Lentigo maligna

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Lentigo maligna
Other namesLentiginous melanoma on sun-damaged skin'
Irregular coloured patch on skin near nose..jpg
Irregular patch about 10mm square after scrape biopsy which concluded "suspicious of early malignant melanoma". Colour before scrape biopsy was light brown. Post excision pathology was "Lentigo maligna - Melanoma in situ"
Specialty Dermatology

Lentigo maligna is where melanocyte cells have become malignant and grow continuously along the stratum basale of the skin, [1] but have not invaded below the epidermis. [2] Lentigo maligna is not the same as lentigo maligna melanoma, as detailed below. It typically progresses very slowly and can remain in a non-invasive form for years.

Contents

It is normally found in the elderly (peak incidence in the 9th decade), on skin areas with high levels of sun exposure like the face and forearms. Incidence of evolution to lentigo maligna melanoma is low, about 2.2% to 5% in elderly patients.

It is also known as "Hutchinson's melanotic freckle". [3] This is named for Jonathan Hutchinson. [4] [5] The word lentiginous comes from the latin for freckle.

Relation to melanoma

Lentigo maligna is a histopathological variant of melanoma in situ . [6] Lentigo maligna is sometimes classified as a very early melanoma, [7] and sometimes as a precursor to melanoma. [8]

When malignant melanocytes from a lentigo maligna have invaded below the epidermis, the condition is termed lentigo maligna melanoma. [2]

Signs and symptoms

Characteristics include a blue/black stain of skin initially. Skin is thin, about 4-5 cell layers thick, which is often related to aging. Histological features include epidermal atrophy and increased number of melanocytes.

Diagnosis

First dilemma in diagnosis is recognition. As lentigo malignas often present on severely sun-damaged skin, it is frequently found amongst numerous pigmented lesions – thin seborrheic keratoses, lentigo senilis, lentigines. It is difficult to distinguish these lesions with the naked eye alone, and even with some difficulty using dermatoscopy. As the lentigo maligna is often very large, it often merges with, or encompasses other skin tumors – such as lentigines, melanocytic nevi, and seborrheic keratosis.

Second dilemma is the biopsy technique. Even though excisional biopsy (removing the entire lesion) is ideal, and advocated by pathologists; practical reason dictates that this should not be done. These tumors are often large and presenting on the facial area. Excision of such large tumor would be absolutely contraindicated if the lesion's identity is uncertain. The preferred method of diagnosis is by using a punch biopsy, allowing the physician to sample multiple full thickness pieces of the tumor at multiple sites. While one section of the tumor might show benign melanocytic nevus, another section might show features concerning for severe cellular atypia. When cellular atypia is noted, a pathologist might indicate that the entire lesion should be removed. It is at this point that one can comfortably remove the entire lesion, and thus confirm the final diagnosis of lentigo maligna. The size of the punch biopsy can vary from 1 mm to 2 mm, but it is preferable to use a punch 1.5 mm or larger. Representative samples of the most atypical parts of the nevus should be biopsied, often guided by dermatoscopy.

Treatment

Scar 13 days after excision of coloured patch about 10mm square with 5mm margins from 1cm to right of base of nose. Length of incision required for skin flap to cover excision site. Scar should lighten and become finer for up to further 6 months if protected from sun. Scars from skin flap.jpg
Scar 13 days after excision of coloured patch about 10mm square with 5mm margins from 1cm to right of base of nose. Length of incision required for skin flap to cover excision site. Scar should lighten and become finer for up to further 6 months if protected from sun.

The best treatment of lentigo maligna is not clear as it has not been well studied. [9]

Standard excision is still being done by most surgeons. Unfortunately, the recurrence rate is high (up to 50%). This is due to the ill-defined visible surgical margin, and the facial location of the lesions (often forcing the surgeon to use a narrow surgical margin). The use of dermatoscopy can significantly improve the surgeon's ability to identify the surgical margin. The narrow surgical margin used (smaller than the standard of care of 5 mm), combined with the limitation of the standard bread loafing technique of fixed tissue histology - result in a high "false negative" error rate, and frequent recurrences. Margin controlled (peripheral margins) is necessary to eliminate the false negative errors. If breadloafing is utilized, distances from sections should approach 0.1 mm to assure that the method approaches complete margin control.

Where the lesion is on the face and either large or 5mm margins are possible, a skin flap or skin graft may be indicated/required. Grafts have their own risks of failure and poor cosmetic outcomes. Flaps can require extensive incision resulting in long scars and may be better done by plastic surgeons (and possibly better again by those with extensive LM or "suspicious of early malignant melanoma" experience.

Mohs surgery has been done with cure rate reported to be 77%. [10] The "double scalpel" peripheral margin controlled excision method approximates the Mohs method in margin control, but requires a pathologist intimately familiar with the complexity of managing the vertical margin on the thin peripheral sections and staining methods. [11]

Some melanocytic nevi, and melanoma-in-situ (lentigo maligna) have resolved with an experimental treatment, imiquimod (Aldara) topical cream, an immune enhancing agent. In view of the very poor cure rate with standard excision, some surgeons combine the two methods: surgical excision of the lesion, then three months treatment of the area with imiquimod cream.

Studies seem to conflict about the level of certainty associated with using imiquimod. [12] [13]

Another treatment to be considered where standard margins cannot be achieved or cosmetics are a major consideration is ultra-soft x-ray/grenz-ray radiation. [14]

In the very elderly or those with otherwise limited life expectancy, the impact of major day surgery for excision with 5mm margins and large skin flap could be worse than doing nothing or the possibility of failed treatments with imiquimod or Grenz ray.

Related Research Articles

<span class="mw-page-title-main">Melanocytic nevus</span> Medical condition

A melanocytic nevus is usually a noncancerous condition of pigment-producing skin cells. It is a type of melanocytic tumor that contains nevus cells. Some sources equate the term mole with "melanocytic nevus", but there are also sources that equate the term mole with any nevus form.

<span class="mw-page-title-main">Cutaneous squamous-cell carcinoma</span> Medical condition

Cutaneous squamous-cell carcinoma (cSCC), or squamous-cell carcinoma of the skin, also known as squamous-cell skin cancer, is, with basal-cell carcinoma and melanoma, one of the three principal types of skin cancer. cSCC typically presents as a hard lump with a scaly top layer, but it may instead form an ulcer. Onset often occurs over a period of months. Cutaneous squamous-cell carcinoma is more likely to spread to distant areas than basal cell cancer. When confined to the outermost layer of the skin, a pre-invasive, or in situ, form of cSCC is known as Bowen's disease.

<span class="mw-page-title-main">Basal-cell carcinoma</span> Most common type of skin cancer

Basal-cell carcinoma (BCC), also known as basal-cell cancer, is the most common type of skin cancer. It often appears as a painless raised area of skin, which may be shiny with small blood vessels running over it. It may also present as a raised area with ulceration. Basal-cell cancer grows slowly and can damage the tissue around it, but it is unlikely to spread to distant areas or result in death.

<span class="mw-page-title-main">Melanoma</span> Cancer originating in melanocytes

Melanoma, also redundantly known as malignant melanoma, is a type of cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin, but may rarely occur in the mouth, intestines, or eye. In women, they most commonly occur on the legs, while in men, they most commonly occur on the back. About 25% of melanomas develop from moles. Changes in a mole that can indicate melanoma include an increase in size, irregular edges, change in color, itchiness, or skin breakdown.

<span class="mw-page-title-main">Nevus</span> Mole or birthmark; visible, circumscribed, chronic skin lesion

Nevus is a nonspecific medical term for a visible, circumscribed, chronic lesion of the skin or mucosa. The term originates from nævus, which is Latin for "birthmark"; however, a nevus can be either congenital or acquired. Common terms, including mole, birthmark, and beauty mark, are used to describe nevi, but these terms do not distinguish specific types of nevi from one another.

<span class="mw-page-title-main">Acral lentiginous melanoma</span> Medical condition

Acral lentiginous melanoma is an aggressive type of skin cancer. Melanoma is a group of serious skin cancers that arise from pigment cells (melanocytes); acral lentiginous melanoma is a kind of lentiginous skin melanoma. Acral lentiginous melanoma is the most common subtype in people with darker skins and is rare in people with lighter skin types. It is not caused by exposure to sunlight or UV radiation, and wearing sunscreen does not protect against it. Acral lentiginous melanoma is commonly found on the palms, soles, under the nails, and in the oral mucosa. It occurs on non-hair-bearing surfaces of the body, which have not necessarily been exposed to sunlight. It is also found on mucous membranes.

<span class="mw-page-title-main">Seborrheic keratosis</span> Skin disease

A seborrheic keratosis is a non-cancerous (benign) skin tumour that originates from cells, namely keratinocytes, in the outer layer of the skin called the epidermis. Like liver spots, seborrheic keratoses are seen more often as people age.

<span class="mw-page-title-main">Actinic keratosis</span> Skin disorder

Actinic keratosis (AK), sometimes called solar keratosis or senile keratosis, is a pre-cancerous area of thick, scaly, or crusty skin. Actinic keratosis is a disorder of epidermal keratinocytes that is induced by ultraviolet (UV) light exposure. These growths are more common in fair-skinned people and those who are frequently in the sun. They are believed to form when skin gets damaged by UV radiation from the sun or indoor tanning beds, usually over the course of decades. Given their pre-cancerous nature, if left untreated, they may turn into a type of skin cancer called squamous cell carcinoma. Untreated lesions have up to a 20% risk of progression to squamous cell carcinoma, so treatment by a dermatologist is recommended.

<span class="mw-page-title-main">Superficial spreading melanoma</span> Medical condition

Superficial spreading melanoma (SSM) is a type of skin cancer that typically starts as an irregularly edged dark spot typically on sun-exposed part of the body. The colour may be variable with dark, light and reddish shades; occasionally no color at all. It typically grows in diameter before spreading to deeper tissue, forming a bump or becoming an ulcer. Itching, bleeding and crust formation may occur in some. The backs and shoulders of males and legs of women are particularly prone.

<span class="mw-page-title-main">Dysplastic nevus</span> Medical condition

A dysplastic nevus or atypical mole is a nevus (mole) whose appearance is different from that of common moles. In 1992, the NIH recommended that the term "dysplastic nevus" be avoided in favor of the term "atypical mole". An atypical mole may also be referred to as an atypical melanocytic nevus, atypical nevus, B-K mole, Clark's nevus, dysplastic melanocytic nevus, or nevus with architectural disorder.

<span class="mw-page-title-main">Lentigo maligna melanoma</span> Medical condition

Lentigo maligna melanoma is a melanoma that has evolved from a lentigo maligna, as seen as a lentigo maligna with melanoma cells invading below the boundaries of the epidermis. They are usually found on chronically sun damaged skin such as the face and the forearms of the elderly.

<span class="mw-page-title-main">Dermatoscopy</span> Medical examination of the skin

Dermatoscopy also known as dermoscopy or epiluminescence microscopy, is the examination of skin lesions with a dermatoscope. It is a tool similar to a camera to allow for inspection of skin lesions unobstructed by skin surface reflections. The dermatoscope consists of a magnifier, a light source, a transparent plate and sometimes a liquid medium between the instrument and the skin. The dermatoscope is often handheld, although there are stationary cameras allowing the capture of whole body images in a single shot. When the images or video clips are digitally captured or processed, the instrument can be referred to as a digital epiluminescence dermatoscope. The image is then analyzed automatically and given a score indicating how dangerous it is. This technique is useful to dermatologists and skin cancer practitioners in distinguishing benign from malignant (cancerous) lesions, especially in the diagnosis of melanoma.

<span class="mw-page-title-main">Lentigo</span> Medical condition

A lentigo is a small pigmented spot on the skin with a clearly defined edge, surrounded by normal-appearing skin. It is a harmless (benign) hyperplasia of melanocytes which is linear in its spread. This means the hyperplasia of melanocytes is restricted to the cell layer directly above the basement membrane of the epidermis where melanocytes normally reside. This is in contrast to the "nests" of multi-layer melanocytes found in moles. Because of this characteristic feature, the adjective "lentiginous" is used to describe other skin lesions that similarly proliferate linearly within the basal cell layer.

<span class="mw-page-title-main">Mohs surgery</span> Surgery used to treat skin cancers

Mohs surgery, developed in 1938 by a general surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat both common and rare types of skin cancer. During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery is the gold standard method for obtaining complete margin control during removal of a skin cancer using frozen section histology. CCPDMA or Mohs surgery allows for the removal of a skin cancer with very narrow surgical margin and a high cure rate.

<span class="mw-page-title-main">Surgical pathology</span> Area of practice for anatomical pathologists

Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists.

<span class="mw-page-title-main">Blue nevus</span> Type of melanocytic tumor

A blue nevus is a type of coloured mole, typically a single well-defined blue-black bump.

<span class="mw-page-title-main">Skin biopsy</span>

Skin biopsy is a biopsy technique in which a skin lesion is removed to be sent to a pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose Mohs surgery. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion. Like most biopsies, patient consent and anesthesia are prerequisites.

Pseudomelanoma is a cutaneous condition in which melanotic skin lesions clinically resemble a superficial spreading melanoma at the site of a recent shave removal of a melanocytic nevus.

Oral pigmentation is asymptomatic and does not usually cause any alteration to the texture or thickness of the affected area. The colour can be uniform or speckled and can appear solitary or as multiple lesions. Depending on the site, depth, and quantity of pigment, the appearance can vary considerably.

Electrodesiccation and curettage is a medical procedure commonly performed by dermatologists, surgeons and general practitioners for the treatment of basal cell cancers and squamous cell cancers of the skin. It provides desiccation, coagulation/cauterization, and curettage to remove lesions from the skin.

References

  1. Oakley, Amanda (2011). "Lentigo maligna and lentigo maligna melanoma". DermNet NZ.
  2. 1 2 Michael Xiong; Ahmad Charifa; Chih Shan J. Chen (2022). "Lentigo Maligna Melanoma". Cancer, Lentigo Maligna Melanoma. PMID   29489150.{{cite book}}: |website= ignored (help) Last Update: May 18, 2019.
  3. Green A, Little JH, Weedon D (January 1983). "The diagnosis of Hutchinson's melanotic freckle (lentigo maligna) in Queensland". Pathology. 15 (1): 33–5. doi:10.3109/00313028309061399. PMID   6856341. S2CID   36643652.
  4. synd/1439 at Who Named It?
  5. J. Hutchinson. Senile freckle with deep staining - a superficial epithelioma of the cheek. Archives of Surgery, London, 1892, 3: 159.
  6. McKenna JK, Florell SR, Goldman GD, Bowen GM (April 2006). "Lentigo maligna/lentigo maligna melanoma: current state of diagnosis and treatment". Dermatol Surg. 32 (4): 493–504. doi:10.1111/j.1524-4725.2006.32102.x. PMID   16681656. S2CID   8312676.
  7. "Precancerous conditions of the skin". Canadian Cancer Society. Retrieved 2020-02-26.
  8. Fleming, C. (2010). "How to manage patients with lentigo maligna". Melanoma Research. 20: e26. doi:10.1097/01.cmr.0000382797.99333.66. ISSN   0960-8931.
  9. Tzellos, T; Kyrgidis, A; Mocellin, S; Chan, A; Pilati, P; Apalla, Z (19 December 2014). "Interventions for melanoma in situ, including lentigo maligna". The Cochrane Database of Systematic Reviews. 12 (12): CD010308. doi:10.1002/14651858.CD010308.pub2. PMID   25526608.
  10. Mikhail, G. Mohs Micrographic Surgery. 1991, Saunders, pp. 13-14
  11. Usefulness of the Staged Excision for Lentigo Maligna and Lentigo Maligna Melanoma: The 'Square' Procedure" (J Am Acad Dermatol 1997;37:758-63)
  12. Li, Lena (2011). "Efficacy of Imiquimod Cream, 5%, for Lentigo Maligna After Complete Excision". Archives of Dermatology. 147 (10): 1191–5. doi: 10.1001/archdermatol.2011.260 . PMID   22006136 . Retrieved 2 November 2011.
  13. Powell, A. M. (2009). "Imiquimod and lentigo maligna: a search for prognostic features in a clinicopathological study with long-term follow-up". British Journal of Dermatology. 160 (5): 994–998. doi:10.1111/j.1365-2133.2009.09032.x. PMID   19222462. S2CID   25643838.
  14. Hedblad, Mari-Anne (2012). "Grenz ray treatment of lentigo maligna and early lentigo maligna melanoma". Journal of the American Academy of Dermatology. 67 (1): 60–68. doi:10.1016/j.jaad.2011.06.029. PMID   22030019.