- Sensitivity and specificity of ex vivo dermatoscopy: a case series. [Journal Article]
- IJInt J Dermatol 2018 May 23
- CONCLUSIONS: For dermatopathologists, EVD offers increased specificity for all categories of tumors and increased diagnostic accuracy, sensitivity, and specificity for melanoma. With EVD view, the dermatopathologist can instantly find areas of interest, thus minimizing the possibility for missing a malignant lesion.
- Lowering the recurrence rate in pigmented villonodular synovitis: A series of 120 resections. [Journal Article]
- RRheumatology (Oxford) 2018 May 16
- CONCLUSIONS: In diffuse-type pigmented villonodular synovitis, total synovectomy might be difficult to achieve. As shown in our results and also in the literature, meticulous open resection, especially in difficult to approach areas such as the popliteal space, reduces local recurrence rates. External beam radiation is an option in prevention of otherwise non-operable local recurrences or in non-operable disease.
- Multiple acquired pigmented lesions in a patient affected by melanoma. [Case Reports]
- JDJ Dtsch Dermatol Ges 2018 May 22
- Raised vulvar lesions: be aware! [Journal Article]
- DPDermatol Pract Concept 2018; 8(2):158-161
- Vulvar melanoma is a rare and deadly cancer in women, and the prognosis is often poor. There are limited studies on the dermoscopic features of vulvar melanoma. Described criteria include the presenc...
Vulvar melanoma is a rare and deadly cancer in women, and the prognosis is often poor. There are limited studies on the dermoscopic features of vulvar melanoma. Described criteria include the presence of blue, gray, or white colors. Herein we present the clinical and dermoscopic characteristics of a hypopigmented and heavily pigmented nodule in a 92-year-old and an 80-year-old woman. Dermoscopy in the former revealed structureless milky-red to white areas, remnants of brown pigmentation at the base and polymorphic vessels, while the latter displayed structureless blue-gray areas with black dots and peripheral lines at the base. In both cases, histopathology revealed a stage III melanoma. Our two cases along with a review of the literature suggest that the dermoscopic features described for diagnosing cutaneous nodular melanoma, apply also for vulvar melanoma. Clinicians should always raise the suspicion if observing plaques or nodules with a dermoscopic polymorphic vascular pattern and blue-black color on the genitals of postmenopausal women.
- Screening for malignant melanoma-a critical assessment in historical perspective. [Journal Article]
- DPDermatol Pract Concept 2018; 8(2):89-103
- Screening for melanoma has been advocated for many years because early detection and excision have been regarded as the most important measure to lower mortality from that neoplasm. In the past decad...
Screening for melanoma has been advocated for many years because early detection and excision have been regarded as the most important measure to lower mortality from that neoplasm. In the past decade, concern has been raised by epidemiologists that screening might result in excision chiefly of "inconsequential cancer," i.e., melanomas that would never have progressed into life-threatening tumors, a phenomenon referred to by the misleading term "overdiagnosis." Without any firm evidence, that speculation has been embraced worldwide, and incipient melanomas have been trivialized. At the same time, efforts at early detection of melanoma have continued and have resulted in biopsy of pigmented lesions at a progressively earlier stage, such as lesions with a diameter of only 2, 3, or 4 mm. Those tiny lesions often lack sufficient criteria for clinical and histopathologic diagnosis, the result being true overdiagnoses, i.e., misdiagnoses of melanocytic nevi as melanoma. This is especially true if available criteria for histopathologic diagnosis are diminuished even further by incomplete excision of lesions. The reliability of histopathologic diagnosis is far higher in excisional biopsies of lesions that were given some more time to develop changes that make them recognizable. Biopsy of pigmented lesions with a diameter of 6 mm has been found to result in a far higher yield of melanomas. In addition to better clinical judgment, slight postponement of biopsies bears the promise of substantial improvement of the reliability of histopathologic diagnosis, and of alleviating true overdiagnoses.
- Role of In Vivo Reflectance Confocal Microscopy in the Analysis of Melanocytic Lesions. [Journal Article]
- ADActa Dermatovenerol Croat 2018; 26(1):64-67
- Worldwide melanoma incidence and mortality are increasing (1). Despite the ongoing research, advanced melanoma is still incurable; therefore, the most appropriate solution seems to be early detection...
Worldwide melanoma incidence and mortality are increasing (1). Despite the ongoing research, advanced melanoma is still incurable; therefore, the most appropriate solution seems to be early detection combined with complete surgical excision (2). Since the diagnostic protocol of suspicious lesions includes a complete excision with safety margins (2), the problem of unnecessary scarring is significant. The real challenge in this case is to have a properly formulated diagnosis before acquiring a biopsy. Currently available non-invasive techniques are coherence tomography, digital dermoscopy, and reflectance confocal microscopy. All these techniques allow for a presumptive diagnosis, but the most promising results are provided by reflectance confocal microscopy. Reflectance confocal microscopy (RCM) is an optical imaging technique that uses a laser diode as a source of coherent monochromatic light which penetrates the tissue and illuminates a single point. Light from the stimulated section is reflected and passes through a filter, thereby forming the image on the detector. This filter enables selective excitation of a particular point on which focus is achieved and rejects reflection from the out-of-focus area, thus obtaining a "confocal" image. Contrast is the result of differences in the refractive index of the cell organelles and microstructures, resulting in white structures on a black background. This technique allows, as opposed to conventional light microscopy, the analysis of sections obtained at a bi- or tri-dimensional level and controlling the depth of the field, permitting out-of-focus artifacts to be eliminated. In dermatology, this technique is useful for both clinical and research purposes. It is the only technique that allows horizontal viewing of the skin up to the superficial dermis (approximately 300 mm, at a cellular level resolution (0.5-1.0 μm in the lateral dimension and 4.0-5.0 μm in the axial dimension) (3). It allows both in vivo and ex vivo diagnosis, while providing the possibility for long-term monitoring. It has proved to be especially valuable for in vivo examinations of melanocytic lesions, whereas melanin and melanosomes are a powerful source of contrast, allowing the individualization of melanocytic cells (4). We report the case of a 65-year-old Caucasian woman who presented to the Dermatology Department of University of Modena and Reggio Emilia, Italy, for the examination of an atypical lesion, of unknown history, localized in the right preauricular area. The patient's personal and family histories were negative for skin malignancies and for other significant medical history. The clinical presentation was highly indicative of malignancy, as it met all the ABCD clinical criteria: an asymmetric papule composed of two areas, one pigmented and another one hypopigmented, with ill-defined borders and a diameter of approximately 2 cm. The dermatoscopic examination revealed an asymmetric multicomponent pattern with atypical network, structureless areas, peripheral irregular globules, and a blue-white veil. Because clinical and dermatoscopic features pointed towards a suspicious lesion which was situated on the face, where unnecessary scarring is unwanted, reflectance confocal microscopy (RCM) examination was proposed and performed (VivaScope 3000; MAVIG GmBH, Munich, Germany) (5). It revealed the following features: the epidermis presented a disarranged pattern; the dermo-epidermal junction and superficial dermis presented a meshwork pattern with edged AND non-edged papillae, non-homogenous junctional clusters, dense nests, dense AND sparse nests, and atypical cells in a sparse distribution (Figure 1). Figure 1. (A) Clinical examination of an atypical melanocytic lesion situated at the right preauricular area. (B) Dermatoscopic examination. (C) Confocal examination of dermo-epidermal junction and superficial dermis which reveals a meshwork pattern (yellow circle) with edged AND non-edged papillae, non-homogenous junctional clusters (yellow star), dense nests, dense AND sparse nests (red star) and atypical cells in a sparse distribution (arrow). The clinical and confocal data indicated a malignant melanocytic tumor, so an excisional biopsy with safety margins was performed. The histopathological report indicated superficial spreading melanoma with a Breslow of 0.55 mm and 0 mitosis/mm2. This case illustrates the important role confocal microscopy examination has in the management of melanocytic lesions situated in special areas like the face. Reflectance confocal microscopy is an imaging technique that allows viewing the layers of the skin up to the superficial dermis and therefore turns out to be extremely useful in obtaining a pertinent diagnosis before acquiring a biopsy. According to the data available so far, it was established that reflectance confocal microscopy increases the diagnostic accuracy for melanocytic lesions in both pigmented and hypopigmented lesions. In a study conducted by Borsari et al., reflectance confocal microscopy proved to have a sensibility and specificity of 95.3% and 83.9%, respectively (6). By improving the accuracy of clinical and dermatoscopic diagnosis, the reflectance confocal microscopy technique contributes to increasing the confidence of the clinical and dermatoscopic diagnosis (7). In this regard, confocal reflectance microscopy reduces unnecessary excisions, particularly in cases of damage to cosmetically important areas, such as the face or the neck, simultaneously detecting the malignant lesions that require a surgical approach, as seen in the case presented, where confirmation of the diagnosis by confocal microscopy allowed for a safe excision. In fact, the head and neck are the most appropriate body location for reflectance confocal examination, especially because RCM showed a high diagnostic accuracy for lesions located on sun-damaged skin, as these two areas frequently are (adjusted odds ratio (aOR), 2.13; 95% confidence interval (CI), 1.37-3.30; P=.001) (6). Reflectance confocal microscopy is very helpful in the management of special lesions, like facial lentigo maligna melanoma. This type of lesion is considered to be a real challenge for the dermatologist because of its clinical and morphological features that are similar to other lesions such as solar lentigines and pigmented actinic keratoses. In this case, reflectance confocal excels at specificity of the diagnosis, but also at to the ability to define the margins more accurately, permitting a pre-surgical mapping and for possibility of identifying the optimal site for biopsy (8,9). By improving diagnostic ability, reflectance confocal microscopy technique may contribute to the selection of lesions that may be eligible for non-surgical treatment. Facial pigmented non-melanocytic macules like solar lentigo, flat seborrheic keratosis, lichen planus-like keratosis, and pigmented actinic keratosis can mimic a lentigo maligna, or even a lentigo maligna melanoma, but with the help of the RCM, an accurate diagnosis can be established, sparing the patient can be from unwanted facial scars using a non-surgical approach (laser, cryotherapy, imiquimod) (10,11). Furthermore, reflectance confocal microscopy can be a valuable method for the monitoring of a skin lesion over time, especially melanocytic nevi, reducing unnecessary surgical excision, such as for patients with multiple atypical nevi that undergo multiple biopsies (12,13). Like all other diagnostic methods, RCM has its limitations: palmoplantar lesions (due to thickened epidermis), ulcers or crusts on a large lesion, lesions localized in inaccessible regions such as interdigital space, nasal wing (3). To summarize, reflectance confocal microscopy can improve clinical and dermatoscopic diagnosis of melanocytic lesions, detecting the lesions that need an invasive approach and preventing unnecessary excision. It has proven to be very helpful in the management of lentigo maligna and lentigo maligna melanoma, achieving high specificity in the diagnosis and simultaneously allowing an optimal approach. This technique can be a reliable bridge between dermoscopy and histopathology, being able to provide an alternative to histopathological examination. Special mention must be made of the factors that may change the result to a false negative such as hyperkeratosis, ulceration, or bleeding, so any results should be integrated with the rest of the patient's data.
- Immunohistochemical and molecular analysis of spitzoid neoplasms with pulverocyte subclones. [Journal Article]
- CEClin Exp Dermatol 2018 May 20
- CONCLUSIONS: We consider spitzoid lesions with a small subclone population to be a variant of a clonal naevus with indolent behaviour, whereas lesions with larger pulverocyte populations are more likely to have chromosomal copy number aberrations and in some cases may represent malignant transformation.
- Identification of tumor margins using diffuse reflectance spectroscopy with an extended-wavelength spectrum in a porcine model. [Journal Article]
- SRSkin Res Technol 2018 May 17
- CONCLUSIONS: Extended-wavelength diffuse reflectance spectroscopy can be used in vivo to delineate the border of pigmented skin lesions in a porcine model with high accuracy, indicating that it may be a useful tool for non-invasive tumor margin delineation in the future.
- Histologic mimics of malignant melanoma. [Journal Article]
- SMSingapore Med J 2018 May 18
- Although spongiotic (eczematous), psoriatic and cutaneous skin infections are among the most common dermatology consultations, melanocytic lesions - including the different types of nevi and melanoma...
Although spongiotic (eczematous), psoriatic and cutaneous skin infections are among the most common dermatology consultations, melanocytic lesions - including the different types of nevi and melanomas - are among those that cause a great deal of concern and stress to patients and their clinicians. A diagnosis of benign melanocytic nevus carries a very good prognosis. However, a diagnosis of melanoma might imply more aggressive treatment, lifelong surveillance and a worse prognosis. Differentiating between these conditions is not always a straightforward process for clinicians and pathologists. Therefore, knowledge of melanoma mimickers is very important for clinicians in general, and dermatologists and pathologists in particular. In this review, we call attention to some of the more frequent benign but unusual melanocytic lesions that are of diagnostic concerns for clinicians evaluating these cutaneous proliferations.
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- Microphthalmia-associated transcription factor (MiTF): Promiscuous staining patterns in fibrohistiocytic lesions is a potential pitfall. [Journal Article]
- PRPathol Res Pract 2018 May 11
- Microphthalmia-associated transcription factor (MiTF) is used as a marker of melanocytic differentiation. However, MiTF immunoexpression has also been observed in histiocytes, macrophages, smooth mus...
Microphthalmia-associated transcription factor (MiTF) is used as a marker of melanocytic differentiation. However, MiTF immunoexpression has also been observed in histiocytes, macrophages, smooth muscle cells and fibroblasts, which raise the concern of fibrohistiocytic (FH) lesions being misdiagnosed as melanoma based on MiTF immunoreactivity. MiTF has been known to be positive in FH tumors, but this is the first study evaluating ninety-three fibrohistiocytic neoplasms to understand and delineate the staining pattern of MiTF in these tumors. Ninety-three cases of FH, 30 cases of melanocytic lesions, and 20 miscellaneous cases were studied. The FH cases included benign fibrous histiocytoma (BFH, n = 29), angiofibroma (AF, n = 11), fibromatosis (FM, n = 14), keloid (KE, n = 10), atypical fibroxanthoma (AFX, n = 7), dermal scar (DS, n = 9), dermatofibrosarcoma protuberans (DFSP, n = 12), and pigmented DFSP (Bednar tumor, n = 1). Benign fibrous histiocytoma were sub-categorized into dermatofibroma (n = 15) and epithelioid fibrous histiocytoma (n = 14). The melanocytic lesions included desmoplastic melanoma (DM, n = 8), melanoma in-situ (MIS, n = 5), re-excision-free of melanoma (RFM, n = 10), blue nevus (BN, n = 5), and spitz nevus (SN, n = 3). The miscellaneous category included osteosarcoma (OS, n = 3), pigmented basal cell carcinoma (PBCC, n = 5), spindle cell squamous cell carcinoma (SCA, n = 2), and giant cell tumor of tendon sheath (GCTTS, n = 10). All BFH, AF, AFX, KE, and DS cases showed a positive MiTF staining of variable extent and intensity. MiTF positivity was observed in 86% (n = 12) cases of FM and 17% (n = 2) cases of DFSP. Amongst the miscellaneous category, all cases of PBCC and GCTTS and 50% (n = 1) cases of SCA were immunoreactive for MiTF. All melanocytic lesions were positive for MiTF. None of the OS and pigmented DFSP showed positive labeling. Because of the promiscuity of MiTF labeling, awareness of its pattern in FH proliferations may avoid potential pitfalls in the diagnosis of spindle cell lesions.