Remission of extensive lentigo maligna after treatment with imiquimod

Abstracts

Lentigo maligno é um melanoma in situ que mais comumente surge em áreas expostas à radiação ultravioleta, nos pacientes idosos. O tratamento é realizado, principalmente, para minimizar o risco de progressão para lentigo maligno melanoma. O presente relato se refere a uma paciente idosa com lesões recorrentes de lentigo maligno na face, tratada com sucesso com imiquimod tópico, mostrando que este pode ser um tratamento útil, em determinados casos da doença.

Melanoma; Melanoma; Sarda melanótica de Hutchinson

CASE REPORT

Remission of extensive lentigo maligna after treatment with imiquimod

Christiane D. Piazza^I; Sebastião A. P. Sampaio^II

^IDermatologist. Master in Dermatology, Faculdade de Medicina, Universidade de Sao Paulo (FMUSP) - Sao Paulo (SP), Brazil

^IIIn memoriam. Professor Emeritus, Faculdade de Medicina, Universidade de Sao Paulo (FMUSP) - Sao Paulo (SP), Brazil

Mailing Address

ABSTRACT

Lentigno maligna is a melanoma in situ that most commonly appears on areas exposed to ultraviolet radiation, in elderly patients. Treatment is required mainly to minimize the risk of progression to lentigo maligna melanoma. The present report refers to an elderly patient with recurrent lesions of lentigo maligna in her face, who was successfully treated with topical imiquimod, which showed to be a useful therapy for some cases of the disease.

Keywords: Melanoma; Melanoma/therapy; Hutchinson's melanotic freckle

INTRODUCTION

Surgical treatment of melanomas may not be indicated in some cases due to the age of patients or size and site of lesions. Imiquimod (IM) is an immune response modifier, with some reports of efficacy in the treatment of lentigo maligna (LM). ¹

CASE REPORT

An 87-year-old female patient, Caucasian, presented with a large hyperpigmentation area on the left side of the face, involving part of the orbit, frontal and zygomatic regions and upper lid for the past two years. An incisional biopsy was performed, the diagnois was LM, with some areas of dermal invasion by atypical melanocytes (Figure 1). The lesion was excised and grafted. The upper lid lesion was not removed in the first moment since the patient did not accept to have a procedure done on this site. A few months later she came for an return visit with LM on the upper lid, recurrent lesions on the graft and a lesion compatible with basal cell carcinoma in the inner corner of the eye (Figure 2).

The patient suffered from diabetes mellitus, hypertension and depression. The therapy prescribed was 5% imiquimod cream, five times a week, for 12 weeks, for the melanocytic lesion and the basal cell carcinoma (BCC), with excellent response (complete clinical and histological remission of both LM and BCC) (Figure 3). The patient was followed for three years, with no signs of relapse. The patient died of acute myeloid leukemia at the age of 91.

DISCUSSION

Imiquimod (IM) is a synthetic compound of the imidazoquinolone family of drugs, an immune response modifier. It has pro-apoptotic activity against tumor cells, and is an agonist of tolllike receptors (TLR), mostly TLR-7, but also TLR-8. In vivo and in vitro, IM induces apoptosis in melanoma cells. The inhibition of angiogenesis is part of the anti-tumor activity, and in skin cancer, it rapidly increases the peritumoral infiltrate. ¹ IM has been approved for treatment of external and perianal genital warts, actinic keratoses and skin malignancies, such as basal cell carcinoma (BCC). ²

Five percent imiquimod cream, has potent antiviral and antitumoral activity and has been reported as effective to treat LM ^3,4,5, preventing the progression to lentigo maligna melanoma (LMM) and skin metastases of melanoma ^6,7,8. The current treatment for malignant melanoma in situ includes surgical excision with at least 0.5-cm margin. Such treatment may not be indicated in some cases (depending on patientÂ's age, size and site of the lesion). Our patient, after partial surgical removal, presented relapse of LM in the graft.

Treatment with imiquimod resulted in clinical and histological cure of the LM, and the patient was followed-up for 3 years. Imiquimod seems to be a good indication for treating LM, especially in elderly patients or when the clinical status is affected.

REFERENCES

• 1.  Vidal D. Topical imiquimod: mechanism of action and clinical applications. Mini Rev Med Chem. 2006;6:499-503.
• 2.  Wenzel J, Uerlich M, Haller O, Bieber T, Tueting T. Enhance type I interferon signaling and recruitment of chemoquine receptor CXCR3-expressing lymphocytes into the skin fol lowing treatment with the TLR7-agonist imiquimod. J Cutan Pathol. 2005;32: 257-62.
• 3.  Fleming CJ, Bryden AM, Evans A, Dawe RS, Ibbotson SH. A pilot study of treatment of lentigo maligna with 5% imiquimod cream. Br J Dermatol. 2004;151:485-8.
• 4.  Powell AM, Russell-Jones R. Amelanotic lentigo melanoma managed with topical imiquimod as immunotherapy. J Am Acada Dermatol. 2004;50:792-6.
• 5.  Wolf IH, Cerroni L, Kodama K, Kerl H. Treatment of lenti go maligna (melanoma in situ) with the immune response modifier imiquimod. Arch Dermatol. 2005;141:510-4.
• 6.  Hesling C, DIncan M, Mansard S, Franck F, Corbin-Duval A, Chèvenet C, et al. In vivo and in situ modulation of the expression of genes involved in metastasis and angiogene sis in a patient treated with topical imiquimod for melanoma skin metastasis. Br J Dermatol. 2004;150:761-7.
• 7.  Wolf IH, Richting E, Kopera D, Kerl H. Locoregional cuta neous metastases of malignant melanoma and their man agement. Dermatol Surg. 2004;30(Pt 2):244-7.
• 8.  Wolf IH, Smolle J, Binder B, Cerroni L, Richtig E, Kerl H. Topical imiquimod in the treatment of metastatic melanoma to skin. Arch Dermatol. 2003;139:273-6.

*

Trabalho realizado na Clínica Dermatológica Prado Sampaio e no Departamento de Dermatologia da Faculdade de Medicina da Universidade de São Paulo (FMUSP) - São Paulo (SP), Brasil.

Publication Dates

• Publication in this collection
  23 June 2009
• Date of issue
  Feb 2009

History

• Accepted
  09 Jan 2009
• Received
  09 Jan 2009