Correlation between digital epiluminescence microscopy parameters and histopathological changes in lentigo maligna and solar lentigo: A dermoscopic index for the diagnosis of lentigo maligna

Lentigo maligna: a review

Lentigo maligna (LM) is a melanoma in situ with distinct clinical features and histology. It commonly affects men after the sixth decade of life. Incidence rates of LM have increased based on early 21st century data from different countries; however, data are suboptimal. Data from England show a plateauing crude incidence between 2013 and 2019. By comparison, invasive melanoma and other types of melanoma in situ commonly appears in younger age groups (median age 58 and 67 years old, respectively) and incidence is rising. The most important risk factors for LM include fair skin and cumulative ultraviolet solar radiation exposure. Although LM is limited to the epidermis and connected skin adnexa, it may progress to invasive LM melanoma. The reported rate of malignant progression varies, reflecting a challenge for LM epidemiology research as often lesions are removed on diagnosis. LM poses a challenge in diagnosis and management. Although it can be diagnosed clinically or dermoscopically, histopathological assessment of biopsied skin tissue remains the gold standard. Reflectance confocal microscopy allows for better appreciation of the complexity of LM at a cellular level, often progressing beyond clinical margins. Management of LM may involve Mohs micrographic surgery or excision, although recurrence may occur even with 5 mm clinical margins. Imiquimod cream may be effective, but incomplete treatment and recurrence has been reported. Conservative management with observation or radiotherapy may be used in selected patients' cases. Five-year net survival rates are excellent. This paper reviews the natural history, epidemiology, aetiology, pathogenesis, diagnosis and management of LM.

Lentigo maligna and lentigo maligna melanoma in vivo differentiation with dermoscopy and reflectance confocal microscopy: A retrospective, multicentre study

INTRODUCTION

Dermoscopic predictors of lentigo maligna (LM) and lentigo maligna melanoma (LMM) have been recently reported, but these have not been reported in reflectance confocal microscopy (RCM).

OBJECTIVES

(i) To validate dermoscopic predictors for LM/LMM, (ii) to identify RCM patterns in LM and LMM, and (iii) correlations between dermoscopic and RCM features in LM and LMM.

MATERIALS AND METHODS

A retrospective, multicentre study of consecutive lesions with histologically proven LM or LMM subtypes of the head and face, with complete sets of dermoscopic and RCM images.

RESULTS

A total of 180 lesions were included (n = 40 LMM). Previously reported differential dermoscopic features for LM subtypes were confirmed. Other features significantly associated with LMM diagnosis included irregular hyperpigmented areas, shiny white streaks, atypical vessels and light brown colour at dermoscopy and medusa head-like structures, dermal nests and nucleated cells within the papillae at RCM (p < 0.05). Correlations among LM lesions between dermoscopic and RCM features included brown to-grey dots and atypical cells (epidermis), grey colour and inflammation and obliterated follicles and medusa head-like structures. Among LMM lesions, significant correlations included obliterated follicles with folliculotropism, both irregular hyperpigmented areas and irregular blotches with widespread atypical cell distribution (epidermis), dermal nests and nucleated cells within the papillae (dermis). Irregular blotches were also associated with medusa head-like structures (dermal epidermal junction [DEJ]).

CONCLUSIONS

Dermoscopic and RCM features can assist in the in vivo identification of LM and LMM and many are correlated. RCM three-dimensional analysis of skin layers allows the identification of invasive components in the DEJ and dermis.

Dermoscopic findings and histopathological correlation in large cell acanthoma

Since large cell acanthoma (LCA) has many overlapping clinical and histopathological features with other epidermal pigmented tumours, an additional method to differentiate it would be of great clinical significance. A retrospective study was performed on 33 lesions (26 patients) to identify distinct dermoscopic findings of LCA and to describe dermoscopic-histopathological correlations. The results revealed that dermoscopy significantly aids in the distinction of LCA from other epidermal tumours included in the differential diagnosis. Yellow opaque homogeneous background, brown dots, and moth-eaten border are common findings, and prominent skin markings and short white streaks are additional distinguishing features. Several important findings that are common in other diseases are rare in LCA.

Folliculotropism in head and neck lentigo maligna and lentigo maligna melanoma

BACKGROUND

Lentigo maligna (LM) and lentigo maligna-melanoma (LMM) are histotypes of melanoma arising in skin with cumulative solar radiation damage. The extension of atypical melanocytes to the hair follicle (folliculotropism) is a histopathological feature of LM/LMM. Its role has not been totally clarified, but it may be correlated to treatment response in LM or to progression in LMM.

OBJECTIVE

This retrospective, multicentric study aims to identify dermatoscopic features associated with folliculotropism in LMs/LMMs.

PATIENTS AND METHODS

We analyzed cases of head and neck LMs/LMMs diagnosed between 2005-2014 at Melanoma Units, University of Bologna/Modena/Florence/Siena (Italy), Nice (France): 25 LMs and 73 LMMs were included.

RESULTS

Grey circles (44 %) indicated an isthmic/bulb level of involvement, which were completely absent in the infundibular LM lesions (P = 0.041). In the group of LMMs, light/dark brown pseudonetwork and light brown structureless areas were an indicator of diffuse distribution of malignant melanocytes in the follicular units (P < 0.001 and P = 0.001, respectively), while grey circles indicated focal or diffuse distribution (P < 0.001).

CONCLUSIONS

A better understanding of the extension of malignant melanocytes is helpful, aiding clinicians in their decision to perform a radical excision or obtaining a biopsy in the most invasive area of the lesion, which includes potential folliculotropism.

Is dermoscopy a good tool for the diagnosis of lentigo maligna and lentigo maligna melanoma? A meta-analysis

Introduction: Dermoscopy is a low-cost examination performed by a dermatologist and good for the diagnosis of pigmented lesions. However, dermoscopy diagnosis of lentigo maligna (LM) and lentigo maligna melanoma (LMM) is still questionable. The objective of this study was to evaluate whether dermoscopy is an effective diagnostic method to diagnose LM/LMM from other pigmented skin lesions, and to identify which are the most frequent dermoscopic criteria associated with LM/LMM

Methods: For this systematic review and meta-analysis, we used the following descriptors: dermoscopy, lentigo maligna, lentigo maligna melanoma, histopathology; and the following databases to search for articles: Cochrane Collaboration, MEDLINE; PMC (PubMed Central) - NIH (National Institutes of Health), EMBASE (The Excerpt Medical Database), and SCISEARCH, from inception to March 30, 2018. The evaluation of studies was performed using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies)-2 tool. The PRISMA (Preferred Reporting Itens for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines were followed for data extraction. Also, we extracted from each study the dermoscopic criteria most commonly found in the lesions of LM/LMM.

Results: This systematic review included 15 articles for qualitative analysis (a total of 2,012 lesions evaluated) and 7 for meta-analysis. In the bivariate model the mean sensitivity was 0.824 and the mean specificity was 0.835. The area under the curve was 0.889. Rhomboid structures, pseudonetwork, and homogeneous areas were the most frequent dermoscopic criteria associated with LM/LMM.

Conclusion: These findings suggest that dermoscopy has good accuracy in the diagnosis of LM/LMM.

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Melanoma of the eyelid and periocular skin: Histopathologic classification and molecular pathology

Cutaneous melanoma, a potentially lethal malignancy of the periocular skin, represents only a small proportion of the roughly 87,000 new cases of cutaneous melanoma diagnosed annually in the United States. Most of our understanding of melanoma of the eyelid skin is extrapolated from studies of cutaneous melanoma located elsewhere. Recent years have witnessed major breakthroughs in molecular biology and genomics of cutaneous melanoma, some of which have led to the development of targeted therapies. The molecular insights have also kindled interest in rethinking how cutaneous melanomas are classified and assessed for risk. We provide a synopsis of the epidemiology, histopathologic classification, and clinical experience of eyelid melanoma since 1990 and then review major advances in the molecular biology of cutaneous melanoma, exploring how this impacts our understanding of classification and predicting risk.

Key dermoscopic signs in the diagnosis and progression of extrafacial lentigo maligna: Evaluation of a series of 41 cases

BACKGROUND/OBJECTIVES

Lentigo maligna is usually located on the face. Extrafacial lentigo maligna is less common, and diagnosis of early forms is very difficult. Confocal microscopy of facial and extrafacial lentigo maligna shares the same features (abundant dendritic cells and generalised atypical junctional thickenings) and helps us to identify the dermoscopic features of extrafacial lentigo maligna.

METHODS

We analysed dermoscopic and clinical features of 41 lesions diagnosed by confocal microscopy of extrafacial lentigo maligna confirmed on histology to identify dermoscopic signs of early lesions.

RESULTS

Erased areas on dermoscopy were the clue to diagnose early lesions. At the borders of these areas, very small, round or triangular structures were found. At the lesion periphery, dermoscopy revealed a fine reticular pattern that helped to identify them as a melanocytic lesion. A progressive increase of the number and size of erased areas was accompanied by the appearance of various angulated structures around them (angulated lines, zig-zag structures or polygonal structures). Analysis of invasive lesions revealed very large erased areas containing white lines and atypical vascularisation.

CONCLUSIONS

We have identified the dermoscopic early features and signs of progression by examining the dermoscopic and reflectance confocal microscopy findings of early and invasive extrafacial lentigo maligna.

Impact of Dermoscopy and Reflectance Confocal Microscopy on the Histopathologic Diagnosis of Lentigo Maligna/Lentigo Maligna Melanoma

BACKGROUND

Equivocal pigmented lesions of the head are usually biopsied to avoid inappropriate treatment. Clinical approach has evolved from simple visual examination to sophisticated techniques for selecting the biopsy sites.

OBJECTIVE

This study aimed to retrospectively evaluate the efficiency of dermoscopy (DE) and reflectance confocal microscopy (RCM) in sampling a histopathologically representative focus of lentigo maligna/lentigo maligna melanoma.

METHODS

Punch biopsies and surgical excisions of 72 patients, 37 men and 35 women (median age 70.6 years, range 39-90 years), affected by lentigo maligna/lentigo maligna melanoma of the head, sent from a single dermatology clinic, were reviewed for the presence of 5 histopathologic criteria: atypical junctional melanocytes, increased junctional melanocytes, follicular colonization, pagetoid spread and melanocytic junctional nests, plus other minor features. Forty-two patients were biopsied under DE and 30 under RCM guidance.

RESULTS

Accuracy of the 2 techniques in sampling a representative tissue overlapped in most cases, although RCM selected sites to biopsy with more histopathologic criteria, in particular pagetoid spread and melanocytic nests. Interestingly, with RCM, inflammation and melanophages were observed more in biopsy than in excision. False positive cases were not registered.

CONCLUSION

Compared with the sampling at naked eye, our results show that DE and RCM help selecting the most appropriate areas for biopsies, thus allowing not only more robust histopathologic diagnoses, but also a more accurate microstaging of tumor.

The effects of a 4-week vibrotherapy programme on the reduction of adipose tissue in young women with cellulite - a pilot study

Introduction: Lipodystrophy is a common problem for modern women. So far, no fully effective therapeutic methods have been developed to eliminate this type of change. Vibration massage is a method that has not yet been studied in the prevention and elimination of lipodystrophy symptoms. Aim of the study: The aim of this study was to evaluate the effectiveness of vibrotherapy on the reduction in lipodystrophic changes. Material and method: 10 volunteers with cellulite changes at the age of 21-23 with physical activity levels described by the international IPAQ questionnaire participated in the study. All women included in the study were evaluated on the basis of 5-day nutrition analysis. Before and after 4 weeks of vibrotherapy, waist, hip and thigh circumferences were measured, and body composition was assessed using bioimpedance and dermatoscope photos were taken. Oscillating cycloidal vibration was generated by the Vitberg+ Rehabilitation Device (Nowy Sącz). Results: After the 4-week series of vibrations, the following average reduction in thigh circumference was observed (Δ1.55 cm, p = 0.002 for right thigh, Δ1.50 cm, p = 0.000 for left), hips (Δ1.25 cm, p = 0.006) and waist (Δ2.30 cm, p = 0.002). The proposed treatment series caused a reduction in body fat mass (Δ0.42 kg, p = 0.009) without affecting the body’s water content, and the analysis of dermatoscopic imaging results revealed improvement in skin perfusion. Conclusion: Oscillating-cycloidal vibration therapy can be an effective tool to alleviate lipodystrophic changes

Lentigo maligna: diagnosis and treatment

Lentigo maligna (LM) is an in situ subtype of melanoma, clinically presenting as a pigmented, asymmetric macule that originates mostly on the head and neck and spreads slowly. The diagnosis may be challenging both for clinicians and pathologists. Dermatoscopy and reflectance confocal microscopy represent a useful tool in the differentiation of LM from other pigmented lesions, such as pigmented actinic keratosis, solar lentigines, seborrheic keratosis and lichen planus-like keratosis. Moreover, those non-invasive diagnostic technique may be crucial in the selection of optimal biopsy sites in equivocal lesions, in pre-surgical mapping and in evaluating and monitoring response to non-surgical treatments. Histologic examination remains the gold standard for the diagnosis of LM, showing a lentiginous proliferation of basal atypical melanocytes on a severe sun-damaged skin. The management of LM is constantly evolving. Treatments include surgery (the first choice, when available), radiotherapy and imiquimod cream (in patients not candidates to surgery). Many other possible treatments for LM have been tested, but they are not yet supported by strong evidences. We collected current guidelines and PubMed available reviews, studies and case-reports in order to make an overview on diagnosis and treatment of LM.