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Wide local excision (WLE) to achieve adequate clearance margins is the standard initial definitive treatment for patients with biopsy-proven primary cutaneous melanoma. Residual melanoma in WLE specimens after prior complete excision-biopsy (CEB) is reported in 0-6.3% of cases. However, studies evaluating the prevalence, clinicopathological features and relevance of persistent disease in WLE specimens are limited. This study sought to determine the frequency of and clinicopathological characteristics associated with residual melanoma in WLE specimens performed after a CEB of primary cutaneous or acral melanoma (in situ or invasive) with clinically and histologically tumour-free margins, and assess its relevance. A review of the research database and pathology archives of a large Australian tertiary referral melanoma treatment centre was performed. Eligible patients were those for whom a definitive WLE was performed after CEB of a primary melanoma (in situ or invasive) with negative clinical and histological margins, between May 2013 and May 2015. All partial biopsies were excluded. Of 640 eligible patients, 510 (79.7%) had invasive melanoma and 130 (20.3%) had melanoma in situ. Residual disease was identified in 20 cases (20/640, 3.1%), of which three (15%) were melanoma in situ on CEB and 17 (85%) were invasive melanoma. On univariate analysis, the presence of residual disease in WLE specimens was associated with lentigo maligna (LM)/LM melanoma (LMM) subtype [odds ratio (OR) 10.33; 95% confidence interval (CI) 2.84-37.54; p=0.004], nodular melanoma (NM) subtype (OR 4.92; 95% CI 1.53-15.85; p=0.0076) and, for invasive tumours, higher tumour mitotic rate (mean 7.7, SD 7.51 vs 3.4, SD 4.83; OR 1.11; 95% CI 1.04-1.18; p=0.0014). Breslow thickness >4 mm was associated with a higher risk of residual disease (OR 7.30; 95% CI 1.88, 28.26; p=0.004). Cases with residual disease had primary tumours with a significantly larger diameter (median 14 mm, range 4-25) than those without residual disease (median 9 mm, range 2-60), (OR 1.07; 95% CI 1.03-1.11; p≤0.001) and were also more likely to be amelanotic (38% vs 14%), (OR 3.69; 95% CI 1.17, 11.60; p=0.026). Residual disease was associated with assessment of >3 slides of tissue (OR 6.98; 95% CI 1.54-31.62; p=0.0118) and complete blocking of the scar (OR 31.69; 95% CI 3.98-252.21; p=0.0011). Residual melanoma in WLE specimens is an infrequent occurrence. Risk factors for residual disease are LM/LMM and NM melanoma subtypes, higher mitotic rate, larger lesion diameter and amelanosis. Tumours with these features warrant more extensive pathological sampling. WLE after CEB for melanoma remains an important procedure to reduce local recurrence; however, limited pathological sampling of the WLE scar is probably appropriate for cases lacking high risk features.

Background Achieving negative margins for melanoma in situ, lentigo maligna type can be challenging, particularly on cosmetically sensitive areas. Objective To assess the utility of intraoperative frozen section margin assessment using a teledermatopathology system in the treatment of head and neck lentigo maligna. Methods and materials Over a 6 year period, 96 patients with lentigo maligna had surgical excisions. The margins were assessed intraoperatively with frozen sections prepared in the manner used in Mohs surgery. The surgeon guided the frozen section slides around the margin while a dermatopathologist assessed the margin remotely. Results In 2/96 (2.1%) cases, the safety margin was positive (frozen sections were false negative). In 1 further case (1%) there was a recurrence of the melanoma 13 months following the excision. Conclusion The described method is effective in treating melanoma in situ, lentigo maligna type with clearance rates similar to previous studies for Mohs surgery.

INTRODUCTION Lentigo maligna (LM), a subtype of melanoma in-situ commonly occurring in the head and neck region, often presents a treatment challenge due to anatomical constraints, particularly on the face of mostly elderly patients. This study sought to assess the clinical outcomes of wide local excision of head and neck LM, identify predictors of recurrence and define optimal excision margins. MATERIALS AND METHODS Patients with LM treated between January 1997 and December 2012 were identified from the large institutional database of a tertiary center and their data were analyzed. RESULTS In 379 patients, 382 lesions were eligible for analysis. Median maximal lesion diameter was 10.5 mm. The mean surgical excision and histopathological clearance margins were 6.2 mm and 4.0 mm, respectively. Median follow-up was 32 months. The LM recurrence rate was 9.9%, and subsequent invasive melanoma developed in 2.3% of cases (mean Breslow thickness 0.7 mm). The recurrence rate was 27.2% if the histological margin was

Background There are no well-defined clinical factors to predict the risk of occult invasion in melanoma of the lentigo maligna type (LM) before complete histopathologic analysis. Objective To evaluate whether clinical size was a predictor of invasion in LM and subclinical extension. Methods Consecutive cases of LM were recorded in a prospectively maintained database from 2006 to 2019. Patient and tumor data were recorded during initial evaluation. The LM clinical area was calculated in square millimeters (length × width). All patients were treated with staged excision. Results We included 600 patients. The mean age was 65.9 years (standard deviation, 12.3; range, 27-95 years); 62.8% (n = 377) were men. The mean LM clinical area was 128.32 mm2 for in situ lesions versus 200.14 mm for invasive lesions (P = .1). Based on quantile regression, the median margin required for complete removal increased with LM clinical area. Limitations The study was performed in a tertiary cancer center with possible referral bias and more complex cases. Conclusions LM can present with variable clinical size, which may correlate with subclinical extension; however, the presence of invasion is not well estimated by LM clinical area.

Background A recently introduced dermoscopic method for the diagnosis of early lentigo maligna (LM) is based on the absence of prevalent patterns of pigmented actinic keratosis and solar lentigo/flat seborrheic keratosis. We term this the inverse approach. Objective To determine whether training on the inverse approach increases the diagnostic accuracy of readers compared to classic pattern analysis. Methods We used clinical and dermoscopic images of histopathologically diagnosed LMs, pigmented actinic keratoses, and solar lentigo/flat seborrheic keratoses. Participants in a dermoscopy masterclass classified the lesions at baseline and after training on pattern analysis and the inverse approach. We compared their diagnostic performance among the 3 timepoints and to that of a trained convolutional neural network. Results The mean sensitivity for LM without training was 51.5%; after training on pattern analysis, it increased to 56.7%; and after learning the inverse approach, it increased to 83.6%. The mean proportions of correct answers at the 3 timepoints were 62.1%, 65.5, and 78.5%. The percentages of readers outperforming the convolutional neural network were 6.4%, 15.4%, and 53.9%, respectively. Limitations The experimental setting and the inclusion of histopathologically diagnosed lesions only. Conclusions The inverse approach, added to the classic pattern analysis, significantly improves the sensitivity of human readers for early LM diagnosis.

Skin cancer is a broad term used to describe a number of different malignant indications of the skin. Skin cancers mostly comprise of the keratinocyte cancers [Basal Cell Carcinoma (BCC) and cutaneous Squamous Cell Carcinoma (SCC)], and melanoma. Surgical excision of these malignancies has been the preferred treatment of patients for decades. However, the decision to perform surgery can be affected by various considerations, including co-morbidities of the patient, the anatomical site of the lesion and potential intolerance for repeated excisions. Topical treatment of skin cancer may therefore be more appropriate in certain instances. Topical treatment potentially allows for higher drug levels at the tumor site, and may result in less overall toxicity than systemic agents. This review will specifically address the current agents used in topical treatment of skin cancers, and introduce emerging treatments from the natural product field that may also find utility in these indications.

There are multiple, genetically distinct pathways that give rise to melanoma. Melanomas on sun-damaged skin (MSDS), including lentigo maligna and desmoplastic melanoma, have distinct genetic profiles and are uniquely linked to chronic ultraviolet exposure. In this article, we discuss the etiologies of lentigo maligna and desmoplastic melanoma, emerging diagnostic adjuncts that might be helpful for accurately identifying these lesions, and the clinical relevance of their frequent co-occurrence. We present unique and overlapping features of these entities and discuss challenges in MSDS management, including margin assessment, excision, and the potential role of nonsurgical therapy. Last, we address the role of immunotherapy in invasive disease. Understanding MSDS as distinct from melanoma arising on intermittently sun-exposed or sun-protected skin will ultimately help optimize patient outcomes.

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

Distinguishing lentigo maligna (LM) and lentigo maligna melanoma (LMM) from background pigmented non-melanoma lesions is challenging. The field of solar damage can obscure clinical assessment, and diagnostic ambiguities are created due to the overlap of the clinical features of LM with other benign lesions. Moreover, margin assessment on histology is limited by the resemblance between melanocytic hyperplasia of actinically damaged skin and scattered atypical melanocytes of LM/LMM. Dermoscopy has made a significant contribution but is often not sufficient for diagnosis and margin assessment. Confocal microscopy has become an important complementary tool in enhancing the management of these complex lesions.

Lentigo maligna is the most common form of in situ melanoma. It is most often found on the head and neck, and its clinical and dermoscopic features in this location have been extensively described in the literature. We present a series of 14 patients diagnosed with extrafacial lentigo maligna and lentigo maligna melanoma at Hospital General de Valencia and Hospital de Manacor in Spain, and describe the clinical, dermoscopic, and histologic features observed. Most of the melanomas were located on the upper limbs; the next most common locations were the trunk and the lower limbs. The dermoscopic patterns were consistent with facial lentigo maligna and superficial spreading melanoma. Extrafacial lentigo maligna is uncommon. It has similar clinical and histologic features to facial lentigo, but dermoscopy may show a mix of patterns typically seen in lentigo maligna and superficial spreading melanoma. This difference in dermoscopic features is essentially due to anatomical differences between skin on the face and on other parts of the body.

Melanomas are a wide range of tumors that differ in their epidemiology, morphology, genetic profile, and biological behavior. They can be grouped as superficial spreading melanoma, lentigo maligna, and nodular melanoma. Reflectance confocal microscopy is useful for the evaluation of skin lesions that are dermoscopically doubtful by increasing diagnostic accuracy and specificity. This article provides a comprehensive overview of the different confocal main morphologies of distinct melanoma types as a function of the anatomic location of the tumor.

Lentigo maligna (LM) is considered a precursor to LM melanoma (LMM). We assessed trends in LM and LMM incidence rates between 1989 and 2013 in the Netherlands, and estimated the risk of an LMM after LM. Data on newly diagnosed LM and LMM were obtained from the Netherlands Cancer Registry and PALGA: Dutch Pathology Registry. Age-standardized incidence rates (European standardized rate), estimated annual percentage changes, and the cumulative incidence of LMM after LM were calculated. Between 1989 and 2013, 10,545 patients were diagnosed with a primary LM and 2,898 with a primary LMM in the Netherlands. The age-standardized incidence rate for LM increased from 0.72 to 3.84 per 100,000 person-years, and for LMM from 0.24 to 1.19 between 1989 and 2013. LM incidence increased from 2002 to 2013 with 6.8% annually, before an even steeper rise in LMM incidence from 2007 to 2013 (estimated annual percentage change: 12.4%). The cumulative incidence of LMM after a primary LM after 25-year follow-up was 2.0% for males and 2.6% for females. The increased incidence of LM and LMM in the Netherlands seems, besides increased awareness and increased histological confirmation of LM, to reflect a true increase. The absolute risk of an LMM (at any location) after a histologically confirmed LM was low (2.0-2.6%).

Background Reflectance confocal microscopy (RCM) provides real-time noninvasive imaging of cell structure and may be useful in diagnosing lentigo maligna (LM). Few studies have compared performance of RCM with histopathology in diagnosing LM, and specific features influencing RCM interpretation are not well described. Objective We sought to determine concordance rate between RCM and histopathology in the evaluation of suspected LM and to identify factors that may obscure diagnosis. Methods We designed a prospective study involving 17 participants seen for evaluation at a large tertiary referral center. Cases included primary lesions and possible recurrent and/or previously treated lesions. A total of 63 clinically equivocal sites were assessed by RCM and histopathology. Results RCM and histopathology interpretations were concordant in 56 of 63 sites (89%). There were no false-negative and 7 false-positive results using RCM (sensitivity 100%, specificity 71%, positive predictive value 85%, negative predictive value 100%). Features suggestive of LM in the false-positive group included the presence of numerous hyperreflectile large cells at the dermoepidermal junction and follicular localization of these cells. Limitations A larger test set is needed to more reliably distinguish LM from benign lesions using RCM and to improve specificity. Conclusion RCM shows excellent sensitivity for detecting LM although features of benign macules on a background of actinically damaged skin can obscure diagnosis and limit its specificity.

Melanoma is a common cutaneous tumour. It is of great importance due to its increasing incidence and aggressive behaviour, with metastasis to lymph nodes and internal organs. When suspecting melanoma, excisional biopsy should be performed to obtain complete histological information in order to determine the adverse factors such as ulceration, mitosis rate, and Breslow depth, which influence preoperative staging and provide data for sentinel lymph biopsy decision making. The indicated management for melanoma is wide local excision, observing recommended and well-established excision margins, depending on Breslow depth and anatomical location of the tumour. Therapeutic lymphadenectomy is recommended for patients with clinically or radiologically positive lymph nodes.This article reviews surgical treatment of melanoma, adverse histological factors, sentinel lymph node biopsy, and radical lymphadenectomy.Details are presented on special situations in which management of melanoma is different due to the anatomical location (plantar, subungual, lentigo maligna), or pregnancy.

Background The reported efficacy of imiquimod for lentigo maligna varies widely, without consensus on tumor or treatment factors that can impact tumor clearance. Objective We sought to provide a more precise estimate of clearance rates in patients with lentigo maligna who are treated with imiquimod and to analyze factors that can impact tumor clearance. Methods We performed a literature search for biopsy-proven lentigo maligna treated with imiquimod monotherapy, linked treatment and outcome data to individual tumors, calculated histologic and clinical clearance rates with 95% confidence intervals (CIs), and analyzed the impact of tumor and treatment factors on tumor clearance using logistic regression. Results Based on 347 tumors from 45 studies, histologic and clinical clearance rates were 76.2% (95% CI, 71.4-81.0%) and 78.3% (95% CI, 73.6-82.9%), respectively. The incidence of clinical recurrence was 2.3% (95% CI, 0.5-4.2%), with a mean follow-up of 34.2 ± 11.8 months. Treatment with >60 total applications, or with >5 applications per week was associated with a higher likelihood of histologic clearance (odds ratio, 8.4 [95% CI, 2.9-24.1] and odds ratio, 6.0 [95% CI, 2.4-14.7], respectively). Limitations Our limitations included the accuracy and scope of published data, variable follow-up times, potential patient selection, and publication bias related to case series/cohort designs of previous studies. Conclusion Imiquimod offers a 76% histologic and 78% clinical clearance rate for lentigo maligna. Both cumulative dose and treatment intensity affect tumor clearance.

Summary Established in 2012, the Mersey Regional Centre for Mohs Surgery is the first UK Mohs service to be led by a Mohs trained Plastic & Reconstructive surgeon. We evaluate the resection requirements and reconstructive techniques of our patient group and compare their surgical outcome to that which would have been gained with conventional excision (CE) and reconstruction for the same lesions. 157 patients were analysed over 13 months. Had CE and reconstruction been used, 56% of patients would have received a more invasive or cosmetically less desirable reconstruction, and 24% of margins would remain incomplete. The outcome was unchanged in 20% of patients. A small but significant subgroup (9%) of patients would have lost fundamental structures e.g. orbital exenteration, or undergone reconstructions unnecessarily crossing aesthetic subunits. Whilst in its infancy, the Plastic & Reconstructive Mohs surgery service has provided a valuable contribution to the care given to patients in the Mersey and Cheshire Skin Cancer Network. Detailed referral criteria, thorough preoperative patient evaluation, and appreciation of the abilities and limits of CE have enabled the service to produce a demonstrable reconstructive benefit in 80% of patients when compared to non-Mohs resection and reconstruction.

Background Melanomas on chronically sun-damaged skin (CSDS) can be difficult to identify and often manifest morphologic features that overlap with benign lesions. Objective We describe and analyze the clinical and dermoscopic characteristics of melanomas on nonfacial CSDS. Methods Melanoma cases on nonfacial CSDS were retrospectively identified from the biopsy specimen logs of 6 melanoma clinics. Clinical and dermoscopic images were combined into 1 database. Demographics, clinical, dermoscopic, and histopathologic information were analyzed. Descriptive frequencies were calculated. Results One hundred eighty-six cases met the inclusion criteria: 142 melanomas in situ (76%) and 39 invasive (21%; mean thickness, 0.49 mm). Lentigo maligna was the most common histopathologic subtype (n = 76; 40.9%). The most frequent dermoscopic structures were granularity (n = 126; 67.7%) and angulated lines (n = 82; 44%). Vascular structures were more frequent in invasive melanomas (56% vs 12% of in situ melanomas). Most manifested 1 of 3 dermoscopic patterns: patchy peripheral pigmented islands, angulated lines, and tan structureless with granularity pattern. Limitations This was a retrospective study, and evaluators were not blinded to the diagnosis. In addition, interobserver concordance and sensitivity and specificity for dermoscopic structures were not evaluated. Conclusion Outlier lesions manifesting dermoscopic structures, such as granularity, angulated lines, or vessels and any of the 3 described dermoscopic patterns should raise suspicion for melanoma.

Background Little is known about the frequency of clinical and dermoscopic patterns of lentigo maligna (LM) in relation to specific anatomic subsites and patients characteristics. Objective We sought to assess the frequency of clinical and dermoscopic features of LM and to correlate them to specific anatomic subsites, and patients' age and gender. Methods This was a retrospective analysis of clinical and dermoscopic images of a series of consecutive, histopathologically diagnosed, facial and extrafacial LM. Results A total of 201 cases from 200 patients (mean age 69.51 ± 12.26 years) including 120 women were collected. Most cases were located on the face (n = 192, 95.5%). In 102 cases, LM presented as clinically solitary facial macule (s/LM), whereas it was associated with multiple surrounding freckles in the remaining cases. s/LM were significantly smaller ( 10 mm; P = .020) and associated with younger age compared with LM associated with multiple surrounding freckles (mean age 67.73 ± 12.68 years vs 71.34 ± 11.59 years, respectively; P = .036). Dermoscopically, gray color irrespective of a specific pattern was the most prevalent finding seen in 178 (88.6%) cases. Limitations This was a retrospective study. Conclusions The knowledge about patient age, patient gender, and site-related clinical features of LM associated with gray color upon dermoscopy may enhance the clinical recognition of LM.

Background The incidence of lentigo maligna (LM) may be increasing, but no population-based epidemiologic studies have been performed to our knowledge. Objective We sought to determine the incidence of LM in Olmsted County, Minnesota, along with overall and recurrence-free survival. Methods Using the Rochester Epidemiology Project, we identified all adult residents of Olmsted County, Minnesota, with a first lifetime diagnosis of LM between 1970 and 2007. Medical records were reviewed to determine demographic, clinical, and surgical data, and incidence and survival were calculated. Results Among 145 patients identified, median (range) age at diagnosis of LM was 70 (33-97) years. Treatment changed over time, with Mohs micrographic surgery becoming available after 1986. No patients died of LM; 5 had local recurrence. Estimated local recurrence-free survival at 5, 10, 15, and 20 years after diagnosis was 98%, 96%, 92%, and 92%, respectively. Overall age- and sex-adjusted incidence of LM among adults was 6.3 per 100,000 person-years, increasing from 2.2 between 1970 and 1989 to 13.7 between 2004 and 2007. Limitations Retrospective study design and homogeneous population are limitations. Conclusion The incidence of LM increased significantly among residents of Olmsted County, Minnesota, over an extended time frame, with incidence being significantly higher among men than women and increasing with age.

Melanoma in situ (MIS) is a non-invasive lesion accounting for up to 27% of all melanomas by Coory et al. (2006).(1) MIS may be a precursor to invasive disease. The Lentigo Maligna (LM) subgroup of MIS carries upto a 4.7% lifetime risk of developing an invasive component by Agarwal-Antal et al. (2002).(2) Surgical excision is recommended however other modalities of treatments are possible. In this study we aim to assess whether histological margins following excision of in situ melanoma has any bearing on recurrence or progression to malignancy.We retrospectively reviewed data accumulated on all melanomas referred to the hospital between the dates of February 2001 to February 2009. We identified all patients with melanoma in situ and for these patients recorded age, sex, anatomical site of lesion, histological type, histological excision margin, recurrence after excision and transformation to malignant melanoma.A total of 2121 patents were identified having been diagnosed and treated for melanoma of which 192 cases were identified with melanoma in situ representing 9.1% of all melanomas treated. 38% of all the lesions were of the LM subgroup. We noted a higher incomplete excision rate in this subgroup (p0.01) compared to the non-LM subgroup. We only noted two recurrences following complete excision (1.1%) and one recurrence in lesions completely excised with histological margins less than 2 mm (1.4%). Both of the lesions that recurred following complete excision were LM lesions. Recurrence following complete excision of LM was 2.9%.Our data suggests that MIS lesions that were not LM and adequately excised even with narrow margins are unlikely to recur therefore reducing the need for wider excision. LM however poses a more challenging clinical problem not only with the higher inadequate primary excision and higher recurrence rates following excision but also the fact that it occurs in much older patients who may be less able to tolerate more extensive surgery. In keeping with the literature we would suggest treating LM lesions more aggressively if possible.

Differentiating dysplastic nevi from melanoma remains one of the main objectives of dermoscopy. Melanomas tend not to manifest any of the benign patterns described for nevi and instead usually display chaotic dermoscopic morphologies. Melanomas located on the face, chronically sun-damaged skin, volar surfaces, nails, and mucosal surfaces have additional features that can assist in their identification. However, some melanomas lack any defined dermoscopic structures. These so-called featureless melanomas can be identified via digital surveillance. This article reviews the melanoma-specific structures as a function of anatomic location (ie, melanomas on nonglabrous skin, face, volar surfaces, mucosae, and nails).

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

Background Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM). A wide variety of modalities has been used to manage LM, including conventional surgery, staged excision, Mohs micrographic surgery, cryotherapy, radiotherapy, laser therapy, and, recently, imiquimod. Objectives Soft x-radiation is an accepted treatment for LM/LMM. The aim of the present study was to evaluate the efficacy and safety of ultra-soft x-ray/grenz-ray (GR) treatment in patients with LM and early LMM. Methods Five hundred ninety-three patients were treated with GR (primary therapy, n = 350; partial excision followed by GR, n = 71; radical excision followed by GR as recurrence-prophylactic treatment, n = 172) at the Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden between 1990 and 2009. The treatment was given twice a week over 3 consecutive weeks in total doses of 100 to 160 Gy. Dosage depended on the stage of LM and the depth of periadnexal atypical melanocytic extension in histologically examined materials before treatment. Four hundred twenty-five patients have been followed up for at least 2 years; of these, 241 for 5 years. Results Overall, 520 of 593 patients (88%) showed complete clearance after one fractionated treatment. Residual lesions were seen in 15 patients, and 58 relapsed, 53 of whom (72%) within 2 years. Limitation Woods light examination was not used in the clinical diagnosis of lentigo maligna. Conclusions GR is an efficient and safe treatment in LM and early LMM when administered according to the recommendations presented herein. Moreover, GR offers an excellent cosmetic result.

In 2002, the Collaboration for Cancer Outcomes Research and Evaluation of Australia estimated that over the course of their disease approximately 23% of patients diagnosed with cutaneous melanoma (CM) would be appropriately treated with radiation therapy (RT) based on the best available evidence. Using population registry data, these investigators found that RT was part of the treatment of 13% of patients in New South Wales, Australia, and 1-6% of patients in the United States of America (USA)1. Others have noted the infrequent and dwindling use of RT for CM over time2,3. Awareness of the evidence supporting the use of RT for the treatment of CM is vital to delivering the optimal care of patients with this potentially lethal disease. Several general aspects of RT for melanoma will not be addressed in this review. The myth that melanoma is not responsive to RT has been adequately described and dispelled elsewhere4,5 The curative and organ-preserving potential of RT for uveal melanoma has been demonstrated by the Collaborative Ocular Melanoma Study6 and is beyond the scope of this review. Likewise, the role of RT in the management of mucosal melanoma is beyond the scope of this review. Herein, data providing the highest levels of evidence supporting the use of RT for CM will be presented and discussed, acknowledging a significant dearth of high level evidence in many situations.

Background Lentigo maligna (LM) and acral lentiginous melanoma (ALM) are often large and clinically ill defined. The surgical challenge is to spare tissue while still achieving clear margins. Objective We sought to provide a retrospective assessment of a two-phase surgical technique for lentiginous melanomas (MM) not suitable for en bloc resection. Methods In the first phase, a narrow band of skin, "the spaghetti", is resected just beyond the clinical outline of the MM, immediately sutured, and sent for pathological examination without removing the MM. The same procedure is repeated beyond the segments which are shown to be not tumor free and so forth until the minimal tumor-free perimeter is outlined. No operative wound is left between operative sessions. In the second phase, the MM resection and reconstruction are performed at the same time. Results In 21 patients with LM (n = 16) or ALM (n = 5), the mean operative defect size was 27.5 cm 2 (range, 1.97-108.4 cm 2 ). The mean number of steps in the procedure was 1.55 (1-4). Grafts were used for reconstruction in all cases. The relevance of the "spaghetti"-defined outline was confirmed in 19 of 21 patients. After a median follow-up period of 25.36 months (range, 0-72 months), the local control rate was 95.24% with one case (4.76%) of in-transit invasive recurrence after 48 months. Limitations This study was performed at a single center and included a limited number of patients. The follow-up time was relatively brief. Conclusion The "spaghetti technique" is simple and reliable for LM and ALM. Unlike Mohs surgery, it does not require specific training of surgeons or pathologists. Unlike staged surgery, it does not leave patients with an open wound on the face or soles before final reconstruction.

Introduction Spreading pigmented actinic keratosis (SPAK) is a common, but uncommonly reported or appreciated, variant of classic actinic keratosis (AK). It can mimic different pigmented lesions, which may be benign (eg, solar lentigo) or malignant (eg, lentigo maligna). Objective We sought to review current data and identify areas needing further research to establish diagnostic guidelines for SPAK and to increase awareness of this common entity. Methods A literature search was performed in both PubMed and MEDLINE databases using the search terms "spreading pigmented actinic keratosis," "pigmented solar keratosis," "pigmented actinic," and "pigmented solar." Each article was retrieved, reviewed, and summarized. Results SPAK is a rarely reported lesion that can be difficult to distinguish from other benign and malignant pigmented lesions, including seborrheic keratosis, melanoma in situ (lentigo maligna type), and lentigo maligna melanoma. Located mainly on sun-exposed areas and with a size greater than 1.5 cm, the lesion typically spreads laterally. Pathologically, the lesion resembles classic AK with increased basal melanization. The malignancy potential has not yet been elucidated but destructive therapies such as cryotherapy are recommended. Limitations Reports not yet published or not included in the comprehensive databases we used may exist that were not analyzed. Conclusions SPAK can be associated with adjacent melanoma in situ; therefore, its diagnosis merits increased suspicion for coexisting melanoma.

Limited studies have reported the in vivo reflectance confocal microscopy (RCM) features of lentigo maligna (LM). A total of 64 RCM features were scored retrospectively and blinded to diagnosis in a consecutive series of RCM sampled, clinically equivocal, macules of the face (n=81 LM, n=203 benign macules (BMs)). In addition to describing RCM diagnostic features for LM (univariate), an algorithm was developed (LM score) to distinguish LM from BM. This comprised two major features each scoring +2 points (nonedged papillae and round large pagetoid cells > 20 microm), and four minor features; three scored +1 point each (three or more atypical cells at the dermoepidermal junction in five 0.5 x 0.5 mm(2) fields, follicular localization of atypical cells, and nucleated cells within the dermal papillae), and one (negative) feature scored -1 point (a broadened honeycomb pattern). A LM score of > or = 2 resulted in a sensitivity of 85% and specificity of 76% for the diagnosis of LM (odds ratio (OR) for LM 18.6; 95% confidence interval: 9.3-37.1). The algorithm was equally effective in the diagnosis of amelanotic lesions and showed good interobserver reproducibility (87%). In a test set of 29 LMs and 44 BMs, the OR for LM was 60.7 (confidence interval: 11.9-309) (93% sensitivity, 82% specificity).

Lentigo maligna is an overgrowth of atypical melanocytes at the dermal-epidermal junction also known as melanoma in situ. Left untreated, these lesions can continue to grow, resulting in dermal invasion and progression to lentigo maligna melanoma. Many operative and nonoperative treatments have been developed with the goals of preserving function and cosmesis while at the same time addressing the diffuse nature of these lesions. Previous recommendations have led plastic surgeons to commonly perform wide local excision with 5 mm margins. More recent literature has suggested that in many cases this treatment can result in high recurrence rates. This has led to margin control procedures becoming the treatment of choice for these lesions.

Recently the term lentiginous melanoma of the elderly has been suggested for a pattern of melanocytic neoplasia characterized by frequent occurrence in elderly patients, broad lentiginous growth pattern, with poorly cohesive nesting, suprabasilar extension of melanocytes and moderate cytological atypia. However, there are limited reported cases with follow-up information to confirm the malignant nature of these neoplasms. Using fluorescence in situ hybridization (FISH) targeting chromosomal loci that are frequently found to have copy number changes in melanoma, we evaluated cases of lentiginous junctional melanoma of the elderly in order to compare with the frequencies and patterns of chromosomal aberrations identified in other subtypes of melanoma. Previous studies have shown that by using a FISH assay targeting 6p25, 6q23, 11q13 and CEP6 with previously validated criteria, one could discriminate benign nevi from melanoma with high sensitivity and specificity. In this study, 16 of 19 cases (84%) showed sufficient copy number changes in one of the targeted chromosomal loci to meet FISH criteria for melanoma. A total of 17 control cases of lentiginous junctional nevi tested negative for all criteria. These findings support the classification of this pattern of melanocytic neoplasia as a subtype of melanoma.

Forty years ago, a clinical and histological classification scheme and prognostic factors were described for cutaneous melanoma. This scheme included the subtypes superficial spreading, nodular and lentigo maligna, and prognostic factors including tumor thickness, ulceration, and mitotic activity. There have been some tweaks to the classification scheme, but these basic findings form the foundation for melanoma diagnosis and staging today. Currently, no molecular marker or target has proved reliably useful in the staging or treatment of melanoma. Measurement with a simple ruler serves as the basis for the staging of primary cutaneous melanoma, while the recognition of primary tumor mitotic activity and ulceration also remain significant factors. Recently, mutational analysis has revealed a correlation of activating mutations with the morphological descriptors from decades ago. Future classification schemes may have more power in predicting response to therapy by integrating specific genomic and intra-tumoral expression profiles with histologic findings.

Background Topical imiquimod therapy has proven to be effective for a variety of infectious, neoplastic, and inflammatory dermatologic diseases. Several published reports have validated the benefit of imiquimod therapy for actinic keratoses and superficial melanoma and nonmelanoma skin cancers. There is, however, limited evidence demonstrating the use of topical imiquimod application as an antiaging treatment. Objectives We examined the effectiveness of imiquimod 5% cream in the treatment of photoaging by evaluating pretreatment and posttreatment biopsy specimens and documenting the histologic changes. Methods This study represents an extension of an earlier project in our department in which patients with biopsy-proven lesions of lentigo maligna (LM) were recruited from a university dermatology service, a hospital, and referrals from private practitioners for an open-labeled efficacy trial with daily topical application of 5% imiquimod for 3 months. Biopsy of clinically affected skin was carried out on all patients before and after treatment. Using a semiquantitative method, biopsy specimens were analyzed for changes in the dermal collagen table (solar elastosis vs papillary dermal fibroplasia). Additional parameters analyzed included epidermal changes (atrophy vs acanthosis, melanin content, and hypergranulosis) and inflammatory effects (epidermal and dermal cell populations along with presence of pigment incontinence). Variables were compared using paired Wilcoxan rank sums. Results Of 26 evaluable patients who completed 3 months of daily application, 24 (>92.3%) showed a significant increase in papillary dermal fibroplasia ( P P = .0036). Other noteworthy findings were restoration of normal epidermal thickness ( P = .0073) and melanization ( P Limitations This study only evaluates the effect of imiquimod in the lesional skin of LM. It is not known whether the results are applicable to nonlesional, photoaged skin. Conclusion Topical imiquimod appears to induce reparative changes to the epidermis and the dermal collagen table in chronically sun-damaged skin associated with LM, indicating its potential use as an antiaging treatment. These findings need to be confirmed in photodamaged skin not associated with LM.

Worldwide, lentigo maligna melanoma (LMM) comprises 4%-15% of cutaneous melanoma and occurs less commonly than superficial spreading or nodular subtypes. We assessed the incidence of melanoma subtypes in regional and national Surveillance, Epidemiology, and End Results (SEER) cancer registry data from 1990 to 2000. Because 30%-50% of SEER data were not classified by histogenetic type, we compared the observed SEER trends with an age-matched population of 1024 cases from Stanford University Medical Center (SUMC) (1995-2000). SEER data revealed lentigo maligna (LM) as the most prevalent in situ subtype (79%-83%), and that LMM has been increasing at a higher rate compared with other subtypes and to all invasive melanoma combined for patients aged 45-64 andor =65 y. The SUMC data demonstrated LM and LMM as the only subtypes increasing in incidence over the study period. In both groups, LM comprisedor =75% of in situ melanoma and LMMor =27% of invasive melanoma in men 65 y and older. Regional and national SEER data suggest an increasing incidence of LM and LMM, particularly in menor =age 65. An increased incidence of LM subtypes should direct melanoma screening to heavily sun-exposed sites, where these subtypes predominate.

This article reviews the clinical characteristics, histology, biologic behavior, and recommended treatment for several benign and malignant lesions that may arise on the head and neck. Nevus sebaceus and congenital melanocytic nevus are two benign lesions that can present at a size of several centimeters. Surgical excision may be considered for cosmetic purposes and to reduce the small risk for the development of malignancy within each lesion. Basal and squamous cell carcinoma, lentigo maligna and lentigo maligna melanoma, dermatofibrosarcoma protuberans, and Merkel cell carcinoma are malignant lesions for which surgical excision is the recommended treatment. Local flap reconstruction may be used to address the surgical defects resulting from excision of these benign and malignant conditions.

In 1976, Hübner described a new technique to repair full-thickness defects of the eyelids. In 1993, we decided to adopt this simple and easily reproducible technique that guarantees restoration of the normal aspect of the margin. Subsequently, 17 eyelid reconstructions were performed on 13 patients, requiring the harvesting of 22 tarsomarginal grafts. No cosmetic or functional sequelae in the donor eyelids were observed. One or several functional complications were present in seven out of 17 reconstructed eyelids, including two cases of epiphora, one case of lagophtalmos and two cases of lid notch. Loss of the eyelids was observed in three cases out of six upper eyelid reconstructions and in nine cases out of 11 lower eyelid reconstructions. In all cases, the margin integrity was otherwise preserved. Very few simple techniques achieve that level of quality in the eyelid reconstruction process.

We have treated extensive lentigo maligna in two elderly patients with Imiquimod 5% (Aldara). It was applied 3 times weekly, for 3 to 5 months. Clinical and histological remission was observed over 13 months of follow-up care. Tolerance was good. We suggest that topical imiquimod could be an interesting therapeutic alternative.

Purpose Our goal was to evaluate 2 design properties, pivot point and secondary defect, that affect the results of rotation flaps used to treat skin cancer defects of the head and neck. Materials and methods We conducted a retrospective review of the last 50 patients who underwent rotation flaps for closure of skin cancer defects on the head and neck with regard to postoperative complications. Results Four patients experienced complications, all of which were managed to an acceptable conclusion. These complications included tip necrosis and ectropion. Conclusion Rotation flaps, although simple in design, are often modified during their execution. Understanding the basic design and possible modifications of pivot point and secondary defect will yield a successful outcome.

The increasing prevalence of melanoma in the United States is alarming. The limited efficacy of adjuvant therapies in successfully treating regional or distant disease underscores the importance of surgical treatment of primary cutaneous melanoma. The historic paradigm of wide margin excision (5 cm) with or with lymphadenectomy has been proven in multiple clinical trials to show no benefit of improved patient survival. Conservative margin resection of melanoma is a procedure of low morbidity that offers statistically identical outcomes and spares the patient excessive surgical efforts. Mohs micrographic surgery may have a role in the management of melanomas in anatomic sites where standard margins may prove difficult to achieve.