Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy

JAMA Dermatol. 2013 Jun;149(6):692-8. doi: 10.1001/jamadermatol.2013.2301.


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.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Australia
  • Dermoscopy / methods*
  • Female
  • Humans
  • Hutchinson's Melanotic Freckle / pathology
  • Hutchinson's Melanotic Freckle / therapy*
  • Male
  • Microscopy, Confocal / methods*
  • Middle Aged
  • Neoplasm Recurrence, Local
  • Practice Guidelines as Topic*
  • Retrospective Studies
  • Skin Neoplasms / pathology
  • Skin Neoplasms / therapy*