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Presentation

Alternative Therapies for Lentigo Maligna: Imiquimod, Practical Management, and Radiation Therapy

Description

The speaker reviews non-surgical options for lentigo maligna, focusing on imiquimod and briefly on radiation therapy. Surgery remains the gold standard, but non-surgical approaches are often considered for frail patients or for cases where surgery would be difficult, and increasingly these options are being incorporated into guidelines. Imiquimod is explained as an off-label cream that stimulates the immune system to attack cancer cells, with the best evidence for lentigo maligna rather than other melanoma types, where data are sparse. The talk distinguishes primary, adjuvant, and neoadjuvant uses of imiquimod and notes that outcomes are best when patients develop a clear clinical inflammatory reaction; lack of inflammation usually means poor benefit and higher recurrence risk. Practical tips include carefully palpating and biopsying any indurated areas to rule out invasive melanoma before treatment, marking the treatment field, photographing the margin, using a paper calendar, and counseling patients to expect inflammation without overreacting to every red spot. A typical regimen starts with 5% imiquimod five times weekly for about 12 weeks, with escalation or adjustment using 5-FU or calcipotriene if there is little reaction, or pausing and treating side effects if inflammation is excessive; fatigue can also occur. Close follow-up with photos and biopsies is emphasized. For radiation therapy, guidelines allow it for medically inoperable patients or when surgery would cause too much morbidity, but one randomized study showed higher recurrence with radiation than with imiquimod. Overall, imiquimod is presented as the most commonly used non-surgical tool, effective when it produces inflammation, but requiring careful patient selection and surveillance.

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Conclusions

Imiquimod can be a useful non-surgical option for lentigo maligna, especially when surgery is not feasible or is undesired, but surgery remains the gold standard.
The benefit of imiquimod appears to depend on producing a noticeable inflammatory skin reaction, with little apparent benefit when there is no inflammation.
Careful pre-treatment evaluation is essential because lesions that look like melanoma in situ may hide invasive melanoma, so palpation and targeted biopsy of indurated areas are recommended.
When imiquimod is used, treatment should generally cover the entire therapeutic margin rather than only a focal positive spot to reduce the risk of recurrence.
Practical success with imiquimod depends on close patient coaching, including marking the treatment field, using calendars, and adjusting dosing to balance adequate inflammation against excessive toxicity.
Recurrence risk after imiquimod varies by intended use, with primary treatment having higher recurrence than adjuvant use, and neoadjuvant use remaining less certain and less established.
Radiation therapy is a guideline-supported alternative for medically inoperable patients or when surgery would be too morbid, but adjuvant radiation does not show clear benefit.
In the comparative trial presented, imiquimod had lower recurrence than radiation therapy at 27 months while quality of life was similar.
Overall, imiquimod is the most commonly used non-surgical therapy for lentigo maligna, but it requires patience, careful monitoring, and ongoing surveillance for recurrence.

Hedblad and Mallbris 2012; Schmid-Wendtner et al 2000
Topical Treatment of Melanoma In Situ, Lentigo Maligna, and Lentigo Maligna Melanoma with Imiquimod Cream#10.1007/978-1-4471-4471-7_48
Topical imiquimod and in situ vulvar melanoma: A promising therapy?#10.1002/ijgo.70087
Imiquimod treatment of vulvar melanoma in situ invading the urethra#10.1016/j.gore.2021.100875
Use of imiquimod for residual acral melanoma#10.1136/bcr-2014-203826
Diagnosis and Management of Acral Lentiginous Melanoma
International Dermoscopy Society consensus recommendations for the management of lentigo maligna
Validation of a patient decision aid for the treatment of lentigo maligna#10.1016/j.jaad.2020.10.043