The diagnosis and treatment of lentigo maligna (LM) present challenges to the dermatopathologist and clinician, who struggle to make an accurate diagnosis, devise a treatment plan appropriate to the age and health status of the patient, and determine when surgical margins are truly negative. All these issues create complexity when managing an increasingly common tumor.1 Because most LM lesions occur in cosmetically sensitive areas —usually on the head and neck2 —surgical morbidity is an unavoidable consequence of staged excisions with relatively large defects. When confronted with an ambiguous pathology report, such as “atypical junctional melanocytic hyperplasia with severe atypia on sun-damaged skin ” or “evolving melanoma in situ, ” the clinician is caught on the horns of a dilemma: is this LM or not? If so, what treatment approach strikes the appropriate balance between the relatively low risk of the tumor becoming invasive (if the LM began when the patient was 65 years old, the estimated lifetime risk is 3.3%)3 vs the morbidity of a large staged excision? When it comes to treatment, if ever there was a tumor for which one size does not fit all, it is LM.
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