INTRODUCTION
A frail 93-year-old woman with multiple medical problems
presented with a biopsy-proven melanoma in situ involving the entire left lower eyelid, involving the conjunctiva
and extending several centimeters into the cheek and lateral canthus. In the middle, there was a nodule, which was a biopsy-proven invasive melanoma of 2.75 mm depth (Figure 1). Computed tomography of the head and neck revealed no lymphatic
spread. Standard treatment of this depth would involve 2.00 cm margins in all directions, as well as a sentinel lymph node biopsy, which would probably involve the parotid and neck lymph nodes. In this case, that would be an extensive and mutilating excision, which presented a therapeutic dilemma.
It has been reported in the literature that topical imiquimod has the ability to clear melanoma in situ and lentigo maligna.1,2 Its effect on invasive melanoma is unknown, although Spieth and colleagues reported on a patient with recurrent oral mucosal melanoma that responded to imiquimod with clinical and histological
clearance.3
After extensive discussion with the patient, we decided to forgo sentinel lymph node biopsy, and instead, to attempt to treat the melanoma in situ with topical imiquimod and then excise the smaller invasive component. The patient completed
5 weeks of topical imiquimod therapy and returned to the office with profound inflammation (Figure 2). The inflammation was allowed to resolve for 10 days (Figure 3), after which the area where the nodular melanoma had previously
been was excised with a 1.00 cm margin (Figure 4). This was immediately repaired with an advancement flap (Figure 5). Histological examination of the excisional specimen revealed
no residual melanoma detected. The block of tissue was extensively examined, and again, absolutely no residual melanoma was detected.
In this case, it appears that 5 weeks of topical imiquimod therapy completely cleared an invasive melanoma of 2.75 mm depth, as well as clearing the component of melanoma in situ. Clearance of invasive melanoma of this magnitude by topical imiquimod has not been previously reported. The patient was followed for 14 months with no evidence of recurrence (Figure 6). Further study is required, but topical imiquimod may represent
a new topical modality for invasive melanoma.
