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Objective To ascertain and clarify the effectiveness and advantages of the geometric staged excision technique for the removal of lentigo maligna (LM) and lentigo maligna melanoma (LMM). Design This was a retrospective review of a patient database composed of 293 cases of LM and LMM. Setting The Laser and Dermatologic Surgery Center in St Louis, Missouri, an academic-affiliated, private dermatologic surgery center. Patients All patients with a diagnosis of LM and LMM treated by staged excision from 1999 to 2007. Main Outcome Measures The overall rate of recrudescence, margins required for clearance, stages required for clearance, and lesional characteristics were examined. Results The rate of recrudescence after geometric staged excision was 1.7% (4/239), with a mean of 32.3 months of follow-up. The mean margin to clearance after excision was 6.6 mm for LM and 8.2 mm for LMM. A total of 11.7% of LMM was initially diagnosed as LM on biopsy, with the invasive component discovered during the excision. Conclusions Geometric staged excision is an optimal method of removal of LM and LMM given its low rate of recrudescence and ability for complete examination of the peripheral and deep margins of the specimens.

Objective To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. Design Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. Setting Mohs surgical clinic in an academic institution. Patients Ninety patients with biopsy-confirmed LM. Interventions Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. Main Outcome Measure The presence or absence of residual LM at the time of staged excision. Results Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P = .17). There have been no recurrences to date, with a mean follow-up period of 42 months. Conclusions Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence. Trial Registration clinicaltrials.gov Identifier: NCT00707174

To investigate risk factors for lentigo maligna melanoma (LMM) compared with superficial spreading melanoma (SSM).Population-based case-control study in Queensland, Australia.General community.Population-based sample of 49 patients with LMM and 141 with SSM (in situ or invasive) aged 14 to 86 years at diagnosis in 1979 and 1980 and 232 control subjects. Response rates were 97.1% in cases and 91.8% in controls.Risks of both subtypes in relation to phenotypic and environmental factors, estimated by multinomial logistic regression.The number of solar lentigines was the strongest determinant for LMM (odds ratio [OR], 15.93; P .001 for trend) and significantly weaker for SSM (4.61; P .001 for trend; P = .04 for homogeneity). Skin cancer history was significantly associated with LMM (OR, 2.84) but not with SSM (1.33; P = .07 for homogeneity). In contrast, the number of nevi was the strongest determinant for SSM (OR, 23.22; P .001 for trend) while significantly weaker for LMM (3.60; P = .02 for trend; P .001 for homogeneity). Multiple lifetime sunburns almost tripled the risk for SSM, whereas no association was detected with LMM (P = .04 for homogeneity). Shared risk factors for both subtypes were the number of solar keratoses (P .001 for trend for both) and sun-sensitive complexion (ie, light eye/hair colors, sunburn propensity, and freckling) (2-fold to 5-fold increased risks).A propensity to lentigines is a stronger predictor of LMM, whereas high nevus propensity is a stronger predictor of SSM. Skin cancer history appears to determine LMM risk only, whereas the number of lifetime sunburns determines SSM only. Prevention strategies could be tailored differently given these distinctive points of difference.

D E R M O S C O P I C C L U E S T O L E N T I G O maligna (LM) include asymmetrical pigmented follicular openings, perifollicular slate-gray dots and granules, circles within circles, atypical blood vessels, and linear pigmented lines forming rhomboidal structures. We have observed a previously unreported dermoscopic pattern in LM that consists of brown to bluish gray dots and lines arranged in an angulated linear pattern, creating a zig-zag appearance (Figures 1, 2, 3, and 4). The zig-zag pattern probably represents incompletely formed rhomboidal structures. Like other dermoscopic findings, the zigzag pattern is not pathognomonic for LM, but in our experience, it is a suggestive dermoscopic pattern that may aid in the diagnosis of some otherwise difficult to diagnose LMs. All of the dermoscopic structures seen in LM can also be manifested in pigmented actinic keratoses, including the zig-zag pattern. However, one clinical clue to differentiate pigmented actinic keratoses from LMs is the presence of a rough texture in the former.

To examine incidence and survival patterns of acral lentiginous melanoma (ALM) in the United States.Population-based registry study. We used the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute to evaluate data from 17 population-based cancer registries from 1986 to 2005.A total 1413 subjects with histologically confirmed cases of ALM. Main Outcome Measure Incidence and survival patterns of patients with ALM.The age-adjusted incidence rate of ALM overall was 1.8 per million person-years. The proportion of ALM among all melanoma subtypes was greatest in blacks (36%). Acral lentiginous melanoma had 5- and 10-year melanoma-specific survival rates of 80.3% and 67.5%, respectively, which were less than those for all cutaneous malignant melanomas overall (91.3% and 87.5%, respectively; P.001). The ALM 5- and 10-year melanoma-specific survival rates were highest in non-Hispanic whites (82.6% and 69.4%), intermediate in blacks (77.2% and 71.5%), and lowest in Hispanic whites (72.8% and 57.3%) and Asian/Pacific Islanders (70.2% and 54.1%). Acral lentiginous melanoma thickness and stage correlated with survival according to sex and in the different racial groups.Population-based data showed that ALM is a rare melanoma subtype, although its proportion among all melanomas is higher in people of color. It is associated with a worse prognosis than cutaneous malignant melanoma overall. Hispanic whites and Asian/Pacific Islanders have worse survival rates than other groups, and factors such as increased tumor thickness and more advanced stage at presentation are the most likely explanations.

Objective To assess lentigo maligna (LM) as an epidemiological entity separate from other melanomas (OMs) in elderly people. Design Double age- and sex-matched case-control study to compare the risk factors for LMs and OMs. Setting General community. Patients A total of 76 patients with LM were paired by age and sex with 76 patients with OMs and 152 controls. Main Outcome Measures The association of melanoma risk with the following potential risk factors: sun exposure history by 10-year periods, frequency of sunburns, phenotypic traits, density of freckles and sun sensitivity at age 20 years, counts of nevi larger than 2 mm in diameter on the face and forearm, skin aging features (as assessed using a photographic scale), and history of basal and/or squamous cell carcinomas. Results Risk of LMs and OMs were similarly associated with history of sunburns, light skin type, and freckling. Cumulative chronic outdoor and occupational sun exposures were not risk factors in any of the 2 groups of melanomas. Lentigo maligna differed from OMs by the absence of a detectable association with the number of nevi and a greater association with nonmelanoma skin cancers. Conclusions Although chronically sun-exposed skin is a prerequisite for LM, risk of LM does not increase with the cumulative dose of sun exposure, but LM is associated with sunburn history, like all other types of melanomas. The main epidemiological characteristic of LM is the absence of an apparent relation with the genetic propensity to develop nevi. This epidemiological profile is in accordance with recent molecular findings and may also account for the histoclinical and evolutive characteristics of LM.

To compare the prognosis of patients with scalp or neck (scalp/neck) melanomas with that of patients with melanomas at other sites in a large, population-based national data set controlling for known prognostic factors.Retrospective cohort study using US cancer registries that constitute the Surveillance, Epidemiology, and End Results 13 Registries (SEER-13) database.A total of 51 704 non-Hispanic white adults in the United States with a first invasive cutaneous melanoma reported during the period 1992 to 2003.Kaplan-Meier survival estimates were used to compare melanoma-specific survival by anatomic site at 5 and 10 years. Multivariate Cox models were used to examine the hazard ratio (HR) of melanoma-specific death associated with scalp/neck melanoma compared with melanoma of the extremities after controlling for other variables.The 5- and 10-year Kaplan-Meier survival probabilities for scalp/neck melanoma were 83.1% and 76.2%, respectively, compared with 92.1% and 88.7%, respectively, for melanoma of the other sites, including extremities, trunk, face, and ears (log-rank test; P.001). In a multivariate Cox model, the patients with melanoma of the scalp/neck died of melanoma at 1.84 times (HR, 1.84; 95% confidence interval, 1.62-2.10) the rate of those with melanoma on the extremities, controlling for age, Breslow thickness, sex, and ulceration. Neither excluding cases of lentigo maligna and nodular melanoma nor controlling for lymph node involvement materially changed the HR for scalp/neck melanoma.A notable survival difference remained between scalp/neck melanoma and melanoma of other sites even after adjustment for important prognostic factors. This finding has implications for screening and public health recommendations, and we urge physicians, physician assistants, nurses, and nurse practitioners to examine the scalp/neck carefully during routine skin examinations. Further studies are needed to understand the biological or environmental factors leading to survival differences by anatomic site.

Objective To assess current practices of US dermatologists regarding the diagnosis, treatment, and management of melanoma in situ (MIS). Design Survey. Participants A total of 1200 dermatologists randomly selected from the American Board of Medical Specialists Directory of Board Certified Medical Specialists. Main Outcome Measures Results based on 597 questionnaires returned. Results The overall response rate was 63% (597 of 945 eligible participants). To aid in clinical assessment, respondents reported using a magnifying lens (57.4%) and dermoscopy (17.4%). Most dermatologists preferred excisional and saucerization biopsies as the method of choice for sampling. A large percentage of physicians (78.9%) preferentially used dermatopathologists for the evaluation of the majority of pigmented lesions. Although most respondents would not unquestioningly accept a benign pathology diagnosis when there was a clinical suspicion of MIS, 16.1% would accept a pathologist’s diagnosis without further action. There was no consensus on the appropriate surgical margins or depth of excision for MIS. Of the respondents who characterized MIS as premalignant and malignant, 63.2% and 46.4%, respectively, did not know what percentage of MISs would progress to metastatic disease if left untreated. Conclusions Considerable variability exists in the clinical concept and management of MIS. Dermoscopy is underutilized. The true nature of the evolution of MIS is unknown. Surgical margins and depth of excision need to be standardized to help dermatologists manage disease. Further research in the specific area of MIS is warranted to develop clear guidelines in the management and prevention of further disease.

Background Surgical excision is the treatment of choice for lentigo maligna (LM), or melanoma in situ. Topical application of imiquimod, a local immune response modifier, is a novel therapeutic approach that leads to LM tumor clearance. This pilot, open-label, nonrandomized study evaluates the efficacy of imiquimod in patients with LM and other systemic problems that make them poor surgical risks. Observations Six biopsy-proven cases of LM from 5 patients (age range, 67-80 years) in whom standard surgical therapy was contraindicated were enrolled in the study. Five tumors were located on the face and 1 on the right shoulder. Imiquimod was used as a 5% cream once a day for a maximum of 13 weeks. Immediate clinical responses and follow-up, as well as histopathologic changes and immunohistologic parameters (in 2 patients), were analyzed. The complete response rate for all LM cases was 100%. Time to complete clearing varied from 5 to 13 weeks based on both clinical and histopathologic findings. The inflammatory infiltrate following imiquimod treatment consisted of T-helper lymphocytes mixed with a significant number of cytotoxic cells and monocytes or macrophages. These results indicate that imiquimod induces a cytotoxic T-cell–mediated immune response. In all patients, erythema and erosions occurred at the treated area 2 to 4 weeks after initiation of imiquimod therapy. The patients have been followed up for 3 to 18 months without evidence of recurrences. Conclusions Topical imiquimod appears to be an excellent therapeutic option for LM. Close evaluation of patients, including posttherapy histopathologic investigation, is essential. Imiquimod can be added to the list of therapeutic approaches for carefully selected patients with LM.

Objective To compare identification of the border of lentigo maligna (LM) with digital epiluminescence microscopy (DELM) with clinical and Wood light assessment. Design The borders of lesions identified clinically with the Wood light, with DELM, and after excision by Mohs micrographic surgery were traced onto plastic sheets. The borders defined on the tracings were compared for congruence and mean surface area. Setting Cardinal Bernardin Cancer Center for Skin Cancer, Loyola University Health System, Maywood, Ill. Patients Twenty-six consecutive patients with LM of the head and neck. Main Outcome Measures Results of the comparison of the outlines of the borders and the mean surface area identified by the 4 methods. Results The border determined by clinical examination was smaller than that determined with the Wood lamp or by DELM. Most lesions underwent an additional excision 5 mm beyond the DELM-defined border. The DELM pattern of LM with asymmetric follicular openings and dark brown rhomboidal structures changed at the periphery and became a pigmented thin mesh that was associated with the histopathological features of melanoma in situ. More homogeneous pigmented areas extending from the LM were associated with the pathologic features of melanocytic hyperplasia. Conclusions Visualization of LM by DELM (dermoscopy) helps to guide resection. Because LM arises in sun-damaged skin with melanocytic hyperplasia, determining the tumor-free margin requires the judgment of an experienced physician.

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

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

Background Lentigo maligna (LM) is a form of melanoma in situ most often seen in white patients on sun-exposed areas, primarily the head and neck. Spread of LM onto the conjunctiva has been reported. There have been no reports of LM extending onto oral mucosa. Observations We report 4 cases of LM in white women with contiguous spread from perioral areas to oral mucosa. The locations of the primary lesions were the vermilion of the lip, vermilion and perioral skin, cheek, and cutaneous aspect of the lip. Three cases showed focal histopathologic evidence of invasion during the course of the disease. The lesions ran a prolonged course characterized by repeated recurrences after surgery. Three of the cases required a complicated reconstruction after surgical excision. Mohs surgery with rush permanent (paraffin-embedded) sections resulted in a long remission in 2 cases, while in 1 patient, treatment with carbon dioxide laser was unsuccessful. Conclusions In a perioral distribution, LM can spread onto oral mucosa. This clinical presentation may cause significant long-term morbidity, as indicated by a high recurrence rate and/or progression to invasive melanoma. The oral mucosa should be examined in patients with atypical pigmented perioral lesions.

Lentigo maligna can be defined as ''melanoma in situ,'' histologically showing atypical melanocytes confined to the epidermis and appendageal epithelium. The clinical appearance of lentigo maligna features inhomogeneously pigmented, polycyclic macules arising predominantly in sun-exposed areas in elderly whites ( Figure , left). The lesions tend to enlarge slowly in a horizontal direction. They may, within years, give rise to metastatic disease. Complete but conservative excision should be the treatment of choice to achieve accurate microstaging and to reduce the likelihood of recurrence. In patients showing hazardous health conditions due to systemic diseases, malformations, or advanced age, or presenting with large lentigo maligna lesions in cosmetically precarious locations that require flaps or skin grafts, surgical excision may be not be possible. We performed carbon dioxide laser vaporization of histopathologically verified lentigo maligna lesions in four selected patients ( Table ). Materials and Methods. Carbon Dioxide Laser . The carbon dioxide laser emits invisible infrared light

Although surgical excision is considered the treatment of choice for lentigo maligna, some elderly patients presenting with large lesions in the head and neck region may not be suitable candidates for surgical management. Radiotherapy has been used for this tumor at the Princess Margaret Hospital, Toronto, Ontario, for over the past 20 years with encouraging results. Fifty-four patients treated between 1968 and 1988 were identified, and their records were reviewed to determine treatment outcome.Younger patients with smaller lesions were treated with surgical excision (n = 18) and achieved an actuarial tumor control rate of 94% at 3 years. Older patients with larger lesions located in the head and neck area were treated by radiotherapy (n = 36), with an actuarial tumor control rate of 86% at 5 years. Three of the four patients not achieving tumor control by radiation were successfully treated with surgical excision, and two of them proved to have malignant melanomas (both Clark's level II) when examined histologically. One patient with residual pigmentation 4 months after treatment was unavailable for follow-up. No patients developed metastatic melanoma. The late cosmetic appearance was acceptable in the majority of irradiated patients, with 11% showing poor cosmesis due to progressive skin pallor, atrophy, and telangiectasia in the treated area.Conventional fractionated radiation therapy with superficial x-rays is a simple and effective method of management for lentigo maligna of the head and neck region. It is an excellent alternative treatment to surgical excision, with low morbidity and acceptable long-term cosmetic results.

Objective To determine the efficacy of imiquimod cream, 5%, in the treatment of lentigo maligna (LM). Design Open-label before-and-after interventional study. Setting A multidisciplinary melanoma clinic at a major tertiary hospital. Patients Forty-three patients with biopsy-proven LM of greater than 5 mm in diameter completed this study. Interventions Imiquimod cream, 5%, was applied to the lesion 5 days a week for 12 weeks. The original lesion was excised with a 5-mm margin. Main Outcome Measures The primary outcome was histopathologic evidence of LM in the excision specimen assessed independently by 2 of 3 dermatopathologists. Visible inflammation during treatment and macroscopic clearance were recorded. Results When 5 of the 43 patients with discordant histopathologic assessment of the excision specimen were excluded, 20 of 38 patients (53% [95% confidence interval, 36%-69%]) demonstrated histopathologic clearance of LM after imiquimod treatment. Visible inflammation was significantly associated with histopathologic clearance (P = .04), but the positive predictive value was low (62%). Macroscopic clearance showed some association with histopathologic clearance (P = .11). Dermatopathologist concordance for all 43 specimens was substantial ( κ = 0.77; 95% confidence interval, 0.57-0.96). Conclusions Imiquimod cream, 5%, has limited efficacy in the treatment of LM when determined by histopathologic assessment of the entire treated area. The clinical signs of visible inflammation during treatment and apparent lesion clearance cannot be relied on to assess efficacy. Trial Registration anzctr.org.au Identifier: ACTRN12610000066088

Objectives To assess interobserver and intraobserver concordance for identifying positive and negative margins in staged excisions of lentigo maligna and lentigo maligna melanoma and to determine if control biopsy specimens are useful to improve concordance. Design Retrospective, randomized interobserver and intraobserver comparison study of archived pathologic specimens. The study was conducted in 3 phases, and slides were evaluated blindly and independently by 5 pathologists: in phase 1, all slides were randomized and diagnosed as positive or negative. In phase 2, every third slide was evaluated again and diagnosed as positive or negative. In phase 3, slides were organized into cases, allowing evaluation of each margin in the context of the positive control (tumor from the center of the lesion) and negative control (control biopsy specimen), if available. Setting University referral center. Study Material A total of 301 glass microscopic slides from 27 patients who underwent staged excision for lentigo maligna or lentigo maligna melanoma from March 1997 to April 2001. Main Outcome Measures Interobserver and intraobserver concordance between original diagnoses and study diagnoses rendered on all slides by 5 pathologists. Results Phase 1 and 3 agreement was moderate (κ range, 0.4-0.5). Phase 2 (intraobserver) agreement was moderate to good for all pathologists (κ range, 0.6-0.9). Subset analysis revealed a statistically significant increase in agreement with the use of a control strip biopsy specimen for difficult slides. Conclusions Interobserver concordance for margin analysis in lentigo maligna and lentigo maligna melanoma is moderate, and intraobserver concordance is moderate to good. A control strip biopsy specimen may improve concordance in some cases.

Melanotic freckle is a pigmented, precancerous lesion that is clinically distinctive, sometimes difficult to interpret histopathologically, and which presents a problem in histological diagnosis, prognosis, and in treatment. It progresses slowly, sometimes to a malignant tumor stage (superficial melanocarcinoma) which may be indistinguishable from malignant melanoma, and yet its prognosis as to metastasis, morbidity, and mortality is comparatively favorable. Dermatologic literature contains several comprehensive reports of this unusual entity since its original description by Hutchinson. 1 Noteworthy are those of Dubreuilh, 2,3 Meischer, 4,5 Justitz, 6 and more recently, Klauder and Beerman. 7 There have been two hundred cases reported in all. The purpose of this presentation is to record twelve additional cases seen in private practice and clinic practice. Nomenclature Melanotic freckle has been described under many names, such as senile freckle, infective melanotic freckle, melanose circonscrite precancereuse, lentigo malin des vieillards

IT HAS been stated that diagnosis of cutaneous malignant melanoma is comparable to writing the death certificate of the patient. An exception to this gloomy prognosis is the malignant melanoma arising from the pigmented lesion that Hutchinson * first described as senile freckle or infective melanotic freckle, later termed by Darier and by Dubreuilh lentigo malin des vieillards and still later by Dubreuilh 3 melanose circonscrite precancereuse . We believe this disease is too briefly discussed in the usual textbooks of dermatology to afford comprehensive understanding of the pathologic process and differentiation from the more serious malignant melanoma arising from the pigmented dermoepidermal nevus (junction type nevus). Such differentiation is of importance from the standpoint of prognosis and of treatment. Discussion of these features is the object of this report. Since Hutchinson's * brief description of the disease relatively few comprehensive reports have been published. Notable exceptions