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Elshot YS, Lasso Peña DJP, Zupan-Kajcovski B, Bekkenk MW, Balm AJM, Klop WMC, de Rie MA. Successful implementation of handheld reflectance confocal microscopy as the standard of care in the (surgical) management of lentigo maligna (melanoma). J Eur Acad Dermatol Venereol 2024. [PMID: 38923079 DOI: 10.1111/jdv.20210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Reflectance confocal microscopy (RCM) has shown promise in predicting surgical outcomes by non-invasively detecting subclinical lentigo maligna (melanoma) (LM/LMM). OBJECTIVES To assess the effects of presurgical mapping using handheld RCM (HH-RCM) on surgical treatment, follow-up outcomes and management decisions. METHODS A total of 117 consecutive LM/LMM cases (2015-2023) were included. The diagnostic accuracy of HH-RCM in detecting subclinical LM and invasive components was evaluated. The primary endpoints included histological margin status and changes in management based on the outcomes of the HH-RCM mapping procedure. Margin and follow-up outcomes were compared to a historical cohort before HH-RCM was introduced in our center (n = 94) (2003-2014). RESULTS HH-RCM detected subclinical LM in 60% (n = 60) of cases. The median mapping duration was 14 min (range 4-50). In 27% (n = 33), the mapping procedure resulted in modified management, the majority consisting of limited surgery with adjuvant imiquimod (n = 15) or imiquimod monotherapy (n = 14). The remaining cases (n = 84) underwent HH-RCM-assisted surgery. Histological margins were cleared in 96.5% of the patients with a median histological margin of 3.0 mm, significantly higher than 81% in the historical cohort (median 2.0 mm) (p = 0.001). The sensitivity and specificity for detecting the extent of subclinical LM were 94% (95% CI 80.4-99.3) and 84% (95% CI 70.3-92.7), respectively. The negative predictive value for the detection of LMM was 94% (95% CI 84.4-97.7), and 75% of the initially missed LMM (n = 12) were identified during the HH-RCM mapping procedure. The study cohort had a 1.6% local recurrence rate compared with 25% in the historical cohort. CONCLUSIONS Integrating HH-RCM as the standard of care could lead to more personalized treatment strategies for LM/LMM and allows for the selection of patients suitable for nonsurgical treatment.
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Affiliation(s)
- Y S Elshot
- Department of Dermatology, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - D J P Lasso Peña
- Department of Dermatology, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - B Zupan-Kajcovski
- Department of Dermatology, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - M W Bekkenk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W M C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Rie
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Karponis D, Stratigos IA, Joshy J, Craig PJ, Mistry K, van Bodegraven B, Venables ZC, Levell NJ. Lentigo maligna: a review. Clin Exp Dermatol 2024; 49:218-225. [PMID: 37966718 DOI: 10.1093/ced/llad394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
Lentigo maligna (LM) is a melanoma in situ with distinct clinical features and histology. It commonly affects men after the sixth decade of life. Incidence rates of LM have increased based on early 21st century data from different countries; however, data are suboptimal. Data from England show a plateauing crude incidence between 2013 and 2019. By comparison, invasive melanoma and other types of melanoma in situ commonly appears in younger age groups (median age 58 and 67 years old, respectively) and incidence is rising. The most important risk factors for LM include fair skin and cumulative ultraviolet solar radiation exposure. Although LM is limited to the epidermis and connected skin adnexa, it may progress to invasive LM melanoma. The reported rate of malignant progression varies, reflecting a challenge for LM epidemiology research as often lesions are removed on diagnosis. LM poses a challenge in diagnosis and management. Although it can be diagnosed clinically or dermoscopically, histopathological assessment of biopsied skin tissue remains the gold standard. Reflectance confocal microscopy allows for better appreciation of the complexity of LM at a cellular level, often progressing beyond clinical margins. Management of LM may involve Mohs micrographic surgery or excision, although recurrence may occur even with 5 mm clinical margins. Imiquimod cream may be effective, but incomplete treatment and recurrence has been reported. Conservative management with observation or radiotherapy may be used in selected patients' cases. Five-year net survival rates are excellent. This paper reviews the natural history, epidemiology, aetiology, pathogenesis, diagnosis and management of LM.
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Affiliation(s)
- Dimitrios Karponis
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Jilse Joshy
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Paul J Craig
- Cellular Pathology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Khaylen Mistry
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Birgitta van Bodegraven
- British Association of Dermatologists, London, UK
- National Disease Registration Service, Data and Analytics, NHS England, UK
| | - Zoe C Venables
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- National Disease Registration Service, Data and Analytics, NHS England, UK
| | - Nick J Levell
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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3
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Guida S, Alma A, Fiorito F, Megna A, Chester J, Kaleci S, Ciardo S, Manfredini M, Rongioletti F, Perrot JL, Rubegni P, Chello C, Cantisani C, Pellacani G, Cinotti E, Farnetani F. Lentigo maligna and lentigo maligna melanoma in vivo differentiation with dermoscopy and reflectance confocal microscopy: A retrospective, multicentre study. J Eur Acad Dermatol Venereol 2023; 37:2293-2300. [PMID: 37357442 DOI: 10.1111/jdv.19291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/26/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION 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). OBJECTIVES (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. MATERIALS AND METHODS A retrospective, multicentre study of consecutive lesions with histologically proven LM or LMM subtypes of the head and face, with complete sets of dermoscopic and RCM images. RESULTS 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 colour 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-grey dots and atypical cells (epidermis), grey colour 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]). CONCLUSIONS Dermoscopic and RCM features can assist in the in vivo identification of LM and LMM and many are correlated. RCM three-dimensional analysis of skin layers allows the identification of invasive components in the DEJ and dermis.
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Affiliation(s)
- Stefania Guida
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Dermatology Clinic, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Alma
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Flavio Fiorito
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Megna
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Johanna Chester
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Shaniko Kaleci
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvana Ciardo
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Manfredini
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Rongioletti
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Dermatology Clinic, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jean L Perrot
- Department of Dermatology, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Pietro Rubegni
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Camilla Chello
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmen Cantisani
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giovanni Pellacani
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Elisa Cinotti
- Dermatology Section, Department of Medical, Surgical and Neurological Science, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Francesca Farnetani
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
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Hoang MP, Karpinski P, Zúñiga-Castillo M, Foreman RK, Emerick KS, Sober AJ. Histologic margin status is a predictor of relapse in lentigo maligna melanoma. J Am Acad Dermatol 2023; 89:959-966. [PMID: 37454699 DOI: 10.1016/j.jaad.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/03/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Most surgical margins for lentigo maligna melanomas reported in the literature are clinical and not histologic. OBJECTIVES We sought to determine whether histologic margin status is an independent predictor of progression. METHODS Clinicopathologic information of 268 invasive lentigo maligna melanomas diagnosed from 1990-2019 were analyzed. Statistical analyses were performed using Cox proportional hazards model and Boruta method. RESULTS A total of 75% of the lesions were located on the head and neck. The range of follow-up for all patients was 0 to 31.8 years (median, 10.2 years). Time to local recurrence ranges from 0 to 20 years (median, 3 years). Progression developed in 54 (20.1%) of 268 patients. Local recurrence was seen only in 36 (13.4%), both local recurrence and subsequent metastasis in 7 (2.6%), and only metastasis in 11 (4.1%) of 268 patients. Histologic margin status (positive and close/<3 mm) and tumor site (head and neck location) significantly correlated with worse progression-free survival. LIMITATIONS Single institution and retrospective study. CONCLUSIONS Histologic margin status is the strongest predictor of progression for lentigo maligna melanoma. Patients with positive or close/<3 mm histologic margins should consider a re-excision due to the increased risk of relapse.
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Affiliation(s)
- Mai P Hoang
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Pawel Karpinski
- Department of Genetics, Wroclaw Medical University, Wroclaw, Poland; Laboratory of Genomics and Bioinformatics, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Miguel Zúñiga-Castillo
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ruth K Foreman
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kevin S Emerick
- Department of Surgery, Massachusetts Eye and Ear Institute and Harvard Medical School, Boston, Massachusetts
| | - Arthur J Sober
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Huang C, Burke H, Scolyer RA, Guitera P. Lentigo maligna and lentigo maligna melanoma in young patients in Australian tertiary centres. Clin Exp Dermatol 2023; 48:799-800. [PMID: 36916530 DOI: 10.1093/ced/llad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/22/2023] [Indexed: 03/15/2023]
Abstract
This was a retrospective study of all patients with a diagnosis of lentigo maligna or lentigo maligna melanoma at 50 years of age or younger at the time of their first diagnosis in two Australian tertiary centres. The low recurrence rate in younger patients in this study warrants further investigation. Early diagnosis in young patients is crucial to allow early treatment and lifestyle changes to reduce actinic damage and subsequent development of further melanomas.
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Affiliation(s)
- Cheng Huang
- Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Melanoma Institute Australia
| | | | - Richard A Scolyer
- Melanoma Institute Australia
- Faculty of Medicine and Health
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Pascale Guitera
- Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Melanoma Institute Australia
- Faculty of Medicine and Health
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Martinez-Molina M, Richarz N, Jaka A, Bassas-Vila J, Mora-Fernández V, Pi-Sunyer AQ, Podlipnik S, Carrascosa JM, Boada A. Spaghetti Technique Versus Wide Local Excision for Lentigo Maligna Affecting the Head and Neck Regions: Surgical Outcome and Descriptive Analysis of 79 Cases from a Single Practice Cohort. Dermatol Pract Concept 2023; 13:e2023193. [PMID: 37557139 PMCID: PMC10412079 DOI: 10.5826/dpc.1303a193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Lentigo maligna is a subtype of melanoma in situ that typically affects the head and neck region with an increasing incidence. Margin-controlled techniques, such as spaghetti technique (ST), have gained popularity over wide local excision (WLE) with a margin of 5 mm. OBJECTIVES To evaluate the outcomes of lentigo maligna cases in the head and neck area treated by either WLE or ST in a tertiary referral hospital. The secondary goal was to describe the demographic and clinical characteristics of our series. METHODS Cohort study of patients diagnosed with lentigo maligna on the head and neck region between January 2014 and February 2022 in a tertiary hospital. RESULTS In total, 79 lentigo maligna were studied, corresponding to 77 patients. Fifty-three lesions (67%) were treated with WLE and 26 (33%) with ST. The mean age of the patients was 73 years and 58% were men. Most of the tumors were located on the cheek (50%) and mean lesion diameter was 2.2 cm for the ST group and 1.2 cm for the WLE group. Mean duration follow-up was 44 months. There were two local recurrences in the WLE group (2/53; 3.7%) and none in the ST group. CONCLUSIONS Both WLE and ST are appropriate surgical approaches for lentigo maligna. ST offers an efficient alternative to Mohs surgery for treating lentigo maligna in the head and neck area, especially when guided by reflectance confocal microscopy.
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Affiliation(s)
- Manel Martinez-Molina
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Nina Richarz
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Ane Jaka
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Juli Bassas-Vila
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Verónica Mora-Fernández
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Ariadna Quer Pi-Sunyer
- Department of Pathology, Hospital University Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Sebastian Podlipnik
- Department of Dermatology, Melanoma Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Manuel Carrascosa
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
| | - Aram Boada
- Department of Dermatology, Hospital University Germans Trias i Pujol, Badalona. Autonomous University of Barcelona, Barcelona, Spain
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Han J, Tai H, Poplausky D, Young J, Revankar R, Baek P, Walsh S, Gulati N. Management of lentiginous melanoma with imiquimod assessed by reflectance confocal microscopy. SKIN HEALTH AND DISEASE 2023; 3:e212. [PMID: 37013121 PMCID: PMC10066750 DOI: 10.1002/ski2.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Joseph Han
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Hansen Tai
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Dina Poplausky
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Jade Young
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Rishab Revankar
- Levy LibraryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Peter Baek
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Samantha Walsh
- Levy LibraryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Nicholas Gulati
- Department of DermatologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Pizzichetta MA, Polesel J, Perrot JL, Rubegni P, Fiorani D, Rizzo A, Stanganelli I, Magi S, Mazzoni L, Medri M, Dominici MM, Toffolutti F, Farnetani F, Lippolis N, Pedroni G, Ciardo S, Condorelli AG, Conforti C, Pellacani G, Zalaudek I, Puglisi F, Cinotti E. Amelanotic/hypomelanotic lentigo maligna: Dermoscopic and confocal features predicting diagnosis. J Eur Acad Dermatol Venereol 2023; 37:303-310. [PMID: 36196781 PMCID: PMC10092015 DOI: 10.1111/jdv.18636] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/12/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma (AHLM/LMM) may be very difficult to diagnose at an early stage. OBJECTIVES To quantify the predictive value of dermoscopic and reflectance confocal microscopy (RCM) features for AHLM/LMM. METHODS Dermoscopic and RCM images of histopathologically diagnosed AHLM/LMM, amelanotic/hypomelanotic benign lesions (AHBL), and amelanotic/hypomelanotic basal and squamous cell carcinomas (AHBCC/AHSCC) of the head and neck from consecutive patients were retrospectively collected and blindly evaluated by three observers to assess presence or absence of dermoscopic and RCM criteria. RESULTS Overall, 224 lesions in 216 patients including LM/LMM (n = 55, 24.6%), AHBL (n = 107, 47.8%) and AHBCC/AHSCC (n = 62, 27.7%) were analysed. Multivariable analysis showed that milky-red areas (OR = 5.46; 95% CI: 1.51-19.75), peripheral light brown structureless areas (OR = 19.10; 4.45-81.96), linear irregular vessels (OR = 5.44; 1.45-20.40), and asymmetric pigmented follicles (OR = 14.45; 2.77-75.44) at dermoscopy, and ≥3 atypical cells in five fields (OR = 10.12; 3.00-34.12) and focal follicular localization of atypical cells at dermo-epidermal junction (DEJ) (OR = 10.48; 1.10-99.81) at RCM were significantly independent diagnostic factors for AHLM/LMM vs. AHBL. In comparison with AHBCC/AHSCC, peripheral light brown structureless area (OR = 7.11; 1.53-32.96), pseudonetwork around hair follicles (OR = 16.69; 2.73-102.07), and annular granular structures (OR = 42.36; 3.51-511.16) at dermoscopy and large dendritic (OR = 6.86; 3.15-38.28) and round pagetoid cells (OR = 26.78; 3.15-227.98) at RCM led to a significantly increased risk of diagnosing AHLM/LMM. CONCLUSIONS Amelanotic/hypomelanotic lentigo maligna and lentigo maligna melanoma may have the same dermoscopic features of AHM on other body sites, such as milky red areas, peripheral light brown structureless areas and linear irregular vessels. These features, asymmetric pigmented follicles and at RCM ≥ 3 atypical cells in five fields and focal follicular extension of atypical cells at DEJ may help in recognizing AHLM/LMM even when LM conventional features (e.g., obliteration of hair follicles under dermoscopy and large pagetoid cells under RCM) are absent or present only in very small areas of the lesion.
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Affiliation(s)
- Maria A Pizzichetta
- Department of Dermatology, University of Trieste, Trieste, Italy.,Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Jerry Polesel
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Jean L Perrot
- Department of Dermatology, University Hospital of Saint Etienne, Saint-Etienne, France
| | - Pietro Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Diletta Fiorani
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Arianna Rizzo
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
| | - Ignazio Stanganelli
- Department of Dermatology, University of Parma, Parma, Italy.,Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Serena Magi
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Laura Mazzoni
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Matelda Medri
- Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio dei Tumori "Dino Amadori" (IRST) IRCCS, Meldola, Italy
| | - Michele M Dominici
- Division of Dermatology, Department of Medicina and Surgery, Azienda Ospedaliera-Universitaria di Parma, Parma, Italy
| | - Federica Toffolutti
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Francesca Farnetani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Lippolis
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Gioia Pedroni
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvana Ciardo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra G Condorelli
- Dermatologic Unit, Department of Medical Specialities Arcispedale Santa Maria Nuova, IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Claudio Conforti
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Giovanni Pellacani
- Department of Dermatology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Iris Zalaudek
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.,Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Elisa Cinotti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, Siena, Italy
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9
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Elshot YS, Tio DCKS, van Haersma-de With ASE, Ouwerkerk W, Zupan-Kajcovski B, Crijns MB, Limpens CEJM, Klop WMC, Bekkenk MW, Balm AJM, de Rie MA. Lentigo maligna (melanoma): A systematic review and meta-analysis on surgical techniques and presurgical mapping by reflectance confocal microscopy. J Eur Acad Dermatol Venereol 2023; 37:871-883. [PMID: 36652277 DOI: 10.1111/jdv.18880] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase and PubMed databases through 20 May 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non-Randomized Studies instrument. Meta-analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n = 1355), staged excision (n = 2442) and Mohs' micrographic surgery (MMS) (n = 2909). Six studies included RCM. The guideline-recommended margin was insufficient in 21.6%-44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%-1.9%), and highest for WLE (13%; 95% CI, 7.2%-21.6%). The mean follow-up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld-RCM decreased both the rate of positive histological margins (p < 0.0001) and necessary surgical stages (p < 0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma-associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH-RCM showed a trend in the reduction in incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
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Affiliation(s)
- Y S Elshot
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - D C K S Tio
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - W Ouwerkerk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection & Immunity Institute, Cancer Center, University of Amsterdam, Amsterdam, The Netherlands.,National Heart Centre Singapore, Singapore, Singapore
| | - B Zupan-Kajcovski
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M B Crijns
- Department of Dermatology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - C E J M Limpens
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W M C Klop
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Bekkenk
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A J M Balm
- Department of Head and Neck Oncology and Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Rie
- Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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10
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Rashid S, Shaughnessy M, Tsao H. Melanoma classification and management in the era of molecular medicine. Dermatol Clin 2022; 41:49-63. [DOI: 10.1016/j.det.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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11
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Bustos MA, Hoon DSB. Prognostic Utility of CpG Island Hypermethylated Phenotype in Early-Stage Invasive Primary Melanomas. J Invest Dermatol 2022; 142:1770-1772. [PMID: 35031134 DOI: 10.1016/j.jid.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Matias A Bustos
- Department of Translational Molecular Medicine, Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.
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12
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Muir J, McCormack C, De'Ambrosis B, Brown H, Kennedy D, Louie B, Smithers BM. Reply to: A practical guide on the use of imiquimod cream to treat lentigo maligna. Australas J Dermatol 2022; 63:e197-e198. [PMID: 35262178 DOI: 10.1111/ajd.13771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/01/2021] [Indexed: 11/27/2022]
Affiliation(s)
- James Muir
- Department of Dermatology, Mater Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Bri, Queensland, Australia
| | - Chris McCormack
- Surgical Oncology Department, Peter MacCallum Cancer Centre, Parkvile, Victoria, Australia.,Department of Dermatology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Brian De'Ambrosis
- Faculty of Medicine, University of Queensland, Bri, Queensland, Australia.,Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Hilary Brown
- Department of Dermatology, Mater Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Bri, Queensland, Australia
| | - Daniel Kennedy
- Pacific Plastic Surgery Clinic, Brisbane, Queensland, Australia
| | - Brendan Louie
- Department of Plastic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - B Mark Smithers
- Faculty of Medicine, University of Queensland, Bri, Queensland, Australia.,Queensland Melanoma Project, Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia
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13
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Ahn GS, Pousti B, Singh G, Elsensohn A, Jiang SIB. No Recurrence in Primary Invasive Stage 1a and 1b Melanoma and Melanoma in Situ Treated With Serial Disk Staged Excision. Dermatol Surg 2022; 48:276-282. [PMID: 34935746 DOI: 10.1097/dss.0000000000003357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal surgical treatment modality for invasive melanoma (IM) and melanoma in situ (MIS) has been debated with proponents for standard wide local excision (WLE), serial disk staged excision, and Mohs micrographic surgery. OBJECTIVE The purpose of this study is to identify the recurrence rates and surgical margins of invasive stage 1 melanoma and MIS lesions using serial disk staged excision technique with rush permanent processing and "bread loafing" microscopic analysis. MATERIALS AND METHODS Recurrence rates and surgical margins of 63 IM and 207 MIS at the University of California Dermatology Surgery Unit were retrospectively reviewed. RESULTS No recurrences were observed with average follow-up of 34 and 36 months for IM and MIS, respectively (range, 10-92 months). Average surgical margins were 19.8 mm (SD 9.7) for IM and 12.1 mm (SD 12.2) for MIS. CONCLUSION This SSE technique for the treatment of IM and MIS is comparable in efficacy to other SSE techniques, and it offers physicians a simple and accessible alternative to WLE and MMS.
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Affiliation(s)
- Grace Sora Ahn
- All authors are affiliated with the Department of Dermatology, University of California San Diego, La Jolla, California
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14
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Guitera P, Waddell A, Paton E, Fogarty GB, Hong A, Scolyer RA, Stretch JR, O'Donnell BA, Pellacani G. Re: Reply to letter to the editor re: 'practical guide on the use of imiquimod cream to treat lentigo maligna'. Australas J Dermatol 2022; 63:e198-e199. [PMID: 35107826 PMCID: PMC9305957 DOI: 10.1111/ajd.13797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Pascale Guitera
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Andreanne Waddell
- Department of Medicine/Division of Dermatology, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elizabeth Paton
- Melanoma and Skin Cancer Trials (MASC Trials), Monash University, Melbourne, Australia
| | - Gerald B Fogarty
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Genesis Cancer Care, North Sydney, Australia
| | - Angela Hong
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Genesis Cancer Care, North Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Brett A O'Donnell
- Departments of Ophthalmology, Royal North Shore Hospital, Sydney, Australia
| | - Giovanni Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
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15
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Guitera P, Waddell A, Paton E, Fogarty GB, Hong A, Scolyer RA, Stretch JR, O'Donnell BA, Pellacani G. A practical guide on the use of imiquimod cream to treat lentigo maligna. Australas J Dermatol 2021; 62:478-485. [PMID: 34529272 DOI: 10.1111/ajd.13720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
Lentigo maligna (LM) is a common in situ melanoma subtype arising on chronically sun-damaged skin and mostly affects the head and neck region. Localisation in cosmetically sensitive areas, difficulty to obtain wide resection margins and advanced patient age/comorbidities have encouraged investigation of less invasive therapeutic strategies than surgery in managing complex cases of LM. Radiotherapy and imiquimod have emerged as alternative treatment options in this context. The treatment of LM with imiquimod cream can be challenging due to the nature of the disease including its often large size, variegated appearance, involvement of adnexal structures, poorly defined peripheral edge and frequent localisation close to sensitive structures such as the eyes and lips, and elderly patients with multiple comorbidities. Prolonged and unpredictable inflammatory reaction and side effects and compliance with a patient-delivered therapy can also be challenging. In the literature to date, studies evaluating the use of imiquimod to treat LM have utilised varying methodologies and provided short follow-up and these limitations have impaired the development of clear guidelines for dosage and management of side effects. Based on our multidisciplinary experience and review of the literature, we propose practical clinical strategies for the use of imiquimod for treating LM, detailing optimal administration procedures in various clinical scenarios and long-term management, with the aim of facilitating optimal patient outcomes.
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Affiliation(s)
- Pascale Guitera
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Australia
| | - Andreanne Waddell
- Department of Medicine/Division of Dermatology, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elizabeth Paton
- Melanoma and Skin Cancer Trials (MASC Trials), Monash University, Australia
| | - Gerald B Fogarty
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Australia.,Genesis Cancer Care, NSW, Australia
| | - Angela Hong
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Australia.,Genesis Cancer Care, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Australia.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney, Australia
| | - Brett A O'Donnell
- Departments of Ophthalmology, Royal North Shore Hospital, Sydney, Australia
| | - Giovanni Pellacani
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
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16
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Pietkiewicz P. Lentiginous melanoma - should we change the paradigm? J Eur Acad Dermatol Venereol 2021; 35:1246-1247. [PMID: 34004063 DOI: 10.1111/jdv.17291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 12/01/2022]
Affiliation(s)
- P Pietkiewicz
- General and Oncological Surgery Clinic I, Greater Poland Cancer Centre, Poznań, Poland.,Polish Dermatoscopy Group, Poznań, Poland
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