Imiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type

doi:10.1016/j.jaad.2015.02.008

Journal of the American Academy of Dermatology

Volume 72, Issue 6, June 2015, Pages 1047-1053

https://doi.org/10.1016/j.jaad.2015.02.008 Get rights and content

Background

Surgical resection of lentigo maligna (LM) is complicated by noncontiguous, subclinical extension and actinic melanocytic hyperplasia in sun-damaged skin of older individuals.

Objective

We sought to determine the long-term effectiveness of imiquimod as primary or adjuvant therapy for LM.

Methods

Patients were retrospectively identified from January 1, 2003, to December 31, 2013, with LM, early/evolving LM, and LM melanoma who had used topical imiquimod 5% cream for either primary therapy after diagnostic biopsy, or adjuvant therapy after narrow-margin surgical resection or complete clinical but not histologic resection of LM. Follow-up occurred through December 31, 2014.

Results

In all, 63 cases were identified in 61 patients, mean (SD) age 71.1 (12.4) years; 58 were analyzed for local recurrence. Imiquimod was used as primary therapy in 22 of 63 (34.9%) and adjuvant therapy in 41 of 63 (65.1%) for mean duration of 11.7 (range 2-60) weeks. Fifty cases (86.2%) demonstrated clinical clearance at mean (SD) follow-up of 42.1 (27.4) months: 72.7% primary and 94.4% adjuvant at 39.7 (23.9) and 43.1 (28.9) months, respectively.

Limitations

Retrospective cohort study and lack of standardized imiquimod application are limitations.

Conclusion

Imiquimod cream appears to be a viable option for primary or adjuvant treatment of LM in older patients who are poor surgical candidates.

Section snippets

Methods

Patients given a diagnosis of LM, early/evolving LM, and LMM were retrospectively identified from January 1, 2003, to December 31, 2013, in the Veterans Affairs Palo Alto Health Care System (VAPAHCS) Pathology Service database and Stanford Cancer Institute Research Database, who had undergone treatment with topical imiquimod 5% cream as either primary therapy of LM after diagnostic biopsy, or as adjuvant therapy after narrow-margin surgical resection or complete clinical, but not histologic,

Patients

In all, 63 cases of biopsy-proven LM/early LM or LMM were identified in 61 patients, mean (SD) age 71.1 (12.4) years, in whom imiquimod was used for primary or adjuvant treatment. Most patients were treated at VAPAHCS (63.9%) vs Stanford (36.1%), and the majority were male (76.7%). Mean diameter of the initial clinical lesion was 15 (range 4-40) mm; 18 of 63 (29.0%) were diagnosed as atypical intraepidermal melanocytic proliferation favoring early LM, 29 of 63 (46.0%) were diagnosed as LM, and

Discussion

The incidence of LM and LMM subtypes of melanoma is increasing in the United States, particularly in older, fair-complexioned individuals.14, 15, 16 In an institutional analysis of the VAPAHCS Tumor Registry data from 2003 through 2013, LM accounted for 75.5% (237/314) of subtyped MIS cases and LMM for 46.2% (147/318) of invasive melanomas. Management of LM is complicated by its typical location on the head and neck in older individuals, in whom surgical options may be limited, and histologic

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Imiquimod tópico ha sido utilizado como monoterapia o tratamiento adyuvante fuera de indicación para el lentigo maligno (LM). Nuestro objetivo es describir las modalidades de tratamiento, los resultados clínicos y el manejo de la recidiva en los pacientes que reciben imiquimod para lentigo maligno.
Se incluyó en este estudio a los pacientes de nuestra unidad con lentigo maligno o lentigo maligno melanoma tratados con imiquimod 5% en régimen de monoterapia o junto con cirugía.
Se seleccionaron 14 casos (el 85,7% de lentigo maligno y el 14,3% de lentigo maligno melanoma). Ocho pacientes (57,1%) recibieron imiquimod sin cirugía, y seis (42,9%) fueron sometidos a resección antes de iniciar el tratamiento. Durante el periodo de seguimiento, reapareció la pigmentación en seis pacientes (cuatro con hiperpigmentación postinflamatoria y dos recidivas). Las recidivas fueron tratadas con un margen de resección muy estrecho (1 mm) y retratamiento con imiquimod 5%.
Todas las modalidades de imiquimod reflejaron buena tolerancia de efectos secundarios y bajas tasas de recidiva. Imiquimod parece ser una opción muy versátil para tratar LM en candidatos idóneos.
Topical imiquimod has been used off-label as monotherapy or adjuvant treatment for lentigo maligna. Our aim is to describe treatment modalities, clinical outcomes, and management of recurrence in patients receiving imiquimod for lentigo maligna.
Patients from our unit with lentigo maligna or lentigo maligna melanoma treated with imiquimod 5% as monotherapy or in combination with surgery were included in this study.
Fourteen cases were recruited (85.7% lentigo maligna and 14.3% lentigo maligna melanoma). Eight patients (57.1%) received imiquimod without surgery, and six (42.9%) underwent narrow excision before beginning treatment. During the follow-up period, pigmentation reappeared in 6 patients (4 postinflammatory hyperpigmentation and 2 relapses). Relapses were managed with very narrow excision (1 mm margin) and retreatment with imiquimod 5%.
All imiquimod modalities showed well-tolerated side effects and low recurrence rates, with long periods of follow-up. Imiquimod appears to be a versatile option for treating LM in suitable candidates.
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Original articleImiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type

Background

Objective

Methods

Results

Limitations

Conclusion

Section snippets

Methods

Patients

Discussion

J Am Acad Dermatol

Br J Plast Surg

J Am Acad Dermatol

J Invest Dermatol

J Am Acad Dermatol

J Am Acad Dermatol

The risk of progression of lentigo maligna to lentigo maligna melanoma

Br J Dermatol

National Institutes of Health Consensus Development Conference Statement on Diagnosis and Treatment of Early Melanoma, January 27-29, 1992

Am J Dermatopathol

Staged excision of lentigo maligna and lentigo maligna melanoma: a 10-year experience

Plast Reconstr Surg

Original article
Imiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type