Lentigo maligna D03.-

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 11.01.2021

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Synonym(s)

Hutchinson's melanotic freckle; Hutchinson\'s melanotic freckle; Melanosis circumscripta Dubreuilh; Melanosis circumscripta praeblastomatosa; melanosis circumscripta praecancerosa (Dubreuilh); Melanotic precancerosis; Precancerous melanotic; Premalignant melanosis

History
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Hutchinson, 1892

Definition
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Slow-growing (non-invasive) in situ melanoma arising in actinically damaged skin. Development of an invasive growing lentigo-maligna melanoma is possible. Histological clarification by staged sections and securing the precise tumour stage (pTis = melanoma in situ, Clark level I) is mandatory.

Occurrence/Epidemiology
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In a Danish study (2014), an increase in the "age-adjusted percentage change" incidence rate from 1997-2011 from 2.6 to 8.1 cases/100,000 for women and from 1.4 to 5.6/100,000 for men was demonstrated. These figures refer to both lentigo maligna and the precursor stage of SSM.

Manifestation
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Preferred population > 50 years. w > m

Localization
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Mostly located in the face.

Clinical features
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Integument: Solitary, brown or blackish-brown, roundish-oval or bizarre, peripherally growing, (not palpable) inhomogeneous spot or patch of varying colour intensity; often with polycyclic or reticulated, sharp or blurred edges.

Reflected light microscopy: Highly irregular, prominent pigmentary net with breaks in the periphery.

Also visible are spots of diffuse pigmentation, central and peripheral black dots, possibly also irregularly limited depigmentation and a delicate grey cast.

Histology
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Mostly atrophic surface epithelium. Differently pronounced actinic elastosis. Initially, linear basal compression and later nestlike aggregation of atypical, pigmented melanocytes are noticeable. Individual atypical melanocytes are found in higher epithelial layers. Regularly a dense linear colonization of the hair follicular epithelium is found. An infiltration of the dermis by atypical melanocytes is not detectable. Interstitial infiltrates of varying density and numerous melanophages are found in the dermis.

Differential diagnosis
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  • Verruca seborrhoica: Colour pattern may resemble the lentigo maligna. Mostly horn beads are detectable by reflected light microscopy. In case of doubt, a biopsy is decisive.
  • Lentigo solaris: Less pigmented, homogeneous or inhomogeneous brown spot with mostly blurred edges. Transitions to lentigo maligna can be fluid.
  • Melanoacanthoma: Deep black plaque not preferentially occurring in sunlight-exposed areas. Histological clarification.
  • Pigmented basal cell carcinoma: Irregularly pigmented plaque; typical BCC criteria are usually detectable by incident light microscopy.
  • pigmented Bowen's disease. Mostly sharply edged, irregularly configured plaque (no stain) with a rough surface.

Therapy
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Therapy of first choice is the (micrographically controlled) excision of the lesion with a (possible) safety margin of 0.5 cm. Here, a serial histological processing of the peripheral areas is an absolute prerequisite. The reported recurrence rates are between 0 and 6.25%. 85% of all dermatologists prefer excision as the method of choice in patients <60 years of age, 87% in patients between 60-70 years of age, 67% in patients > 70 years (Thio D et al. 2018).

Alternative cryosurgery: particularly indicated for larger foci in the facial area, whose surgery would result in a disfiguring scar. It may also be an option for patients of advanced age. The closed contact method with 2 cycles is recommended. In case of the open spray method a moulage has to be applied (25% of dermatologists use this method).

Alternative radiotherapy: especially indicated for patients > 70 years. Carried out with Dermopan (Siemens) or R.T. 100 (C. H. Müller, Hamburg) with a tube voltage up to 12 kV (borderline radiotherapy; GHWT 1.3 mm). Use 4-5 times 20 Gy in 2-day intervals (procedure is recommended by 27% of dermatologists).

Alternatively Imiquimod: currently widely used procedure (50% of all dermatologists use this therapeutic approach). In particular, the use of Imiquimod is indicated in patients > 70 years of age with significant limitations in operability. Local treatment with 5% Imiquimod cream (e.g. Aldara®) for 5-6 weeks (3 times/week, left for 12 hours). Recurrences or therapy failure were observed (27.5% residual lentigo maligna - results of a 5-year follow-up study; Kai AC et al. 2016). Furthermore, progressions with development of lentigo maligna melanoma were reported after completion of therapy.

Progression/forecast
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High recurrence rates (7-20%; mostly within the first 42 months after excision). If not treated, gradual enlargement and development of a lentigo-maligna melanoma.

Aftercare
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According to the malignant melanoma, initial control of the local findings every 3 months (period 1 year); later larger intervals. S.u. melanoma, malignant.

Case report(s)
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The 84-year-old patient had noticed a pigmentation mark on her left cheek for several years. This spot was first light brown, then in places darkened to a brown-black colour. Findings: Symptomless, 5.5 x 1.7 cm large, light brown to black-brown, polycyclically limited spot in clearly actinically stressed (strong actinic elastosis) skin. Continuous follicular structure (no deep invasion). Furthermore, a light brown area was found on the bridge of the nose which was not connected to the pigmentation of the cheek. Histology (summarizing findings): Atrophic surface epithelium. Clumpy actinic elastosis. Linear basal and also nestlike aggregation of atypical pigmented melanocytes are conspicuous. Single atypical melanocytes are found in higher epithelial layers. Dense, deep reaching, linear colonization of the hair follicle epithelium. An infiltration of the dermis by atypical melanocytes is not detectable. Here numerous melanophages. A second biopsy of the nasal bridge showed an initial lentigo maligna. Therapy and course: The pigment lesion was removed by micrographic surgery in a multi-step procedure. The large defect could be closed by means of rotational plastic surgery. After complete healing of the wounds, the lentigo maligna on the bridge of the nose was treated with imiquimod (1x/day for 4 weeks). This included complete and over 1 year verifiable healing of the findings.

Literature
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  1. Cognetta AB Jr et al (2001) Dermatoscopy of lentigo maligna. Dermatol Clin 19: 307-318
  2. Elsner Pet al (2014) Lentigo maligna and lentigo maligna melanoma as occupational skin diseases in a forestry worker with long-standing occupational UV exposure. J Dtsch Dermatol Ges 12:915-917
  3. Epstein E (2003) Extensive lentigo maligna clearing with topical imiquimod. Arch Dermatol 139: 944-945
  4. Farshad A et al (2002) A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using border or soft X-rays. Br J Dermatol 146: 1042-1046
  5. Gambichler T et al (2014) Clinicopathological characteristics of 270 patients with lentigo maligna and lentigo maligna melanoma: data from a German skin cancer centre. Br J Dermatol 171:1605-1607
  6. Hutchinson J (1892) On senile moles and senile freckles and on their relationship to cancerous processes. Arch Surge 2: 218
  7. Kai AC et al (2016) Five-year recurrence rate of lentigo maligna after treatment with imiquimod. Br J Dermatol 174:165-168.
  8. Kroumpouzos G et al (2002) Lentigo maligna with spread onto oral mucosa. Arch Dermatol 138: 1216-1220
  9. Meseg A et al (2011) Imiquimod for the therapy of lentigo maligna. Act Dermatol 37: 182-183
  10. Rehberger et al (2006) Therapy of skin metastases in malignant melanoma. dermatologist 57: 1143-1153
  11. Tio D et al (2018) Variation in the diagnosis and clinical management of lentigo maligna acrossEurope
    : a survey study among European Association of Dermatologists andVenereologists
    members.J Eur Acad Dermatol Venereol 32:1476-1484.
  12. Toender A et al (2014) Increased incidence of melanoma in situ in Denmark from 1997 to 2011: results from a nationwide population-based study. Melanoma Res 24:488-495

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 11.01.2021