standard treatment for lentigo maligna (LM). Excision, however, is often incomplete as many of these tumors have indistinct borders. ObjectiveTo identify clinical predictors of subclinical extension in primary and recurrent LM of the head and thereby determine which lesions might require wider surgical margins. Material and methodsWe reviewed the clinical records of patients with LM of the head treated definitively with conventional surgical excision or slow micrographic Mohs surgery (MMS) at the dermatology department of Instituto Valenciano de Oncología between January 1993 and April 2011. ResultsSurgical margins larger than 0.5cm were required in 69.2% of recurrent LM and 26.5% of primary LM. Factors associated with the need for wider margins were prior treatment that might have interfered with the clinical delineation of the border, lesions in the center of the face, and skin phototypes III to V. ConclusionsSurgical margins of 0.5cm are inadequate for the treatment of a considerable number of LM lesions located on the head, particularly if these are recurrent. Slow MMS using paraffin-embedded sections appears to be the treatment of choice in such cases, particularly for recurrent lesions or lesions with poorly defined borders or possible subclinical extension.

Treatment options in melanoma in situ: topical and radiation therapy, excision and Mohs surgery

The treatment of melanoma in situ (MIS), particularly the lentigo maligna (LM) subtype, has been a controversial subject in the literature for over a decade. Surgical excision with 5 mm margins is the standard of care in the USA, while several variations of Mohs surgery are frequently used to treat clinically ill-defined lesions. Radiation is much less frequently used. Topical imiquimod has also been more recently proposed, in small case reports in the literature, as a therapy for MIS. However, controversies exist with all approaches. To review the current literature regarding topical imiquimod, radiation therapy, surgical excision, and the various forms of Mohs surgery for MIS, focusing on the LM subtype. A literature search was performed in the PubMed database using the following terms: "melanoma in situ,""lentigo maligna,""excisional surgery,""Mohs micrographic surgery,""radiation therapy," and "imiquimod." Articles relevant to the treatment of MIS were reviewed and reported herein. Studies of imiquimod therapy for MIS are hampered by small study numbers and short follow-up periods. The few, better-designed studies reveal relatively low cure rates. In addition, literature review reveals that a significant percentage of cases of MIS that are initially diagnosed as in situ disease by biopsy subsequently prove to have an invasive component upon complete excision. This finding suggests that topical therapy of any kind may be problematic. Studies of radiation therapy for MIS have relatively small numbers of patients and short follow-up. Multiple studies of excisional surgery have shown that 5 mm margins are often insufficient to clear the LM subtype of MIS due to unseen subclinical extension, accounting for this treatment's reported 8-20% recurrence rate. Finally, a number of variants of traditional frozen section Mohs surgery have been utilized to try and achieve complete peripheral margin assessment of clinically ill-defined LM lesions. All studies are retrospective, and most are single-institution and frequently single-operator, limiting the meaningfulness of their results. Nevertheless, they involve moderate numbers of patients, and many have at least a five year follow-up. Collectively, they suggest recurrence rates in the range of 0.5-3.0%. Topical imiquimod therapy appears to provide relatively low cure rates for MIS, and because some of these lesions contain an unrecognized invasive component, should be used with extreme caution to treat this disease. Radiation therapy may be a useful second-line therapy if surgery is contraindicated. Excisional surgery is an appropriate therapy for clinically well-defined MIS; however, margins larger than 5 mm may be required when treating larger or indistinct lesions. Finally, for clinically ill-defined LM arising on sun-damaged skin, especially in regions of aesthetic concern, some form of complete peripheral margin assessment - one of the various forms of Mohs surgery - may provide the highest cure rate and create the smallest surgical defect.

Remissão de lentigo maligno extenso após tratamento com imiquimod

Lentigno maligna is a melanoma in situ that most commonly appears on areas exposed to ultraviolet radiation, in elderly patients. Treatment is required mainly to minimize the risk of progression to lentigo maligna melanoma. The present report refers to an elderly patient with recurrent lesions of lentigo maligna in her face, who was successfully treated with topical imiquimod, which showed to be a useful therapy for some cases of the disease.

Treatment of Lentigo Maligna with Imiquimod before Staged Excision

BACKGROUND Imiquimod 5% cream has demonstrated effectiveness in the treatment of lentigo maligna (LM) in several small studies. None of the studies to date have included posttreatment surgical removal to confirm negative histologic margins. OBJECTIVE The aim of this retrospective analysis was to assess the efficacy of topical imiquimod in LM by circumferentially examining vertically oriented sections from a geometrically designed “picture frame” margin as well as bread-loafed sections of the central portion after staged excisions of imiquimod-treated lesions of LM. METHODS Forty patients with biopsy-confirmed LM were treated five times a week for 3 months with 5% imiquimod cream before staged excision. Tazarotene 0.1% gel was added when no clinical signs of erythema developed with imiquimod alone after 1 month (10 patients). After the course of topical therapy, patients were assessed for clinical and complete histologic clearance after staged excision. RESULTS A total of 33 of 40 patients had a complete clinical response as determined by the absence of remaining clinical lesion on physical examination. Upon histologic review, 30 of 40 patients had no evidence of LM whereas 10 of 40 harbored residual disease. One patient was found to have histologic evidence of invasion after completing the topical protocol. After a mean follow-up of 18 months (range, 12–34 months) and after complete surgical excision of the treatment site, none of the imiquimod-treated patients had evidence of recurrence. CONCLUSIONS Imiquimod appears to be an effective adjunctive treatment for LM but does not qualify as a replacement therapy for surgery.