Pathology of Lentigo Maligna -...
Transcript of Pathology of Lentigo Maligna -...
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Pathology of Lentigo Maligna
Memorial Sloan-Kettering Cancer Center, New York City KJ Busam, M.D.; Dept of Pathology
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Normal sun-damaged skin
Lentigo maligna
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Terminology – Lentigo Maligna
• Lentigo Maligna Melanoma in situ
• Lentigo Maligna – Histopathologically pauci-cellular or subtle – “Early evolving lesion”
• “Atypical intraepidermal melanocytic proliferation”
– Ambiguous histopathology; biopsy too small
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Lentigo maligna with junctional nests
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Lentigo Maligna
Multinucleated “star burst” giant cells; lichenoid inflammatory reaction
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Differential Diagnosis
• EPIDERMIS: Melanoma in situ vs benign – Solar melanocyte hyperplasia – Solar lentigo, pigm SK, LPLK, pigm AK – Junctional melanocytic nevus
• DERMIS: Invasion or not? – Scar vs invasive desmoplastic melanoma – Invasive melanoma vs incidental melanocytic nevus – Invasion vs adnexal involvement by MIS
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LM vs Keratosis - Pitfalls
• Melanocyte hyperplasia vs neoplasm
• Collision scenario – LM colliding with keratosis – Melanocytic nevus colliding with keratosis
• Epidermal and/or inflammatory changes
simulating a keratosis
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Junctional Melanocytic Nevus
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Junctional Nevus of MIS?
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Melanoma in Situ
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MIS vs Junctional Nevus
• A new melanocytic proliferation of sun-damaged skin with features of a junctional “dysplastic nevus” is likely MIS
• Not all junctional melanocytic proliferations of sun-damaged skin are MIS
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Diff. Diagnosis – Invasion or Not?
• Adnexal involvement vs dermal invasion • Incidental nevus vs invasion • Microinvasion • Scar vs desmoplastic melanoma
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LMM with Perifollicular Stromal Invasion
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Melanoma simulating a BLK
Melan-A
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Part II
Processing of Excisions for Margin Assessment
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Margins for LM MIS – Often more than 5 mm needed for
clearance
J Am Acad Dermatol. 2012;66:438-44.
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Biopsy of MIS with Subsequent Invasion in Tumor Debulk
Percentage of tumors with invasion Cohen et al Dermatol Surg 1998 10 Agarwal-Antal et al JAAD 2002 16 Zalla et al Dermatol Surg 2000 6.5 Bub et al Arch Dermatol 2002 5.2 Iorizzo et al Dermatol Surg 2013 8 MSKCC (unpublished 2016) 6
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Management of Lentigo Maligna
Initial Shave Excision for Dx and prelimin margin assessment
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