Correspondence 1605

Clinicopathological characteristics of 270 patients with lentigo maligna and lentigo maligna melanoma: data from a German skin cancer centre DOI: 10.1111/bjd.13204 DEAR EDITOR, Recurrence rates following conventional surgery for lentigo maligna (LM) – a form of in situ melanoma – and lentigo maligna melanoma (LMM) – the invasive form of LM – have previously been reported as between 7% and 15%.1,2 We aim to present our single-centre experience with LM and LMM, focusing on clinical and pathological characteristics including recurrence and survival analysis. This monocentric study was performed at the Skin Cancer Center Ruhr-University (Bochum, North Rhine-Westphalia, Germany). The study was approved by the ethics review board of the Ruhr-University Bochum. We assessed the records of patients with LM and LMM from 2000 to 2012. Clinicopathological parameters such as age, sex, anatomical site of primary, melanoma subtype, Clark level, tumour regression, ulceration and thickness (Breslow) were analysed. Follow-up data were collected using chart review and by contacting resident practitioners and dermatologists. LM and LMM were entirely removed with a small excision margin and then assessed by micrographically controlled histology. All tumours were stained with haematoxylin and eosin. Immunohistochemistry included staining with S100 and Melan-A/MART-1 (melanoma-associated antigen recognized by T cells). All melanomas had been assessed by two senior dermatohistopathologists. Patients with LMM of tumour thickness ≥ 1 mm and/or ulcerated LMM (> 0
75 mm) underwent sentinel lymph node biopsy. Patients with positive sentinel lymph nodes were treated with complete lymph node dissection and high-dose interferon-a2b. Data analysis was performed using the statistical package MedCalc Software (MedCalc, Mariakerke, Belgium). Non-normally distributed data were expressed as median and range. Data were analysed using the v2-test. Local recurrencefree survival and overall survival were examined using the Kaplan–Meier method and Cox regression analysis. Survival curves were calculated from the time of diagnosis of the primary melanoma, and were considered censored for patients alive at the last follow-up, or in the event of nonmelanomarelated deaths or unavailable data. P-values < 0
05 were considered significant. Data were available for 270 patients [122 (45
2%) female; 148 (54
8%) male]; median age 80 years (range 47–102); with LM (124/270, 45
9%) or LMM (146/270, 54
1%). The median LMM tumour thickness was 0
35 mm (range 0
1–6
9), and Clark level was II in 88 patients, III in 30, IV in 27 and V in one patient. Overall 133 of 146 patients (91%) had LMM with tumour thickness < 1 mm. Ulceration was observed in five patients (1
9%), and regression was not observed (Table 1). In total 241 of 270 tumours (89
3%) © 2014 British Association of Dermatologists

were found on the head and neck, 25 (9
3%) on the upper extremities and three (1
1%) on the lower extremities. At primary diagnosis we found only one patient (0
7%) with LMM with lymph node metastases. In 140 patients (51
9%), the tumour was completely removed with the first excision, in 91 (33
7%) with the second, 16 (5
9%) with the third, one (0
4%) with the fourth and four (1
5%) with the fifth excision. The corresponding micrographically determined median tumour-free excision margin (also referring to the LM component in LMM) was 3 mm (range 0
1–15 mm). In six of the 270 patients (2
2%) – three of 124 (2
4%) with Table 1 Clinicopathological findings in 270 patients with lentigo maligna (LM, n = 124) and LM melanoma (LMM, n = 146) Parameter

Data

Age (years), median (range) 80 (47–102) Sex (male/female), n (%) 148 (54
8)/122 (45
2) Anatomical site of primary, n (%) Head/neck 241 (89
3) Upper extremities 25 (9
3) Lower extremities 3 (1
1) Trunk 1 (0
4) Tumour ulceration, n (%) 5 (1
9) Tumour regression Not observed LMM tumour thickness (Breslow) 0
35 (0
1–6
9) (mm), median (range) Clark level, n I 124 II 88 III 30 IV 27 V 1 Surgeries until complete excision, n (%) 1 140 (51
9) 2 91 (33
7) 3 16 (5
9) 4 1 (0
4) 5 4 (1
5) Not available 18 (6
7) Smallest tumour margin after 3 (0
1–15) complete excision (mm), median (range) Tumour stage (AJCC 2002) at primary diagnosis, n (%) 0 124 (45
9) IA 117 (43
3) IB 12 (4
4) IIA 13 (4
8) IIB 2 (0
7) IIC 1 (0
4) IIIB 1 (0
4) Local recurrence, n (%)a LM 3 (2
4), all Clark level I LMM 3 (2
1), all Clark level II Disease-related deaths, n (%)a LM 0 LMM 1 (0
7) AJCC, American Joint Committee on Cancer. aMean follow-up 64
4 months (range 5–151).

British Journal of Dermatology (2014) 171, pp1555–1608

1606 Correspondence

(a)

(b)

Fig 1. Kaplan–Meier curves showing the 10-years local recurrencefree survival (a) and disease-related survival (b) probabilities of patients with lentigo maligna (dashed line) and lentigo maligna melanoma (solid line).

in situ LM (all with Clark level I) and three of 146 (2
1%) with invasive LMM (all with Clark level II) – we observed local recurrent disease. In all of these cases, the minimum safety margin was 2
5 mm or smaller. One patient with LMM (tumour thickness 2
3 mm) died from metastatic melanoma (Table 1). Cox proportional hazard regression did not reveal significant covariates with respect to recurrent disease (P = 0
53). The median follow-up was 55 months (range 5–151 months). The 5-year local recurrence-free survival proportions for patients with LM and LMM were 95
9% and 97
6%, respectively, and the 10-year local recurrence-free survival proportions were 95
9% and 85
1%, respectively (Fig. 1). The 5-year and 10-year disease-related survival proportions were 100% and 97
1%, respectively. However, survival data did not significantly differ between patients with LM and LMM (P > 0
05). In accordance with the literature we confirm that LM and LMM are located predominantly on the head and neck, indicating the ultraviolet-related background of this skin tumour.1–7 In LM and LMM, the transition at the peripheral margin of the lesion from neoplastic to non-neoplastic melanocytes can be very poorly defined, in particular in severely sun-damaged skin.5,6 Hence, surgery of this melanoma subtype is often incomplete, requiring repeated British Journal of Dermatology (2014) 171, pp1555–1608

excisions, as also indicated by our data demonstrating a complete melanoma removal rate at the first surgery of only 51
9%. Although we observed a minimum median tumour margin of only 3 mm, the local recurrence rates of 2
4% and 2
1% were low for LM and LMM, respectively. The recurrence rates observed in the present study were not associated with higher Clark levels or increased tumour thickness. Micrographically controlled surgery, including a full examination of all excised peripheral margins, results in excellent recurrence-free rates.4–7 Our 5- and 10-year local recurrence-free survival data confirm the great value of micrographically controlled surgery using relatively small excisions margins in LM and LMM diagnosis.4,6 In melanomas (e.g. LMM, acral melanomas) in special anatomical locations, such as border sites in the face, and on the ears, fingers and toes, reduced safety margins may be used. Retrospective studies have demonstrated that with use of micrographically controlled surgery there is no increase in local recurrences or decrease in overall survival. For LMM and acrolentiginous melanomas a more contiguous tumour spread has been reported. Hence, micrographically controlled surgery, including reduced safety margins, is an appropriate method for the management of LM and LMM.8 The data presented here are in line with the literature, even though most authors of previous reports performed shorter follow-up times. For example, Moehrle et al.4 have shown that micrographically controlled (three-dimensional) histology can achieve local tumour control with a simultaneous reduction of excision margins, especially in the treatment of LMM. Overall 3
7% of patients with LMM treated with three-dimensional histology, and 27
6% of those treated with conventional histology, had tumour recurrences.4 Abdelmalek et al.6 found that the rate of recrudescence after geometric staged excision was 1
7% (four of 239), with a mean of 32
3 months (maximum 96 months) of follow-up. There were no melanoma-related deaths. In conclusion, several re-excisions are frequently necessary until complete removal of LM and LMM is achieved. However, micrographically controlled surgery in LM and LMM is associated with a favourable prognosis.2,6,9 Department of Dermatology, Venereology and Allergology, Skin Cancer Center RuhrUniversity, Ruhr-University Bochum, Gudrunstraße 56, Bochum 44791, Germany E-mail: [email protected]

T. GAMBICHLER J. KEMPKA P. KAMPILAFKOS F.G. BECHARA P. ALTMEYER M . S T U€ C K E R

References 1 Osborne JE, Hutchinson PE. A follow-up study to investigate the efficacy of initial treatment of lentigo maligna with surgical excision. Br J Plast Surg 2002; 55:611–15. 2 Pflugfelder A, Kochs C, Blum A et al. Malignant melanoma S3guideline ‘diagnosis, therapy and follow-up of melanoma’. J Dtsch Dermatol Ges 2013; 11 (Suppl. 6):1–116, 1–126. © 2014 British Association of Dermatologists

Correspondence 1607 3 Zalaudek I, Horn M, Richtig E et al. Local recurrence in melanoma in situ: influence of sex, age, site of involvement and therapeutic modalities. Br J Dermatol 2003; 148:703–8. 4 Moehrle M, Dietz K, Garbe C, Breuninger H. Conventional histology vs. three-dimensional histology in lentigo maligna melanoma. Br J Dermatol 2006; 154:453–9. 5 Clark GS, Pappas-Politis EC, Cherpelis BS et al. Surgical management of melanoma in situ on chronically sun-damaged skin. Cancer Control 2008; 15:216–24. 6 Abdelmalek M, Loosemore MP, Hurt MA, Hruza G. Geometric staged excision for the treatment of lentigo maligna and lentigo maligna melanoma: a long-term experience with literature review. Arch Dermatol 2012; 148:599–604.

7 Samaniego E, Redondo P. Lentigo maligna. Actas Dermosifiliogr 2013; 104:757–75. 8 Breuninger H, Schlagenhauff B, Stroebel W et al. Patterns of local horizontal spread of melanomas: consequences for surgery and histopathologic investigation. Am J Surg Pathol 1999; 23:1493–8. 9 M€ohrle M, Schippert W, Garbe C et al. [Prognostic parameters and surgical strategies for facial melanomas]. J Dtsch Dermatol Ges 2003; 1:457–63. (in German). Funding sources: none. Conflicts of interest: none declared.

Book Review DOI: 10.1111/bjd.13331 Radiation Therapy for Skin Cancer. Armand B. Cognetta, William M. Mendenhall, eds. New York, NY: Springer, 2013; 251 pp. ISBN: 978-1-4614-6985-8. Price £100
50. DOI: 10.1111/bjd.13331 This book aims to be a reference for dermatologists and ‘cutaneous oncologists’ who refer and treat patients with nonmelanoma skin cancer. The editors have divided the topics into small yet comprehensive chapters covering most aspects of cutaneous radiation oncology. The topics include the physics and radiobiological aspects of treatment delivery, clinical application for basal cell and squamous cell carcinomas, and rarer tumours including Merkel cell carcinoma, cutaneous sarcoma and lymphoma. Some aspects of the book are done well. The physics chapter is particularly well written, especially for readers new to the subject. There are also good evidence-based summaries on the common and rarer skin cancers. The chapter on cutaneous lymphoma is very good. There are excellent colour pictures showing treatment set-up and various types of lead shielding, which are useful adjuncts. There are some good summaries on the history of radiation and brachytherapy in dermatology. However, as a clinical oncologist I feel that this book really does lack detail about the practicalities of treatment delivery and prescription, which may be a reflection of the differing practices between the U.S.A. and U.K. The chapters are written by different authors, making the book feel disjointed in parts.

© 2014 British Association of Dermatologists

It includes a lot of unnecessary repetition in some areas and inadequate coverage in others. For example, the physics chapter comprehensively describes the differences between kilovoltage and electron-depth doses and profiles, but there is little mention of how this translates to clinical practice in the later chapters. There is no mention of how to delineate target volumes and what would be the appropriate margins to account for microscopic spread, set-up uncertainties and differing beam properties. The authors describe prescribing treatment according to the half-value depth so that 50% of the surface dose is delivered to the base of the lesion, and the use of time, dose and fractionation tables to select dose and fractionation, which are not U.K. practices. Treating skin lesions with electrons is common practice in the U.K., but how this is done and the implications of using electrons on target volumes, prescription points etc. are not really featured in this book. Much of the economic, legislative and practical information around setting up a superficial radiation dermatology practice is very specific to the U.S.A., and not necessarily relevant to clinicians practicing in the U.K. In conclusion, although this book does give a good overview of the general aspects of cutaneous radiotherapy, it lacks the necessary relevant detail to make it an essential resource for U.K. practice. Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff CF14 2TL, U.K. E-mail: [email protected]

C. PEMBROKE

British Journal of Dermatology (2014) 171, pp1555–1608