Prospective Lesion-Level Analysis of the Inverse Approach for Lentigo Maligna in Real-World Clinical Practice

Ece Gokyayla; Aylin Türel Ermertcan; Peyker Temiz

doi:10.5826/dpc.160a6658

Prospective Lesion-Level Analysis of the Inverse Approach for Lentigo Maligna in Real-World Clinical Practice

Authors

Ece Gokyayla Usak Training and Research Hospital, Department of Dermatology and Venereology https://orcid.org/0000-0003-0178-6642
Aylin Türel Ermertcan Celal Bayar University, Faculty of Medicine, Department of Dermatology and Venereolgy
Peyker Temiz Celal Bayar University, Faculty of Medicine, Department of Pathology

Keywords:

lentigo maligna, inverse approach, dermoscopy

Abstract

Introduction: Lentigo maligna (LM) is a melanoma subtype that develops predominantly on photodamaged skin. Classic criteria may miss early lesions due to subtle or partially present malignancy-associated features or their overlap with benign or premalignant conditions related to photodamage. The recently introduced inverse approach, which focuses on the absence of typical non-melanoma dermoscopic features, has shown promise in identifying these challenging cases.

Objectives: This study prospectively evaluated the real-life performance of the inverse approach for differentiating LM from its mimickers and assessed its ability to detect lesions lacking classic criteria.

Methods: This prospective study enrolled consecutive patients presenting with pigmented flat lesion(s) on the head and neck region. Each lesion was photographed and independently assessed by two dermatologists using classic and inverse approach criteria. Lesions showing at least one classic LM criterion or that did not predominantly (≥50% of the surface area) display any inverse approach feature were considered suspicious for LM and underwent biopsy for histopathological evaluation.

Results: A total of 956 lesions from 68 patients were initially evaluated. Of these, 795 (83.2%) were diagnosed as solar lentigo or flat seborrheic keratosis and 145 (15.2%) as actinic keratosis. Classic criteria for lentigo maligna identified four lesions as suspicious, all of which were histopathologically confirmed; three additional lesions were suspicious only by the inverse approach and were likewise confirmed as LM.

Conclusions: In this real-life cohort, the inverse approach identified all observed LM cases, including those lacking classic criteria or showing only subtle classic criteria; this approach may serve as a practical adjunct for evaluating pigmented facial lesions. Larger multicenter studies with systematic verification are needed for broader validation.

References

Schiffner R, Schiffner-Rohe J, Vogt T, et al. Improvement of early recognition of lentigo maligna using dermatoscopy. J Am Acad Dermatol. 2000;42(1):25-32. DOI:10.1016/S0190-9622(00)90005-7.

Navarrete-Dechent C, Jaimes N, Dusza SW, et al. Perifollicular linear projections: A dermatoscopic criterion for the diagnosis of lentigo maligna on the face. J Am Acad Dermatol. 2024;90(1):52-57. DOI:10.1016/j.jaad.2023.07.1036.

Lallas A, Tschandl P, Kyrgidis A, et al. Dermoscopic clues to differentiate facial lentigo maligna from pigmented actinic keratosis. Br J Dermatol. 2016;174(5):1079-1085. DOI:10.1111/bjd.1435.

Tschandl P, Rosendahl C, Kittler H. Dermatoscopy of flat pigmented facial lesions. J Eur Acad Dermatol Venereol. 2015;29(1):120-127. DOI:10.1111/jdv.12483.

Lallas A, Argenziano G, Moscarella E, Longo C, Simonetti V, Zalaudek I. Diagnosis and management of facial pigmented macules. Clin Dermatol. 2014;32(1):94-100. DOI:10.1016/j.clindermatol.2013.05.030.

Akay BN, Kocyigit P, Heper AO, Erdem C. Dermatoscopy of flat pigmented facial lesions: Diagnostic challenge between pigmented actinic keratosis and lentigo maligna. Br J Dermatol. 2010;163(6):1212-1217. DOI:10.1111/j.1365-2133.2010.10025.x.

Lallas A, Lallas K, Tschandl P, et al. The dermoscopic inverse approach significantly improves the accuracy of human readers for lentigo maligna diagnosis. J Am Acad Dermatol. 2021;84(2):381-389. DOI:10.1016/j.jaad.2020.06.085.

Lincoln EA. Sun-induced skin changes. Prim Care. 2000;27(2):435-445. DOI:10.1016/S0095-4543(05)70205-0.

Krutmann J, Berneburg M. Sun-damaged skin (photoaging): what is new? Hautarzt. 2021;72(1):2-5. DOI:10.1007/s00105-020-04747-4.

Willenbrink TJ, Ruiz ES, Cornejo CM, Schmults CD, Arron ST, Jambusaria-Pahlajani A. Field cancerization: Definition, epidemiology, risk factors, and outcomes. J Am Acad Dermatol. 2020;83(3):709-717. DOI:10.1016/j.jaad.2020.03.126.

Şahin MT, Öztürkcan S, Ermertcan AT, Güneş AT. A comparison of dermoscopic features among lentigo senilis/initial seborrheic keratosis, seborrheic keratosis, lentigo maligna and lentigo maligna melanoma on the face. J Dermatol. 2004;31(11):884-889. DOI:10.1111/j.1346-8138.2004.tb00621.x.

Micantonio T, Neri L, Longo C, et al. A new dermoscopic algorithm for the differential diagnosis of facial lentigo maligna and pigmented actinic keratosis. Eur J Dermatol. 2018;28(2):162-168. DOI:10.1684/ejd.2018.3246.