Delphi Consensus Among International Experts on the Diagnosis, Management, and Surveillance for Lentigo Maligna

Delphi Consensus Among International Experts on the Diagnosis, Management, and Surveillance for Lentigo Maligna

Authors

  • Caterina Longo Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy; Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Skin Cancer Center, Reggio Emilia, Italy
  • Cristian Navarrete-Dechent Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile. 4 Melanoma and Skin Cancer Unit, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile.
  • Philipp Tschandl Department of Dermatology, Medical University of Vienna, Vienna, Austria
  • Zoe Apalla Second Dermatology Department, Aristotle University of Thessaloniki, Greece
  • Giuseppe Argenziano Dermatology Unit, University of Campania, Naples, Italy
  • Ralph P. Braun Department of Dermatology, University Hospital of Zürich, University of Zürich, Zürich, Switzerland.
  • Veronique Bataille Dermatology, Mount Vernon Cancer Centre, Northwood, Middlesex, UK.
  • Horacio Cabo Dermatology Department "Instituto de Investigaciones Médicas A. Lanari", University of Buenos Aires, Argentina.
  • Rainer Hoffmann-Wellhenhof Nonmelanoma Skin Cancer Unit, Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria.
  • Ana Maria Forsea Dermatology Department, Elias University Hospital, Carol Davila University of Medicine and Pharmacy Bucharest, Romania.
  • Claus Garbe Center for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tübingen, Germany
  • Pascale Guitera Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, Australia.
  • Karls Raimond Derma Clinic Riga, Riga, Latvia.
  • Ashfaq A. Marghoob Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  • Josep Malvehy Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, Spain.
  • Veronique del Marmol Department of Dermatology, CUB Hôpital Erasme - Brussels University Clinics, Université Libre de Bruxelles, Brussels, Belgium
  • David Moreno Dermatology Unit, Hospital Universitario Virgen Macarena, Seville, Spain.
  • Kishwer S. Nehal Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  • Eduardo Nagore Dermatology Department, Instituto Valenciano de Oncología, Valencia, Spain
  • John Paoli Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
  • Giovanni Pellacani Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
  • Ketty Peris Institute of Dermatology, Università Cattolica-Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
  • Susana Puig Dermatology Department, Hospital Clinic of Barcelona, University of Barcelona, Spain.
  • H. Peter Soyer Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, QLD 4102, Australia.
  • Susan Swetter Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, California.
  • Alexander Stratigos Department of Dermatology-Venereology, Faculty of Medicine, National and Kapodistrian University of Athens, 'A. Sygros' Hospital for Skin and Venereal Diseases, Athens, Greece.
  • Wilhelm Stolz Department of Dermatology, Allergology, and Environmental Medicine Clinic Thalkirchen, Hospital Munich, Munich, Germany.
  • Luc Thomas Department of Dermatology, Lyon-1 University, and Cancer research center Lyon, Lyon, France.
  • Danica Tiodorovic Clinic of Dermatovenereology, Clinical Center of Nis, Serbia.
  • Iris Zalaudek Department of Dermatology and Venereology, Dermatology Clinic, Maggiore Hospital, University of Trieste, Trieste, Italy.
  • Harald Kittler Department of Dermatology, Medical University of Vienna, Vienna, Austria
  • Aimilios Lallas First Department of Dermatology, School of Medicine, Aristotle University, Thessaloniki, Greece.

Keywords:

melanoma, lentigo maligna, Delphi, diagnosis, management

Abstract

Introduction: Melanoma of the lentigo maligna (LM) type is challenging. There is lack of consensus on the optimal diagnosis, treatment, and follow-up.

Objectives: To obtain general consensus on the diagnosis, treatment, and follow-up for LM.

Methods: A modified Delphi method was used. The invited participants were either members of the International Dermoscopy Society, academic experts, or authors of published articles relating to skin cancer and melanoma. Participants were required to respond across three rounds using a 4-point Likert scale). Consensus was defined as >75% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing.

Results: Of the 31 experts invited to participate in this Delphi study, 29 participants completed Round 1 (89.9% response rate), 25/31 completed Round 2 (77.5% response rate), and 25/31 completed Round 3 (77.5% response rate). Experts agreed that LM diagnosis should be based on a clinical and dermatoscopic approach (92%) followed by a biopsy. The most appropriate primary treatment of LM was deemed to be margin-controlled surgery (83.3%), although non-surgical modalities, especially imiquimod, were commonly used either as alternative off-label primary treatment in selected patients or as adjuvant therapy following surgery; 62% participants responded life-long clinical follow-up was needed for LM.

Conclusions: Clinical and histological diagnosis of LM is challenging and should be based on macroscopic, dermatoscopic, and RCM examination followed by a biopsy. Different treatment modalities and follow-up should be carefully discussed with the patient.

References

Curtin JA, Fridlyand J, Kageshita T, et al. Distinct sets of genetic alterations in melanoma. N Engl J Med. 2005;353(20):2135-2147. DOI: 10.1056/NEJMoa050092. PMID: 16291983.

FFreedman JA, Tyler DS, Nevins JR, Augustine CK. Use of gene expression and pathway signatures to characterize the complexity of human melanoma. Am J Pathol. 2011;178(6):2513-2252. DOI: 10.1016/j.ajpath.2011.02.037. PMID: 21641377. PMCID: PMC3124358.

DDeWane ME, Kelsey A, Oliviero M, Rabinovitz H, Grant-Kels JM. Melanoma on chronically sun-damaged skin: Lentigo maligna and desmoplastic melanoma. J Am Acad Dermatol. 2019;81(3):823-833. DOI: 10.1016/j.jaad.2019.03.066. PMID: 30930085.

C Cox NH, Aitchison TC, Sirel JM, MacKie RM. Comparison between lentigo maligna melanoma and other histogenetic types of malignant melanoma of the head and neck. Scottish Melanoma Group. Br J Cancer. 1996;73(7):940-944. DOI: 10.1038/bjc.1996.168. PMID: 8611411. PMCID: PMC2074252.

Swetter SM, Boldrick JC, Jung SY, Egbert BM, Harvell JD. Increasing incidence of lentigo maligna melanoma subtypes: northern California and national trends 1990-2000. J Invest Dermatol. 2005;125(4):685-691. DOI: 10.1111/j.0022-202X.2005.23852.x. PMID: 16185266.

Swetter SM, Tsao H, Bichakjian CK, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019;80(1):208-250. DOI: 10.1016/j.jaad.2018.08.055. PMID: 30392755.

Koh HK, Michalik E, Sober AJ, et al. Lentigo maligna melanoma has no better prognosis than other types of melanoma. J Clin Oncol. 1984;2(9):994-1001. DOI: 10.1200/JCO.1984.2.9.994. PMID: 6470757.

GGuitera P, Pellacani G, Crotty KA, et al. The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face. J Invest Dermatol. 2010;130(8):2080-2091. DOI: 10.1038/jid.2010.84. PMID: 20393481.

SSchiffner R, Schiffner-Rohe J, Vogt T, et al. Improvement of early recognition of lentigo maligna using dermatoscopy. J Am Acad Dermatol. 2000;42(1 Pt 1):25-32. DOI: 10.1016/s0190-9622(00)90005-7. PMID: 10607316.

Farrahi F, Egbert BM, Swetter SM. Histologic similarities between lentigo maligna and dysplastic nevus: importance of clinicopathologic distinction. J Cutan Pathol. 2005;32(6):405-412. DOI: 10.1111/j.0303-6987.2005.00355.x. PMID: 15953373.

Connolly KL, Giordano C, Dusza S, Busam KJ, Nehal K. Follicular involvement is frequent in lentigo maligna: Implications for treatment. J Am Acad Dermatol. 2019;80(2):532-537. DOI: 10.1016/j.jaad.2018.07.071. PMID: 30266559. PMCID: PMC6333487.

Navarrete-Dechent C, Aleissa S, Connolly K, et al. Clinical size is a poor predictor of invasion in melanoma of the lentigo maligna type. J Am Acad Dermatol. 2021;84(5):1295-1301. DOI: 10.1016/j.jaad.2020.10.023. PMID: 33096134. PMCID: PMC8046713.

Fosko SW, Navarrete-Dechent CP, Nehal KS. Lentigo Maligna-Challenges, Observations, Imiquimod, Confocal Microscopy, and Personalized Treatment. JAMA Dermatol. 2018;154(8):879-881. DOI: 10.1001/jamadermatol.2018.0531. PMID: 29847677.

ZZoutendijk J, Tio D, Koljenovic S, van den Bos RR. Nine per cent of biopsy-proven lentigo maligna lesions are reclassified as lentigo maligna melanoma after surgery. Br J Dermatol. 2019;181(2):383-384. DOI: 10.1111/bjd.17714. PMID: 30716164. PMCID: PMC6850063.

Moreno A, Manrique-Silva E, Virós A, et al. Histologic Features Associated With an Invasive Component in Lentigo Maligna Lesions. JAMA Dermatol. 2019;155(7):782-788. DOI: 10.1001/jamadermatol.2019.0467. PMID: 31066867. PMCID: PMC6506897.

Aouidad I, Fargeas C, Romero P, et al. Histologic predictors of invasion in partially biopsied lentigo maligna melanoma. J Am Acad Dermatol. 2019;80(4):1150-1152. DOI: 10.1016/j.jaad.2018.10.036. PMID: 30879481.

Peruilh-Bagolini L, Apalla Z, González-Cuevas R, et al. Dermoscopic predictors to discriminate between in situ and early invasive lentigo maligna melanoma: A retrospective observational study. J Am Acad Dermatol. 2020;83(1):269-271. DOI: 10.1016/j.jaad.2020.03.030. PMID: 32199898.

Rzepecki AK, Hwang CD, Etzkorn JR, et al. The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas. J Am Acad Dermatol. 2021;85(2):442-452. DOI: 10.1016/j.jaad.2018.11.008. PMID: 30447316.

Robinson M, Primiero C, Guitera P, et al. Evidence-Based Clinical Practice Guidelines for the Management of Patients with Lentigo Maligna. Dermatology. 2020;236(2):111-116. DOI: 10.1159/000502470. PMID: 31639788.

Hazan C, Dusza SW, Delgado R, Busam KJ, Halpern AC, Nehal KS. Staged excision for lentigo maligna and lentigo maligna melanoma: A retrospective analysis of 117 cases. J Am Acad Dermatol. 2008;58(1):142-148. DOI: 10.1016/j.jaad.2007.09.023. PMID: 18029055.

Fogarty GB, Hong A, Economides A, Guitera P. Experience with Treating Lentigo Maligna with Definitive Radiotherapy. Dermatol Res Pract. 2018;2018:7439807. DOI: 10.1155/2018/7439807. PMID: 30105052. PMCID: PMC6076978.

Drakensjö IRT, Rosen E, Frohm Nilsson M, Girnita A. Ten-year Follow-up Study of Grenz Ray Treatment for Lentigo Maligna and Early Lentigo Maligna Melanoma. Acta Derm Venereol. 2020;100(17):adv00282. DOI: 10.2340/00015555-3631. PMID: 32926174. PMCID: PMC9274915.

Tio D, van der Woude J, Prinsen CAC, Jansma EP, Hoekzema R, van Montfrans C. A systematic review on the role of imiquimod in lentigo maligna and lentigo maligna melanoma: need for standardization of treatment schedule and outcome measures. J Eur Acad Dermatol Venereol. 2017;31(4):616-624. DOI: 10.1111/jdv.14085. PMID: 27987308.

Donigan JM, Hyde MA, Goldgar DE, Hadley ML, Bowling M, Bowen GM. Rate of Recurrence of Lentigo Maligna Treated With Off-Label Neoadjuvant Topical Imiquimod, 5%, Cream Prior to Conservatively Staged Excision. JAMA Dermatol. 2018;154(8):885-889. DOI: 10.1001/jamadermatol.2018.0530. PMID: 29847610. PMCID: PMC6143025.

Wildemore JK 4th, Schuchter L, Mick R, et al. Locally recurrent malignant melanoma characteristics and outcomes: a single-institution study. Ann Plast Surg. 2001;46(5):488-494. DOI: 10.1097/00000637-200105000-00006. PMID: 11352421.

Lallas A, Moscarella E, Kittler H, et al. Real-world experience of off-label use of imiquimod 5% as an adjuvant therapy after surgery or as a monotherapy for lentigo maligna. Br J Dermatol. 2021;185(3):675-677. DOI: 10.1111/bjd.20407. PMID: 33894006.

Florell SR, Boucher KM, Leachman SA, et al. Histopathologic recognition of involved margins of lentigo maligna excised by staged excision: an interobserver comparison study. Arch Dermatol. 2003;139(5):595-604. DOI: 10.1001/archderm.139.5.595. PMID: 12756096.

W Weinstock MA, Sober AJ. The risk of progression of lentigo maligna to lentigo maligna melanoma. Br J Dermatol. 1987;116(3):303-310. DOI: 10.1111/j.1365-2133.1987.tb05843.x. PMID: 3567069.

GGreveling K, Wakkee M, Nijsten T, van den Bos RR, Hollestein LM. Epidemiology of Lentigo Maligna and Lentigo Maligna Melanoma in the Netherlands, 1989-2013. J Invest Dermatol. 2016;136(10):1955-1960. DOI: 10.1016/j.jid.2016.06.014. PMID: 27349862.

Kurtansky NR, Dusza SW, Halpern AC, et al. An Epidemiologic Analysis of Melanoma Overdiagnosis in the United States, 1975-2017. J Invest Dermatol. 2022;142(7):1804-1811.e6. DOI: 10.1016/j.jid.2021.12.003. PMID: 34902365. PMCID: PMC9187775.

Welch HG, Mazer BL, Adamson AS. The Rapid Rise in Cutaneous Melanoma Diagnoses. N Engl J Med. 2021;384(1):72-79. DOI: 10.1056/NEJMsb2019760. PMID: 33406334.

McLeod M, Choudhary S, Giannakakis G, Nouri K. Surgical treatments for lentigo maligna: a review. Dermatol Surg. 2011;37(9):1210-1228. DOI: 10.1111/j.1524-4725.2011.02042.x. PMID: 21631635.

Diamond IR, Grant RC, Feldman BM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-409. DOI: 10.1016/j.jclinepi.2013.12.002. PMID: 24581294.

NNavarrete-Dechent C, Liopyris K, Molenda MA, et al. Human surface anatomy terminology for dermatology: a Delphi consensus from the International Skin Imaging Collaboration. J Eur Acad Dermatol Venereol. 2020;34(11):2659-2663. DOI: 10.1111/jdv.16855. PMID: 32770737. PMCID: PMC8236240.

K Katragadda C, Finnane A, Soyer HP, et al. Technique Standards for Skin Lesion Imaging: A Delphi Consensus Statement. JAMA Dermatol. 2017;153(2):207-213. DOI: 10.1001/jamadermatol.2016.3949. PMID: 27892996.

Tio D, Prinsen CAC, Dréno B, Hoekzema R, Augustin M, van Montfrans C. Variation in the diagnosis and clinical management of lentigo maligna across Europe: a survey study among European Association of Dermatologists and Venereologists members. J Eur Acad Dermatol Venereol. 2018;32(9):1476-1484. DOI: 10.1111/jdv.14850. PMID: 29419913.

Barlow JO, Maize J Sr, Lang PG. The density and distribution of melanocytes adjacent to melanoma and nonmelanoma skin cancers. Dermatol Surg. 2007;33(2):199-207. DOI: 10.1111/j.1524-4725.2006.33039.x. PMID: 17300606.

Weyers W, Bonczkowitz M, Weyers I, Bittinger A, Schill WB. Melanoma in situ versus melanocytic hyperplasia in sun-damaged skin. Assessment of the significance of histopathologic criteria for differential diagnosis. Am J Dermatopathol. 1996;18(6):560-566. DOI: 10.1097/00000372-199612000-00002. PMID: 8989926.

Navarrete-Dechent C, Cordova M, Aleissa S, et al. Lentigo maligna melanoma mapping using reflectance confocal microscopy correlates with staged excision: A prospective study. J Am Acad Dermatol. 2023;88(2):371-379. DOI: 10.1016/j.jaad.2019.11.058. PMID: 31812621. PMCID: PMC10210015.

Navarrete-Dechent C, Cordova M, Liopyris K, Ret al. Reflectance confocal microscopy and dermoscopy aid in evaluating repigmentation within or adjacent to lentigo maligna melanoma surgical scars. J Eur Acad Dermatol Venereol. 2020;34(1):74-81. DOI: 10.1111/jdv.15819. PMID: 31325402. PMCID: PMC7592341.41. N Navarrete-Dechent C, Aleissa S, Cordova M, et al. Incompletely excised lentigo maligna melanoma is associated with unpredictable residual disease: clinical features and the emerging role of reflectance confocal microscopy. J Eur Acad Dermatol Venereol. 2020;34(10):2280-2287. DOI: 10.1111/jdv.16272. PMID: 32030827. PMCID: PMC8409509.

Navarrete-Dechent C, Hibler BP, Cordova F, Cordova M, Rossi AM. Lentigo Maligna Margin Template for Surgical Excision Using Reflectance Confocal Microscopy and a Transparent Adhesive Dressing. Dermatol Surg. 2020;46(7):967-969. DOI: 10.1097/DSS.0000000000001988. PMID: 31356439. PMCID: PMC8422434.

Guitera P, Moloney FJ, Menzies SW, et al. Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy. JAMA Dermatol. 2013 Jun;149(6):692-698. DOI: 10.1001/jamadermatol.2013.2301. PMID: 23553208.

Chen CS, Elias M, Busam K, Rajadhyaksha M, Marghoob AA. Multimodal in vivo optical imaging, including confocal microscopy, facilitates presurgical margin mapping for clinically complex lentigo maligna melanoma. Br J Dermatol. 2005;153(5):1031-1036. DOI: 10.1111/j.1365-2133.2005.06831.x. PMID: 16225620.

Pellacani G, De Carvalho N, Ciardo S, et al. The smart approach: feasibility of lentigo maligna superficial margin assessment with hand-held reflectance confocal microscopy technology. J Eur Acad Dermatol Venereol. 2018;32(10):1687-1694. DOI: 10.1111/jdv.15033. PMID: 29704275.

Yélamos O, Cordova M, Blank N, et al. Correlation of Handheld Reflectance Confocal Microscopy With Radial Video Mosaicing for Margin Mapping of Lentigo Maligna and Lentigo Maligna Melanoma. JAMA Dermatol. 2017;153(12):1278-1284. DOI: 10.1001/jamadermatol.2017.3114. PMID: 29049429. PMCID: PMC5730495.

Menge TD, Hibler BP, Cordova MA, Nehal KS, Rossi AM. Concordance of handheld reflectance confocal microscopy (RCM) with histopathology in the diagnosis of lentigo maligna (LM): A prospective study. J Am Acad Dermatol. 2016;74(6):1114-1120. DOI: 10.1016/j.jaad.2015.12.045. PMID: 26826051.

Mehta PP, Oh Y, Cordova M, et al. Patterns of the use of reflectance confocal microscopy at a tertiary referral dermatology clinic. J Am Acad Dermatol. 2022;87(4):882-884. DOI: 10.1016/j.jaad.2021.11.054. PMID: 34875302. PMCID: PMC9166163.

Ng JC, Swain S, Dowling JP, Wolfe R, Simpson P, Kelly JW. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol. 2010;146(3):234-239. DOI: 10.1001/archdermatol.2010.14. PMID: 20231492.

Navarrete-Dechent C, Cordova M, Sahu A, et al. Optical imaging guided- 'precision' biopsy of skin tumors: a novel approach for targeted sampling and histopathologic correlation. Arch Dermatol Res. 2021;313(7):517-529. DOI: 10.1007/s00403-020-02126-6. PMID: 32844312. PMCID: PMC10185006.

Kelley LC, Starkus L. Immunohistochemical staining of lentigo maligna during Mohs micrographic surgery using MART-1. J Am Acad Dermatol. 2002;46(1):78-84. DOI: 10.1067/mjd.2002.119197. PMID: 11756950.

Navarrete-Dechent C, Aleissa S, Ariyan C, Busam KJ, Nehal KS. Comment on "Comparison of surgical margins for lentigo maligna versus melanoma in situ". J Am Acad Dermatol. 2019;81(4):e115-e116. DOI: 10.1016/j.jaad.2019.05.104. PMID: 31233855.

Kunishige JH, Doan L, Brodland DG, Zitelli JA. Comparison of surgical margins for lentigo maligna versus melanoma in situ. J Am Acad Dermatol. 2019;81(1):204-212. DOI: 10.1016/j.jaad.2019.01.051. PMID: 31014825.

National Comprehensive Cancer Network. Melanoma (Version 2.2018).

Agarwal-Antal N, Bowen GM, Gerwels JW. Histologic evaluation of lentigo maligna with permanent sections: implications regarding current guidelines. J Am Acad Dermatol. 2002;47(5):743-748. DOI: 10.1067/mjd.2002.124085. PMID: 12399768.

Kunishige JH, Doan L, Brodland DG, Zitelli JA. Comparison of surgical margins for lentigo maligna versus melanoma in situ. J Am Acad Dermatol. 2019;81(1):204-212. DOI: 10.1016/j.jaad.2019.01.051. PMID: 31014825.

Karanetz I, Stanley S, Knobel D, et al. Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment. Plast Reconstr Surg. 2016;138(1):256-261. DOI: 10.1097/PRS.0000000000002241. PMID: 27351470.

Navarrete-Dechent C, Aleissa S, Ariyan C, Busam KJ, Nehal KS. Melanoma in situ margins: 9 mm for ALL cases may not be appropriate. J Am Acad Dermatol. 2019. DOI:10.1016/j.jaad.2019.05.104

Adalsteinsson JA, Stoj VJ, Algzlan H, Swede H, Torbeck RL, Ratner D. Limitations in the literature regarding Mohs surgery and staged excision for melanoma: A critical review of quality and data reporting. J Am Acad Dermatol. 2023;88(2):404-413. DOI: 10.1016/j.jaad.2021.02.091. PMID: 33872715.

Swetter SM, Chen FW, Kim DD, Egbert BM. Imiquimod 5% cream as primary or adjuvant therapy for melanoma in situ, lentigo maligna type. J Am Acad Dermatol. 2015;72(6):1047-1053. DOI: 10.1016/j.jaad.2015.02.008. PMID: 25791801.

Downloads

Published

2023-07-31

Issue

2023 Vol 13, No 3 | July

Section

Original Article

License

Copyright (c) 2023 Caterina Longo

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Dermatology Practical & Conceptual applies a Creative Commons Attribution License (CCAL) to all works we publish (http://creativecommons.org/licenses/by-nc/4.0/). Authors retain the copyright for their published work.

How to Cite

1.
Longo C, Navarrete-Dechent C, Tschandl P, et al. Delphi Consensus Among International Experts on the Diagnosis, Management, and Surveillance for Lentigo Maligna. Dermatol Pract Concept. 2023;13(3):e2023244. doi:10.5826/dpc.1303a244

Share

Crossref
Scopus
Google Scholar
Europe PMC