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Carmona-Rocha E, Rusiñol L, García-Melendo C, Iznardo H, Mozos A, López-Sánchez C, Yélamos O. Lentigo maligna: a comprehensive review on diagnosis and treatment. Ital J Dermatol Venerol 2024; 159:390-411. [PMID: 39069838 DOI: 10.23736/s2784-8671.24.07837-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Lentigo maligna (LM), a form of melanoma in situ, and LM melanoma (LMM), its invasive counterpart, exhibit distinctive epidemiology, risk factors, and clinical features compared to other melanoma subtypes. Notably, LM occurs on chronically sun-damaged skin presenting as a slow-growing, ill-defined patch which makes it difficult to diagnose and to treat. Additionally, while LM generally presents a favourable prognosis, it can also lead to dermal invasion and behave similarly to other melanomas with the same Breslow thickness. Hence, surgery continues to be the cornerstone treatment. Wide excisions are often necessary, but challenges arise when these lesions manifest in cosmetically sensitive regions, limiting the feasibility and desirability of large excisions. Specialized approaches, including margin-controlled surgery and image-guided treatment with reflectance confocal microscopy, have been developed to address these issues. Other non-surgical treatments such as cryosurgery, imiquimod, radiotherapy, or photodynamic therapy, may also be used but commonly present with recurrent/persistent disease. Herein we comprehensively review the existing literature on the management of LM/LMM, and discus the potential new advances on managing this challenging skin cancer.
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Affiliation(s)
- Elena Carmona-Rocha
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Lluís Rusiñol
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
| | | | - Helena Iznardo
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Anna Mozos
- Anatomical Pathology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cristina López-Sánchez
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
| | - Oriol Yélamos
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain -
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- Dermatology Department, Teknon Quirónsalud Medical Center, Barcelona, Spain
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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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Ungureanu L, Vasilovici AF, Trufin II, Apostu AP, Halmágyi SR. Lentigo Maligna Treatment-An Update. J Clin Med 2024; 13:2527. [PMID: 38731056 PMCID: PMC11084749 DOI: 10.3390/jcm13092527] [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: 03/11/2024] [Revised: 04/06/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Lentigo maligna (LM) is a melanoma in situ that is prevalent in chronically sun-damaged skin. Characterized by a slow growth pattern and high mutation rates due to chronic UV exposure, LM poses diagnostic and therapeutic challenges, particularly given its tendency to mimic other skin lesions and its occurrence in cosmetically sensitive areas. Its diagnosis is based on an integrated approach using dermoscopy and reflectance confocal microscopy (RCM). Despite its slow progression, LM can evolve into lentigo maligna melanoma (LMM), making its treatment necessary. Treatment modalities encompass both surgical and non-surgical methods. Surgical treatments like Wide Local Excision (WLE) and Mohs Micrographic Surgery (MMS) aim for clear histological margins. WLE, a standard melanoma surgery, faces challenges from LM's subclinical extensions, which increase the recurrence risk. MMS, effective for large or poorly defined lesions, is defined by precise margin control while considering cosmetic outcomes. Non-surgical options, including radiotherapy and imiquimod, are alternatives for non-surgical candidates. Radiotherapy has been effective since the 1950s, offering good control and cosmetic results, especially for older patients. Imiquimod, an immunomodulator, shows promise in treating LM, though its application remains off-label. The increasing incidence of LM/LMM necessitates a balance in treatment choices to minimize recurrence and maintain cosmetic integrity. A multidisciplinary approach, integrating clinical examination with dermoscopy and RCM and histological assessment, is essential for accurate diagnosis and effective LM management.
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Affiliation(s)
- Loredana Ungureanu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Alina Florentina Vasilovici
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | | | - Adina Patricia Apostu
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
| | - Salomea-Ruth Halmágyi
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
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Alma A, Pongetti L, Clementi A, Chester J, Toccaceli M, Ciardo S, Zappia E, Manfredini M, Pellacani G, Greco M, Bennardo L, Farnetani F. Combined Carbon Dioxide Laser with Photodynamic Therapy for Nodular Basal Cell Carcinoma Monitored by Reflectance Confocal Microscopy. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:30. [PMID: 38256291 PMCID: PMC10821002 DOI: 10.3390/medicina60010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024]
Abstract
Introduction: Basal cell carcinoma (BCC) represents around 80% of all malignant skin cancers worldwide, constituting a substantial burden on healthcare systems. Due to excellent clearance rates (around 95%), surgery is the current gold-standard treatment. However, surgery is not always possible or preferred by patients. Numerous non-surgical therapies, sometimes combined, have been associated with promising tumor free survival rates (80-90%) in non-melanoma skin cancers (NMSCs). Most research has enrolled superficial basal cell carcinomas (sBCCs), with limited recent studies also involving low-risk nodular BCCs (nBCCs). Given lower efficacy rates compared to surgery, close monitoring during the follow-up period is essential for patients treated with non-surgical therapies. Monitoring with dermoscopy is constrained by low sensitivity rates. Reflectance confocal microscopy (RCM) is more sensitive in monitoring non-surgically treated NMSCs. Case presentation: A 41-year-old woman with a single nBCC relapse following photodynamic therapy (PDT) located on the dorsum of the nose presented to our center. Given the aesthetically sensitive location of the lesion and the patient's preference for a non-surgical approach, a combined treatment of CO2 laser and PDT was prescribed. A superpulsed CO2 laser (power: 0.5-3 W, frequency: 10 Hz, spot size 2 mm) with two PDT sessions (2 weeks apart) were conducted. At 6 weeks follow-up, monitoring performed with RCM revealed a reduction but not eradication of basaloid tumor islands. Another 2 sessions of PDT were recommended. At 3, 12 and 30 months of follow-up, the nasal dorsum area of the previous nBBC lesion was noted to be slightly hypopigmented (observed clinically), with a mild erythematous background (observed by dermoscopy). RCM evaluation confirmed the absence of RCM BCC criteria. The cosmetic outcome was very much improved. Conclusions: Combined CO2 laser and PDT for the treatment of a localized nBCC on the dorsum of the nose of a 41-year-old proved to offer tumor free survival at 30-month follow-up, as monitored with RCM. RCM is useful for the evaluation of non-surgical therapies as it has comparably higher sensitivity than dermoscopy and is especially useful in cases of suspected late recurrence. Further studies are needed to validate ongoing tumor free survival following this combined nonsurgical approach in the treatment of nBCC.
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Affiliation(s)
- 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, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Linda Pongetti
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Alessandro Clementi
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - 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, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Matteo Toccaceli
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - 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, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Elena Zappia
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, 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, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Giovanni Pellacani
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Maurizio Greco
- Dermatology Unit, Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
| | - Luigi Bennardo
- Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, 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, 41125 Modena, Italy; (A.A.); (L.P.); (A.C.); (J.C.); (M.T.); (S.C.); (M.M.); (M.G.); (F.F.)
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