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Ungureanu L, Vasilovici AF, Trufin II, Apostu AP, Halmágyi SR. Lentigo Maligna Treatment-An Update. J Clin Med 2024; 13:2527. [PMID: 38731056 PMCID: PMC11084749 DOI: 10.3390/jcm13092527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/06/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Lentigo maligna (LM) is a melanoma in situ that is prevalent in chronically sun-damaged skin. Characterized by a slow growth pattern and high mutation rates due to chronic UV exposure, LM poses diagnostic and therapeutic challenges, particularly given its tendency to mimic other skin lesions and its occurrence in cosmetically sensitive areas. Its diagnosis is based on an integrated approach using dermoscopy and reflectance confocal microscopy (RCM). Despite its slow progression, LM can evolve into lentigo maligna melanoma (LMM), making its treatment necessary. Treatment modalities encompass both surgical and non-surgical methods. Surgical treatments like Wide Local Excision (WLE) and Mohs Micrographic Surgery (MMS) aim for clear histological margins. WLE, a standard melanoma surgery, faces challenges from LM's subclinical extensions, which increase the recurrence risk. MMS, effective for large or poorly defined lesions, is defined by precise margin control while considering cosmetic outcomes. Non-surgical options, including radiotherapy and imiquimod, are alternatives for non-surgical candidates. Radiotherapy has been effective since the 1950s, offering good control and cosmetic results, especially for older patients. Imiquimod, an immunomodulator, shows promise in treating LM, though its application remains off-label. The increasing incidence of LM/LMM necessitates a balance in treatment choices to minimize recurrence and maintain cosmetic integrity. A multidisciplinary approach, integrating clinical examination with dermoscopy and RCM and histological assessment, is essential for accurate diagnosis and effective LM management.
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Affiliation(s)
- Loredana Ungureanu
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Alina Florentina Vasilovici
- Department of Dermatology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | | | - Adina Patricia Apostu
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
| | - Salomea-Ruth Halmágyi
- Department of Dermatology, Emergency County Hospital, 400006 Cluj-Napoca, Romania
- Clinical Hospital of Infectious Diseases, 400000 Cluj-Napoca, Romania
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Mansilla-Polo M, Morgado-Carrasco D, Toll A. Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors. ACTAS DERMO-SIFILIOGRAFICAS 2024:S0001-7310(24)00362-4. [PMID: 38648936 DOI: 10.1016/j.ad.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/29/2023] [Accepted: 02/06/2024] [Indexed: 04/25/2024] Open
Abstract
Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.
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Affiliation(s)
- M Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, España; Health Research Institute (IIS) La Fe, Valencia, España
| | - D Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España; Department of Dermatology, Hospital de Figueres, Fundació Alt Empordà, España
| | - A Toll
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España.
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Mansilla-Polo M, Morgado-Carrasco D, Toll A. Review on the Role of Paraffin-embedded Margin-controlled Mohs Micrographic Surgery to Treat Skin Tumors. ACTAS DERMO-SIFILIOGRAFICAS 2024:S0001-7310(24)00159-5. [PMID: 38395222 DOI: 10.1016/j.ad.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/29/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Paraffin-embedded margin-controlled Mohs micrographic surgery (PMMS) includes various procedures such as slow Mohs or deferred Mohs technique, the Muffin and Tübingen techniques, and staged margin excision, or the spaghetti technique. PMMS is a variation of conventional Mohs micrographic surgery (MMS) that allows histopathological examination with delayed margin control. PMMS requires minimum training and may be adopted by any hospital. The setback is that PMMS can require procedures across multiple days. PMMS lowers the rate of recurrence of basal cell carcinoma vs wide local excision in high-risk basal cell carcinoma, and improves the rates of recurrence and survival in lentigo maligna. PMMS can be very useful in high-risk squamous cell carcinoma treatment. Finally, it is a promising technique to treat infrequent skin neoplasms, such as dermatofibrosarcoma protuberans, or extramammary Paget's disease, among others. In this article, we present a literature narrative review on PMMS, describing techniques and indications, and highlighting long-term outcomes.
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Affiliation(s)
- M Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Health Research Institute (IIS) La Fe, Valencia, Spain
| | - D Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Department of Dermatology, Hospital de Figueres, Fundació Alt Empordà, Spain
| | - A Toll
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
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Stefanski M, Le Guern A, Visseaux L, Ehret M, Colomb M, Jeudy G, Le Duff F, Vourc'h M, Baroudjian B, Perea-Villacorta R, Bernigaud C, Mallet S, Norberciak L, Debarbieux S, Perrot JL, Grange F, Modiano P, Monnier J, Bahadoran P. Real-life practice of reflectance confocal microscopy in France: A prospective multicenter study. J Am Acad Dermatol 2024:S0190-9622(24)00383-9. [PMID: 38387851 DOI: 10.1016/j.jaad.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/03/2023] [Accepted: 01/10/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Studies demonstrating the potential utility of reflectance confocal microscopy (RCM) have been performed under experimental conditions. OBJECTIVE To provide an overview of RCM practice in real-life. METHODS A multicenter, prospective study carried out in 10 university dermatology departments in France. RESULTS Overall, 410 patients were enrolled. One-half of the patients (48%) were referred by private practice dermatologists. They were referred for diagnosis (84.9%) or presurgical mapping (13%). For diagnosis, the lesions were located on the face (62%), arms and legs (14.9%), and trunk (13.6%), and presurgical mapping was almost exclusively on the face (90.9%). Among those referred for diagnosis, the main indication was suspicion of a skin tumor (92.8%). Of these, 50.6% were spared biopsies after RCM. When RCM indicated surgery, histology revealed malignant lesions in 72.7% of cases. The correlation between RCM and histopathology was high, with a correlation rate of 82.76% and a kappa coefficient of 0.73 (0.63; 0.82). LIMITATIONS This study was performed in the settings of French tertiary referral hospitals. CONCLUSION This study shows that in real-life RCM can be integrated into the workflow of a public private network, which enables a less invasive diagnostic procedure for patients.
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Affiliation(s)
- Marion Stefanski
- Department of Oncodermatology, Reims University Hospital, Reims France; Department of Dermatology, Saint Vincent de Paul Hospital, Hospital Group of the Catholic Institute of Lille, Lille, France
| | - Aurore Le Guern
- Department of Dermatology, Saint Vincent de Paul Hospital, Hospital Group of the Catholic Institute of Lille, Lille, France
| | | | - Marine Ehret
- Department of Dermatology, Emile Muller Hospital, Mulhouse, France
| | - Michel Colomb
- Department of Oncodermatology, Reims University Hospital, Reims France
| | - Géraldine Jeudy
- Department of Dermatology, Dijon University Hospital, Dijon, France
| | - Florence Le Duff
- Department of Dermatology, Nice University Hospital, Nice, France
| | - Morgane Vourc'h
- Department of Dermatology, Nantes University Hospital, Nantes, France
| | | | - Rosa Perea-Villacorta
- Department of Dermatology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Stéphanie Mallet
- Department of Dermatology and Skin Cancers, La Timone Hospital, AP-HM, Aix-Marseille University, Marseille, France
| | - Laurène Norberciak
- Delegation of Clinical Research and Innovation, Biostatistics, Saint Philibert Hospital, Catholic University of Lille, Lille, France
| | | | - Jean-Luc Perrot
- Department of Dermatology, Saint Etienne University Hospital et Laboratoire Hubert Curien UMR CNRS 5516, Saint Etienne, France
| | - Florent Grange
- Department of Dermatology, Valence Hospital, Valence, France
| | - Philippe Modiano
- Department of Dermatology, Saint Vincent de Paul Hospital, Hospital Group of the Catholic Institute of Lille, Lille, France
| | - Jilliana Monnier
- Department of Dermatology and Skin Cancers, La Timone Hospital, AP-HM, Aix-Marseille University, Marseille, France
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Karponis D, Stratigos IA, Joshy J, Craig PJ, Mistry K, van Bodegraven B, Venables ZC, Levell NJ. Lentigo maligna: a review. Clin Exp Dermatol 2024; 49:218-225. [PMID: 37966718 DOI: 10.1093/ced/llad394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
Lentigo maligna (LM) is a melanoma in situ with distinct clinical features and histology. It commonly affects men after the sixth decade of life. Incidence rates of LM have increased based on early 21st century data from different countries; however, data are suboptimal. Data from England show a plateauing crude incidence between 2013 and 2019. By comparison, invasive melanoma and other types of melanoma in situ commonly appears in younger age groups (median age 58 and 67 years old, respectively) and incidence is rising. The most important risk factors for LM include fair skin and cumulative ultraviolet solar radiation exposure. Although LM is limited to the epidermis and connected skin adnexa, it may progress to invasive LM melanoma. The reported rate of malignant progression varies, reflecting a challenge for LM epidemiology research as often lesions are removed on diagnosis. LM poses a challenge in diagnosis and management. Although it can be diagnosed clinically or dermoscopically, histopathological assessment of biopsied skin tissue remains the gold standard. Reflectance confocal microscopy allows for better appreciation of the complexity of LM at a cellular level, often progressing beyond clinical margins. Management of LM may involve Mohs micrographic surgery or excision, although recurrence may occur even with 5 mm clinical margins. Imiquimod cream may be effective, but incomplete treatment and recurrence has been reported. Conservative management with observation or radiotherapy may be used in selected patients' cases. Five-year net survival rates are excellent. This paper reviews the natural history, epidemiology, aetiology, pathogenesis, diagnosis and management of LM.
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Affiliation(s)
- Dimitrios Karponis
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Jilse Joshy
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Paul J Craig
- Cellular Pathology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Khaylen Mistry
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Birgitta van Bodegraven
- British Association of Dermatologists, London, UK
- National Disease Registration Service, Data and Analytics, NHS England, UK
| | - Zoe C Venables
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- National Disease Registration Service, Data and Analytics, NHS England, UK
| | - Nick J Levell
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Zou Y, Zhu X, Xia R. Concordance between reflectance confocal microscopy and histopathology for the diagnosis of acral lentiginous melanoma. Skin Res Technol 2024; 30:e13570. [PMID: 38200620 PMCID: PMC10781889 DOI: 10.1111/srt.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Acral lentiginous melanoma (ALM) is a highly malignant and invasive type of melanoma with unique locations of onset. Its incidence is increasing and early diagnosis is challenging. Reflectance confocal microscopy (RCM) is a non-invasive technique that provides an accurate image of tissue pathology. There are few reports on the use of RCM for the assessment of ALM. MATERIALS AND METHODS In this retrospective study, data from 31 patients with a clinical diagnosis of ALM were collected. RCM image features were compared with histopathological findings to determine the concordance between the two methods. The sensitivity, specificity, positive predictive value, and negative predictive value of RCM for the diagnosis of ALM were evaluated. RESULTS RCM and histopathology findings were concordant in 29 of 31 patients (93.5%). There were no false-negative results, although there were two false positives in RCM diagnosis. The sensitivity of RCM for diagnosing ALM was 100%, specificity was 50%, positive predictive value was 93.1%, and negative predictive value was 100%. CONCLUSIONS RCM showed substantial concordance with histopathology in the diagnosis of ALM. It is a reliable and valuable non-invasive diagnostic tool that holds promise for the early diagnosis of ALM.
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Affiliation(s)
- Yunmin Zou
- Department of DermatologyWuxi No.2 People's HospitalWuxiJiangsu ProvinceChina
| | - Xiaohong Zhu
- Department of DermatologyWuxi No.2 People's HospitalWuxiJiangsu ProvinceChina
| | - Rushan Xia
- Department of DermatologyWuxi No.2 People's HospitalWuxiJiangsu ProvinceChina
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Martínez-Fernández S, González-Sixto B, Espasandín-Arias M, Soto-García D, Flórez Á. Topical and Intralesional Immunotherapy for Melanoma In Situ: A Review. Cancers (Basel) 2023; 15:4468. [PMID: 37760438 PMCID: PMC10526313 DOI: 10.3390/cancers15184468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
The incidence of in situ melanoma (MIS) has increased over the last decades. The mainstay of treatment for MIS, including lentigo maligna (LM), is complete surgical excision with clear margins (0.5 to 1.0 cm). Nevertheless, MIS lesions often affect elderly patients with comorbidities and involve large lesions in cosmetically sensitive areas, which means surgery is not always appropriate. Non-surgical treatments have a role in these cases, and include radiotherapy, cryosurgery, immunotherapy, laser therapy, and other topical medications. This study aims to review the applications of immunotherapy in MIS, either in monotherapy or in combination with other therapeutic alternatives. The main forms of immunotherapy used are imiquimod and, to a lesser extent, intralesional interferon-α (IL-INF-α) and ingenol mebutate (IM). IL-INF-α and IM have not been studied as extensively as imiquimod, whose results in real-life practice are encouraging. The clearance and recurrence rates reported in MIS treated with imiquimod as monotherapy, or as an adjuvant after surgery with affected or narrow margins, make imiquimod a reliable therapeutic alternative in selected cases. Also, its use as a neoadjuvant therapy before surgery was shown to reduce the final surgical defect size required to confirm negative histologic margins. In conclusion, local immunotherapy is frequently used in clinical practice and experience confirms it to be an excellent option for certain patients.
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Affiliation(s)
- Sandra Martínez-Fernández
- Department of Dermatology, Pontevedra University Hospital, 36001 Pontevedra, Spain; (B.G.-S.); (M.E.-A.); (D.S.-G.); (Á.F.)
- DIPO Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Pontevedra, Spain
| | - Beatriz González-Sixto
- Department of Dermatology, Pontevedra University Hospital, 36001 Pontevedra, Spain; (B.G.-S.); (M.E.-A.); (D.S.-G.); (Á.F.)
- DIPO Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Pontevedra, Spain
| | - Martina Espasandín-Arias
- Department of Dermatology, Pontevedra University Hospital, 36001 Pontevedra, Spain; (B.G.-S.); (M.E.-A.); (D.S.-G.); (Á.F.)
- DIPO Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Pontevedra, Spain
| | - Diego Soto-García
- Department of Dermatology, Pontevedra University Hospital, 36001 Pontevedra, Spain; (B.G.-S.); (M.E.-A.); (D.S.-G.); (Á.F.)
- DIPO Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Pontevedra, Spain
| | - Ángeles Flórez
- Department of Dermatology, Pontevedra University Hospital, 36001 Pontevedra, Spain; (B.G.-S.); (M.E.-A.); (D.S.-G.); (Á.F.)
- DIPO Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36213 Pontevedra, Spain
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