Main Article Content
confocal microscopy, margins of excision, melanoma, lentigo, biopsy
Background: Lentigo maligna (LM) characteristically has an ill-defined margin and may require multiple excisions to achieve complete excision with 5mm margins. In vivo reflectance confocal microscopy (RCM) is a non-invasive tool recognised as useful in the management of LM. The authors aimed to determine whether the use of RCM prior to surgical excision reliably increased the rate of complete excision when compared with standard surgical excision.
Methods: This prospective pilot study included patients with biopsy-proven LM of head and neck region who sought consultation for surgical management from May 2017 to May 2019 at the Victorian Melanoma Service, Melbourne. Patients were randomised to two groups based on the availability of RCM — Group 1, RCM-guided surgical excision, and Group 2, standard surgical excision. Outcomes were measured based on clinical markings and histopathological margins achieved and reported as RCM or surgical margin excess or deficit. Ethics approval for the study was obtained from the Research Governance Unit of The Alfred Hospital, Melbourne.
Results: Results demonstrated that RCM marking of lesion margins was in excess in 69 percent of cases, in deficit in 22 per cent and accurate in nine per cent after histopathological analysis of the specimens. In comparison, lesions that were surgically marked were removed with margins in excess in 43 per cent of cases, in deficit in 11 per cent and accurate in 46 per cent.
Conclusion: This pilot study demonstrates that RCM did not increase the accuracy of LM surgical excision in comparison with standard surgically marked excisions.
2. Cotter MA, McKenna JK, Bowen GM. Treatment of lentigo maligna with imiquimod before staged excision. Dermatol Surg. 2008;34(2):147–51. https://doi.org/10.1097/00042728-200802000-00002 PMid:18093206
3. Agarwal-Antal N, Bowen GM, Gerwels JW. Histologic evaluation of lentigo maligna with permanent sections: implications regarding current guidelines. J Am Acad Dermatol. 2002;47:743–48. https://doi.org/10.1067/mjd.2002.124085 PMid:12399768
4. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol. 2012;66(3):438–44. https://doi.org/10.1016/j.jaad.2011.06.019 PMid:22196979
5. Akhtar S, Bhat W, Magdum A, Stanley PR. Surgical excision margins for melanoma in situ. J Plast Reconstr Aesthet Surg. 2014;67(3):320–23. https://doi.org/10.1016/j.bjps.2013.11.014 PMid:24444795
6. Hazan C, Dusza SW, Delgado R, Busam KJ, Halpern AC, Nehal KS. Staged excision for lentigo maligna and lentigo maligna melanoma: a retrospective analysis of 117 cases. J Am Acad Dermatol. 2008;58(1):142–48. https://doi.org/10.1016/j.jaad.2007.09.023 PMid:18029055
7. Hou JL, Reed KB, Knudson RM, Mirzoyev SA, Lohse CM, Frohm ML, Brewer JD, Otley CC, Roenigk RK. Five-year outcomes of wide excision and Mohs micrographic surgery for primary lentigo maligna in an academic practice cohort. Dermatol Surg. 2015;41(2):211–18. https://doi.org/10.1097/DSS.0000000000000248 PMid:25590473
8. Serban ED, Farnetani F, Pellacani G, Constantin MM. Role of in vivo reflectance confocal microscopy in the analysis of melanocytic lesions. Acta Dermatovenerol Croat. 2018;26(1):64–67.
9. Guitera P, Moloney FJ, Menzies SW, Stretch JR, Quinn MJ, Hong A, Fogarty G, Scolyer RA. Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy. JAMA Dermatol. 2013;149(6):692–98. https://doi.org/10.1001/jamadermatol.2013.2301 PMid:23553208
10. Rajadhyaksha M, González S, Zavislan JM, Anderson RR, Webb RH. In vivo confocal scanning laser microscopy of human skin II: advances in instrumentation and comparison with histology. J Invest Dermatol. 1999;113(3):293–303. https://doi.org/10.1046/j.1523-1747.1999.00690.x PMid:10469324
11. Kunishige JH, Brodland DG, Zitelli JA. Surgical margins for melanoma in situ. J Am Acad Dermatol. 2012;66(3):438–44. https://doi.org/10.1016/j.jaad.2011.06.019 PMid:22196979
12. Akhtar S, Bhat W, Magdum A, Stanley PR. Surgical excision margins for melanoma in situ. J Plast Reconstr Aesthet Surg 2014;67(3):320–23. https://doi.org/10.1016/j.bjps.2013.11.014 PMid:24444795
13. Hazan C, Dusza SW, Delgado R, Busam KJ, Halpern AC, Nehal KS. Staged excision for lentigo maligna and lentigo maligna melanoma: a retrospective analysis of 117 cases. J Am Acad Dermatol. 2008;58(1):142–48. https://doi.org/10.1016/j.jaad.2007.09.023 PMid:18029055
14. Pellacani G, De Carvalho N, Ciardo S, Ferrari B, Cesinaro AM, Farnetani F, Bassoli S, Guitera P, Star P, Rawson R, Rossi E, Magnoni C, Gualdi G, Longo C, Scope A. The smart approach: feasibility of lentigo maligna superficial margin assessment with hand-held reflectance confocal microscopy technology. J Eur Acad Dermatol Venereol. 2018;32(10):1687–694. https://doi.org/10.1111/jdv.15033 PMid:29704275
15. Florell SR, Boucher KM, Leachman SA, Azmi F, Harris RM, Malone JC, Martignoni G, Bowen GM, Gerwels JW, Hood AF. Histopathologic recognition of involved margins of lentigo maligna excised by staged excision: an interobserver comparison study. Arch Dermatol. 2003;139(5):595–604. https://doi.org/10.1001/archderm.139.5.595 PMid:12756096