Improving Management and Patient Care in Lentigo Maligna by Mapping With In Vivo Confocal Microscopy Confocal Microscopy Mapping in Lentigo Maligna

Guitera P, Moloney FJ, Menzies SW, et al. — Wed, 03 Apr 2013 00:00:00 GMT

Importance

Lentigo maligna (LM) is a clinical, pathologic, and therapeutic challenge with a higher risk of local recurrence than other types of melanoma correctly treated and also carries the cosmetically sensitive localization of head and neck.

Objective

To determine whether in vivo reflectance confocal microscopy (RCM) mapping of difficult LM cases might alter patient care and management.

Design

Analysis of LM and LM melanoma (LMM) in a series of patients with large facial lesions requiring complex reconstructive surgery and/or recurrent or poorly delineated lesions at any body sites were investigated.

Settings

Two tertiary referral melanoma centers in Sydney, Australia.

Participants

Thirty-seven patients with LM (including 5 with LMM) were mapped with RCM. Fifteen patients had a recurrent LM, including 9 with multiple prior recurrences. The LM was classified amelanotic in 10 patients, lightly pigmented in 9, and partially pigmented in 18.

Interventions

The RCM images were obtained in 4 radial directions (allowing for anatomic barriers) for LM margin delineation using an RCM LM score previously described by our research team.

Main Outcome Measures

Differences in the margin of LM as determined by RCM vs dermoscopy vs histopathologic analysis.

Results

Seventeen of 29 patients (59%) with dermoscopically visible lesions had subclinical (RCM-identified) disease evident more than 5 mm beyond the dermoscopy margin (ie, beyond the excision margin recommended in published guidelines). The RCM mapping changed the management in 27 patients (73%): 11 patients had a major change in their surgical procedure, and 16 were offered radiotherapy or imiquimod treatment as a consequence of the RCM findings. Treatment was surgical in 17 of 37 patients. Surgical excision margins (based on the RCM mapping) were histopathologically involved in only 2 patients, each of whom had an LM lesion larger than 6 cm.

Conclusions and Relevance

In vivo RCM can provide valuable information facilitating optimal patient care management.

Dermoscopic Evaluation of Nodular Melanoma Dermoscopic Evaluation of Nodular Melanoma

Menzies SW, Moloney FJ, Byth K, et al. — Wed, 03 Apr 2013 00:00:00 GMT

Importance

Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical.

Objective

To determine the dermoscopy features of NM.

Design

Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes.

Setting

Predominantly hospital-based clinics from 5 continents.

Main Outcome Measures

Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma.

Results

Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM.

Conclusions and Relevance

When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

AMA Publishing Group: Skin Imaging Topic Collection

Improving Management and Patient Care in Lentigo Maligna by Mapping With In Vivo Confocal Microscopy Confocal Microscopy Mapping in Lentigo Maligna

Dermoscopic Evaluation of Nodular Melanoma Dermoscopic Evaluation of Nodular Melanoma