The patient is a 73 year old woman with a pigmented macule at the commisure of the lip for a number of years. The lesion measured 2 mm in diameter and it was excised with a 3 mm punch. She has Type II skin and has had BCC of her nose treated with Mohs surgery a number of years ago. She is in good general health.
Photos taken after suture removal.
Pathology: There is a confluent junctional proliferation of pleomorphic melanocytes
that exhibit pagetoid upward migration on a background of epidermal atrophy and solar elastosis.
These are the features of the lentigo maligna variant of melanoma in situ.
Diagnosis: Melanoma-in-situ, Lentigo maligna type
Question: This is an early lesion and surgical treatment may be overkill. What are your thoughts re: imiquimod, vs. Mohs (with MART-1), vs. watchful waiting?The rate of progression of LM to LMM is estimated to be ~ 3.5% per year. (Menzies SW, PMID 31095041 ) Does this information nudge one towards imiquimod over Mohs surgery?
One option is excision with 5mm margins.
ReplyDeleteCould be closed primarily and would not need Mohs at this point. Mohs could be done if clinical re-occurrence.
Imiquimod is the another option.
Some patients insist on Mohs. Let her help you decide.
Doug Johnson