Figure - available from: Journal of Skin Cancer
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Number of WLE attempts to excise MIS (histology clearance >0 mm) per subtype. LM: lentigo maligna; MIS: melanoma in situ; SS-MIS: superficial spreading melanoma in situ.
Source publication
Background:
The incidence of melanoma in situ (MIS) is increasing faster compared to invasive melanoma. Despite varying international practice, a minimum of 5 mm surgical excision margin is currently recommended in the UK. There is no clear guidance on the minimum histological peripheral clearance margins.
Aim:
This study compares the histologic...
Citations
Because of an increased risk of local recurrence following surgical treatment of lentigo maligna (melanoma) (LM/LMM), the optimal surgical technique is still a matter of debate. We aimed to evaluate the effect of different surgical techniques and reflectance confocal microscopy (RCM) on local recurrence and survival outcomes. We searched MEDLINE, Embase, and PubMed databases through May 20th, 2022. Randomized and observational studies with ≥10 lesions were eligible for inclusion. Bias assessment was performed using the Methodological Index for Non‐Randomized Studies instrument. Meta‐analysis was performed for local recurrence, as there were insufficient events for the other clinical outcomes. We included 41 studies with 5059 LM and 1271 LMM. Surgical techniques included wide local excision (WLE) (n=1355), staged excision (n=2442), and Mohs’ micrographic surgery (MMS) (n=2909). Six studies included RCM. The guideline‐recommended margin was insufficient in 21.6%‐44.6% of LM/LMM. Local recurrence rate was lowest for patients treated by MMS combined with immunohistochemistry (<1%; 95% CI, 0.3%‐1.9%), and highest for WLE (13%; 95% CI, 7.2%‐21.6%). The mean follow‐up varied from 27 to 63 months depending on surgical technique with moderate to high heterogeneity for MMS and WLE. Handheld‐RCM decreased both the rate of positive histological margins (P<0.0001) and necessary surgical stages (P<0.0001). The majority of regional (17/25) and distant (34/43) recurrences occurred in patients treated by WLE. Melanoma‐associated mortality was low (1.5%; 32/2107), and more patients died due to unrelated causes (6.7%; 107/1608). This systematic review shows a clear reduction in local recurrences using microscopically controlled surgical techniques over WLE. The use of HH‐RCM showed a trend in the reduction of incomplete resections and local recurrences even when used with WLE. Due to selection bias, heterogeneity, low prevalence of stage III/IV disease, and limited survival data, it was not possible to determine the effect of the different surgical techniques on survival outcomes.
Background:
Imiquimod cream may be used as non-surgical treatment for lentigo maligna or as adjuvant therapy following excision to decrease risk of recurrence.
Objectives:
To evaluate histologic and clinical factors associated with clinical clearance of lentigo maligna treated with imiquimod.
Methods:
We performed a retrospective review of all patients diagnosed with lentigo maligna and treated with imiquimod between 1997 and 2019 at our academic institution.
Results:
We observed clinical clearance in 93% (66/71) of participants who received adjuvant imiquimod following surgery and 79% (19/24) in the primary non-surgical treatment group over a median of 38 months of follow-up. In the adjuvant therapy group, positive surgical margins were associated with a decreased rate of clinical clearance when compared to cases with close (<1mm) margins or background melanocytic dysplasia (83.3% vs. 100%, p = 0.01). The presence of an inflammatory response during treatment was associated with increased clearance (94.1% vs. 66.7%, p = 0.02).
Conclusions:
Adjuvant imiquimod treatment may decrease LM recurrence rates in cases with background melanocytic dysplasia or close margins. LM cases with positive surgical margins need close clinical follow-up given higher recurrence rates.
