Could Lesion Become a Pain in the Neck?

At the insistence of his wife, a 39-year-old man presents to dermatology for evaluation of a lesion on his neck that manifested three years ago. As the lesion has grown, darkened, and become more irregular in outline, she has urged him to have it checked. Her efforts finally succeeded when several of his coworkers also commented on it.

The patient has a history of sun exposure but says he tolerates it well and tans easily. He is otherwise healthy.

EXAMINATION
The irregularly pigmented and bordered dark brown macule, located on the lateral aspect of the left side of his neck,  measures about 2 cm in its greatest dimension. The rest of his neck shows definite signs of chronic UV overexposure, in the form of poikilodermatous changes.

Dermatoscopic examination of the lesion shows focal areas of pigment streaming and blue veiling—both indicative of melanoma. In light of these findings and in the context of his heavily sun-damaged skin, the patient is scheduled for excision. This is performed one week later; the lesion is removed with 5-mm margins, producing a curved, elliptiform defect to match local skin lines, with a two-layer closure.

What is the diagnosis?

DISCUSSION
The pathology report showed the lesion to be an early lentigo maligna (LM). Most authorities in the field do not consider this a true melanoma, although it is probably best considered a type of melanoma in situ. LM definitely involves cellular atypia, but at a very superficial level. Only a tiny fraction of LMs ever become invasive—and only after several years of being left in place.

LM isn’t always as obvious as this patient’s lesion is. It can be brown, red, or even bluish and can blend into surrounding mottled skin lesions (eg, solar lentigines, seborrheic keratoses or actinic keratosis). The key to diagnosis is to observe for change in size and/or color, especially on sun-exposed areas of skin in older, sun-damaged patients.

In this case, the decision to excise the lesion was made easier by its size and location. Larger lesions of uncertain dimensions may be assessed with multiple punch biopsies.

Once LM is diagnosed, the problem becomes obtaining adequate margins surgically, given the often ill-defined dimensions of the lesion. Failure rates, even when Mohs surgery is performed, are all too high. Surgery has therefore been combined with the application of immune-enhancing creams (eg, imiquimod), a method that shows promise but yields conflicting results in studies.

Since many LMs appear on truly elderly patients, and since their evolution to invasive status is so slow, they don’t command the same urgency as a truly invasive melanoma. Clinically, however, this patient’s lesion met the criteria by which we judge potentially malignant lesions: asymmetry, irregular borders, odd color, and large size. It could easily have been an invasive melanoma, either at the time or in future. Finding and identifying it not only delivered peace of mind but also provided a warning that the patient had some serious sun damage—and therefore the potential to develop other cutaneous malignancies.

Fortunately, a whole-body check revealed no other worrisome lesions. The patient has, however, been scheduled for twice-yearly skin checks. He also received education on the recognition of melanoma.

TAKE-HOME LEARNING POINTS
• The prognosis for a melanoma is determined by numerous factors, most notably the vertical thickness of the lesion, as measured under the microscope by the examining pathologist.

• The lentigo maligna lesion, as seen in this case, can be so thin and superficial that some experts don’t consider it a true melanoma.

• Nonetheless, the gross appearance of such lesions typifies the main diagnostic features (ABCDs) of melanoma: Asymmetry, odd Borders, odd Colors, and Diameter (large size).

• The finding of an LM means the patient has increased risk for invasive melanoma in the future.

At the insistence of his wife, a 39-year-old man presents to dermatology for evaluation of a lesion on his neck that manifested three years ago. As the lesion has grown, darkened, and become more irregular in outline, she has urged him to have it checked. Her efforts finally succeeded when several of his coworkers also commented on it.

The patient has a history of sun exposure but says he tolerates it well and tans easily. He is otherwise healthy.

EXAMINATION
The irregularly pigmented and bordered dark brown macule, located on the lateral aspect of the left side of his neck,  measures about 2 cm in its greatest dimension. The rest of his neck shows definite signs of chronic UV overexposure, in the form of poikilodermatous changes.

Dermatoscopic examination of the lesion shows focal areas of pigment streaming and blue veiling—both indicative of melanoma. In light of these findings and in the context of his heavily sun-damaged skin, the patient is scheduled for excision. This is performed one week later; the lesion is removed with 5-mm margins, producing a curved, elliptiform defect to match local skin lines, with a two-layer closure.

What is the diagnosis?

DISCUSSION
The pathology report showed the lesion to be an early lentigo maligna (LM). Most authorities in the field do not consider this a true melanoma, although it is probably best considered a type of melanoma in situ. LM definitely involves cellular atypia, but at a very superficial level. Only a tiny fraction of LMs ever become invasive—and only after several years of being left in place.

LM isn’t always as obvious as this patient’s lesion is. It can be brown, red, or even bluish and can blend into surrounding mottled skin lesions (eg, solar lentigines, seborrheic keratoses or actinic keratosis). The key to diagnosis is to observe for change in size and/or color, especially on sun-exposed areas of skin in older, sun-damaged patients.

In this case, the decision to excise the lesion was made easier by its size and location. Larger lesions of uncertain dimensions may be assessed with multiple punch biopsies.

Once LM is diagnosed, the problem becomes obtaining adequate margins surgically, given the often ill-defined dimensions of the lesion. Failure rates, even when Mohs surgery is performed, are all too high. Surgery has therefore been combined with the application of immune-enhancing creams (eg, imiquimod), a method that shows promise but yields conflicting results in studies.

Since many LMs appear on truly elderly patients, and since their evolution to invasive status is so slow, they don’t command the same urgency as a truly invasive melanoma. Clinically, however, this patient’s lesion met the criteria by which we judge potentially malignant lesions: asymmetry, irregular borders, odd color, and large size. It could easily have been an invasive melanoma, either at the time or in future. Finding and identifying it not only delivered peace of mind but also provided a warning that the patient had some serious sun damage—and therefore the potential to develop other cutaneous malignancies.

Fortunately, a whole-body check revealed no other worrisome lesions. The patient has, however, been scheduled for twice-yearly skin checks. He also received education on the recognition of melanoma.

TAKE-HOME LEARNING POINTS
• The prognosis for a melanoma is determined by numerous factors, most notably the vertical thickness of the lesion, as measured under the microscope by the examining pathologist.

• The lentigo maligna lesion, as seen in this case, can be so thin and superficial that some experts don’t consider it a true melanoma.

• Nonetheless, the gross appearance of such lesions typifies the main diagnostic features (ABCDs) of melanoma: Asymmetry, odd Borders, odd Colors, and Diameter (large size).

• The finding of an LM means the patient has increased risk for invasive melanoma in the future.

At the insistence of his wife, a 39-year-old man presents to dermatology for evaluation of a lesion on his neck that manifested three years ago. As the lesion has grown, darkened, and become more irregular in outline, she has urged him to have it checked. Her efforts finally succeeded when several of his coworkers also commented on it.

The patient has a history of sun exposure but says he tolerates it well and tans easily. He is otherwise healthy.

EXAMINATION
The irregularly pigmented and bordered dark brown macule, located on the lateral aspect of the left side of his neck,  measures about 2 cm in its greatest dimension. The rest of his neck shows definite signs of chronic UV overexposure, in the form of poikilodermatous changes.

Dermatoscopic examination of the lesion shows focal areas of pigment streaming and blue veiling—both indicative of melanoma. In light of these findings and in the context of his heavily sun-damaged skin, the patient is scheduled for excision. This is performed one week later; the lesion is removed with 5-mm margins, producing a curved, elliptiform defect to match local skin lines, with a two-layer closure.

What is the diagnosis?

DISCUSSION
The pathology report showed the lesion to be an early lentigo maligna (LM). Most authorities in the field do not consider this a true melanoma, although it is probably best considered a type of melanoma in situ. LM definitely involves cellular atypia, but at a very superficial level. Only a tiny fraction of LMs ever become invasive—and only after several years of being left in place.

LM isn’t always as obvious as this patient’s lesion is. It can be brown, red, or even bluish and can blend into surrounding mottled skin lesions (eg, solar lentigines, seborrheic keratoses or actinic keratosis). The key to diagnosis is to observe for change in size and/or color, especially on sun-exposed areas of skin in older, sun-damaged patients.

In this case, the decision to excise the lesion was made easier by its size and location. Larger lesions of uncertain dimensions may be assessed with multiple punch biopsies.

Once LM is diagnosed, the problem becomes obtaining adequate margins surgically, given the often ill-defined dimensions of the lesion. Failure rates, even when Mohs surgery is performed, are all too high. Surgery has therefore been combined with the application of immune-enhancing creams (eg, imiquimod), a method that shows promise but yields conflicting results in studies.

Since many LMs appear on truly elderly patients, and since their evolution to invasive status is so slow, they don’t command the same urgency as a truly invasive melanoma. Clinically, however, this patient’s lesion met the criteria by which we judge potentially malignant lesions: asymmetry, irregular borders, odd color, and large size. It could easily have been an invasive melanoma, either at the time or in future. Finding and identifying it not only delivered peace of mind but also provided a warning that the patient had some serious sun damage—and therefore the potential to develop other cutaneous malignancies.

Fortunately, a whole-body check revealed no other worrisome lesions. The patient has, however, been scheduled for twice-yearly skin checks. He also received education on the recognition of melanoma.

TAKE-HOME LEARNING POINTS
• The prognosis for a melanoma is determined by numerous factors, most notably the vertical thickness of the lesion, as measured under the microscope by the examining pathologist.

• The lentigo maligna lesion, as seen in this case, can be so thin and superficial that some experts don’t consider it a true melanoma.

• Nonetheless, the gross appearance of such lesions typifies the main diagnostic features (ABCDs) of melanoma: Asymmetry, odd Borders, odd Colors, and Diameter (large size).

• The finding of an LM means the patient has increased risk for invasive melanoma in the future.