Dermatology - Lentigo maligna melanoma (LMM)
LMM, or lentigo maligna melanoma, is a melanoma subtype that is quite uncommon, affecting less than 5% of light-skinned individuals. It primarily affects older adults, with a median age of beginning at 65 years. LMM typically appears on the portions of the body that are most exposed to the sun, such as the face and forearms. LMM initially manifests as lentigo maligna (LM), which is a flat neoplasm located inside the epidermis. It is important to note that LM is not a precursor but rather a developing lesion of melanoma. Papular and nodular lesions indicate a transition from radial to vertical growth, indicating an infiltration into the dermis. The process of LMM gradually transitions from LM over a span of many years, occasionally lasting as long as two decades. Dermatoheliosis is almost always present in the background. The lesions in question are flat and uniform macules, ranging in size from 0.5 cm to 20 cm. They often have well-defined borders, although they may occasionally exhibit fuzzy or extremely uneven edges, frequently with a notch. These lesions often have a "geographic" appearance, resembling inlets and peninsulas. Initial lesions appear tan, but more developed lesions exhibit a brown and black (speckled) appearance. These mature lesions resemble irregular networks of black markings on a brown backdrop, lacking any shades of red or blue. Lentigo maligna melanoma LMM is characterized by the presence of red, white, and blue patches, bumps, or lumps, similar to LM but with a varied appearance. Occasionally, LMM may lack pigmentation, have a skin-colored appearance, and exhibit patchy redness, requiring a biopsy for diagnosis. The diagnosis is established through clinical examination using dermoscopy and subsequently confirmed through histological analysis. The differential diagnosis includes seborrheic keratosis, which can be distinguished by the presence of scaling upon excoriation, and solar lentigo, which lacks the same level of intensity or variation in brown, dark brown, and black colors as found in LM. Administer imiquimod to address first lesions promptly. Remove advanced lesions by excising tissue down to the fascia, ensuring 1-cm margins beyond the apparent lesion or biopsy scar. However, if the eyelids or critical organs are affected, smaller margins can be used. Utilize a Woods light and dermoscopy to delineate the boundaries of the lesion. Perform a biopsy on the sentinel nodes if the lesion measures more than 1 millimeter in thickness. Utilize skin flaps or grafts to achieve closure and restoration. Following the complete eradication of all identifiable tumors, it is advisable to contemplate the use of additional therapy based on the stage of the disease.
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