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Liang Y, Yu Y, Luan W, Xu J. "Red Spitz Tumor" on the Ear: Case Report and Review of the Literature. Clin Cosmet Investig Dermatol 2022; 15:339-345. [PMID: 35250288 PMCID: PMC8896374 DOI: 10.2147/ccid.s349749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/12/2022] [Indexed: 11/23/2022]
Abstract
Spitz nevus (SN) is a benign melanocytic lesion with cytologic and architectural atypia. It is sometimes difficult to distinguish SNs from atypical Spitz tumor (AST), Spitz melanoma, or conventional melanoma. SNs frequently develop in Caucasians and appear on the skin of the head and lower extremities. Lesions on the ear in Asian populations are rare. Here, we report a “red Spitz tumor” on the ear of a Chinese 18-year-old boy. Dermoscopic examination revealed possibly malignant features presented as polymorphous vessels along with central white area, pseudo-network depigmentation and atypical peripheral globular pattern. The results of histopathological examination strongly suggested that the neoplasm was a compound SN and no recurrences or metastases occurred during 1-year follow-up post-surgery. Further, we review the literature on 4 previously reported cases of SN on the ear and summarize the main points of SN diagnosis and differential diagnosis with atypical Spitz tumors and melanoma.
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Affiliation(s)
- YeHua Liang
- Department of Plastic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yijia Yu
- Department of Plastic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Weimin Luan
- Department of NeuroSurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jinghong Xu
- Department of Plastic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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2
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Benton S, Zhao J, Asadbeigi S, Kim D, Zhang B, Gerami P. Pigmented Epithelioid Melanocytoma: Morphology and Molecular Drivers. Surg Pathol Clin 2021; 14:285-292. [PMID: 34023106 DOI: 10.1016/j.path.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pigmented epithelioid melanocytoma (PEM) was originally described based on keen morphologic analysis identifying a group of melanocytic tumors sharing heavily pigmented epithelioid melanocytes. It is defined as heavily pigmented epithelioid, spindled, and dendritic melanocytes with characteristic vesicular nuclei, prominent nucleoli, and melanophages. PEM often involves regional lymph nodes. Recent advances in molecular analysis have allowed for subclassification of PEM into more specific subsets of melanocytic tumors. The most common subsets include PRKCA fusions, which result in pure PEMs with sheets of monomorphic epithelioid melanocytes, and PEMs with combined pattern and mutations in both PRKAR1A and BRAF.
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Affiliation(s)
- Sarah Benton
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Jeffrey Zhao
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Sepideh Asadbeigi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Daniel Kim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Bin Zhang
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Pedram Gerami
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA; Robert H. Lurie Cancer Center, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA.
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3
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De Giorgi V, Venturi F, Scarfì F, Trane L, Silvestri F, Savarese I, Facchini F, Buccoliero AM, Massi D. Clinical and dermoscopic polymorphisms in agminated Spitz nevi: Ugly presentation but benign behavior. Pediatr Dermatol 2021; 38:461-463. [PMID: 33528051 DOI: 10.1111/pde.14535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/09/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
Agminated Spitz nevi are an uncommon entity, and their management is challenging due not only the young age of the patients but also the tumor's uncertain malignant potential and the variability in the dermoscopic and clinical presentation. We report a case of a 6-year-old boy with multiple agminated Spitz nevi on a café au lait macule with different atypical clinical patterns and dermoscopic features.
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Affiliation(s)
- Vincenzo De Giorgi
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Federico Venturi
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Federica Scarfì
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Luciana Trane
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Flavia Silvestri
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Imma Savarese
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | | | | | - Daniela Massi
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
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Papageorgiou C, Apalla Z, Bobos M, Gkentsidi T, Kyrgidis A, Lallas K, Manoli SM, Moutsoudis A, Nikolaidou C, Spyridis I, Lallas A. Dermoscopy of Spitz/Reed naevi and management. GIORN ITAL DERMAT V 2019; 154:457-465. [DOI: 10.23736/s0392-0488.19.06294-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dika E, Neri I, Fanti PA, Barisani A, Ravaioli GM, Patrizi A. Spitznävi: unterschiedliche klinische, dermatoskopische und histopathologische Merkmale in der Kindheit. J Dtsch Dermatol Ges 2017; 15:70-76. [DOI: 10.1111/ddg.12904_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Emi Dika
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
| | - Iria Neri
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
| | - Pier Alessandro Fanti
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
| | - Alessia Barisani
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
| | - Giulia Maria Ravaioli
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
| | - Annalisa Patrizi
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italien
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6
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Dika E, Ravaioli GM, Fanti PA, Neri I, Patrizi A. Spitz Nevi and Other Spitzoid Neoplasms in Children: Overview of Incidence Data and Diagnostic Criteria. Pediatr Dermatol 2017; 34:25-32. [PMID: 27874206 DOI: 10.1111/pde.13025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Spitz nevi are benign melanocytic neoplasms characterized by epithelioid or spindle melanocytes or both. In some rare cases their presentation overlaps with the clinical and histopathologic features of malignant melanoma, so a differential diagnosis can be difficult to make. Intermediate forms between Spitz nevi and malignant melanoma, with unpredictable behavior, have been called atypical Spitz tumors. A literature search was performed to review the clinical, dermoscopic, genetic, and histopathologic aspects of spitzoid tumors. Spitz nevi mainly occur in children, with no predilection for sex, and in young women. Common sites are the head and lower arms, where Spitz nevi present as pink nodules or hyperpigmented plaques. Spitzoid lesions may have diverse dermoscopic patterns: vascular, starburst, globular, atypical, reticular, negative homogeneous, or targetoid. The management of spitzoid lesions can be invasive or conservative; surgical excision is usually reserved for those with doubtful features, whereas clinical and dermoscopic follow-up is preferred for typical pediatric Spitz nevi. The role of sentinel lymph node biopsy in atypical Spitz tumors is debated. Immunohistochemistry and new molecular techniques such as comparative genomic hybridization, polymerase chain reaction, and fluorescence in situ hybridization offer new diagnostic perspectives, investigating genetic alterations that are specific for malignant melanoma or for Spitz nevi.
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Affiliation(s)
- Emi Dika
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giulia Maria Ravaioli
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Pier Alessandro Fanti
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Iria Neri
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Annalisa Patrizi
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Dika E, Neri I, Fanti PA, Barisani A, Ravaioli GM, Patrizi A. Spitz nevi: diverse clinical, dermatoscopic and histopathological features in childhood. J Dtsch Dermatol Ges 2016; 15:70-75. [PMID: 27860221 DOI: 10.1111/ddg.12904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/30/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The characterization of clinical features and biological potential of Spitz nevi has attracted a lot of interest in past decades. The aim of our paper was to describe the clinical, dermatoscopic features as well as the clinical outcome of surgically excised Spitz nevi in three different pediatric age groups. PATIENTS AND METHODS A retrospective study analyzing clinical features, videodermatoscopic images, histopathological diagnosis and patient outcome. The level of pigmentation was evaluated both clinically and histopathologically. RESULTS 72 spitzoid neoplasms were excised from 71 pediatric patients. Videodermatoscopic images were available for 41 patients. The distribution of pigmentation significantly correlated with patient age: hyperpigmented lesions were rather rare in preschool children, becoming more frequent in patients aged 7 to 12 years and older than 13 years. The histopathological diagnosis of atypical Spitz nevus was uncommon. None of the patients originally diagnosed with atypical Spitz nevi developed local recurrence or metastases during subsequent follow-up. CONCLUSIONS Pigmented Spitz nevi were more common after 13 years of age. The study confirms other reports regarding the distribution of pigmentation patterns, and underlines the low number of atypical Spitz nevi in pediatric patients as well as their low recurrence rate during long-term follow-up.
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Affiliation(s)
- Emi Dika
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Iria Neri
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Pier Alessandro Fanti
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Alessia Barisani
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Giulia Maria Ravaioli
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Annalisa Patrizi
- Dermatology, Department of -Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
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Clinical and dermoscopic features of atypical Spitz tumors: A multicenter, retrospective, case-control study. J Am Acad Dermatol 2016; 73:777-84. [PMID: 26475536 DOI: 10.1016/j.jaad.2015.08.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/06/2015] [Accepted: 08/09/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Few studies have described the clinical and dermoscopic features of atypical Spitz tumors. OBJECTIVE We sought to describe the clinical and dermoscopic features of a series of atypical Spitz tumors as compared with those of conventional Spitz nevi. METHODS This was a multicenter, retrospective, case-control study, analyzing the clinical and dermoscopic characteristics of 55 atypical Spitz tumors and 110 Spitz nevi that were excised and diagnosed histopathologically. RESULTS The majority of atypical Spitz tumors presented clinically as a plaque or nodule, dermoscopically typified by a multicomponent or nonspecific pattern. A proportion of lesions (16.4%) exhibited the typical nonpigmented Spitzoid pattern of dotted vessels and white lines under dermoscopy. Nodularity, ulceration, linear vessels, polymorphic vessels, white lines, and blue-white veil were associated with atypical Spitz tumors by univariate analysis, but only nodularity and white lines remained significant after multivariate analysis. In contrast, a pigmented typical Spitzoid pattern was a potent predictor of Spitz nevi, associated with 6.5-fold increased probability. LIMITATIONS Differentiation from Spitzoid melanoma and other nonmelanocytic lesions was not investigated. CONCLUSION Atypical Spitz tumors are polymorphic melanocytic proliferations with a nodular clinical appearance. Dermoscopically they demonstrate a multicomponent and nonspecific pattern. A typical nonpigmented Spitzoid pattern on dermoscopy (with dotted vessels and white lines) does not exclude atypical Spitz tumors.
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Ferrara G, Cavicchini S, Corradin MT. Hypopigmented atypical Spitzoid neoplasms (atypical Spitz nevi, atypical Spitz tumors, Spitzoid melanoma): a clinicopathological update. Dermatol Pract Concept 2015; 5:45-52. [PMID: 25692081 PMCID: PMC4325689 DOI: 10.5826/dpc.050106] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 10/05/2014] [Indexed: 01/21/2023] Open
Affiliation(s)
- Gerardo Ferrara
- Department of Oncology, Anatomic Pathology Unit, Gaetano Rummo Hospital, Benevento, Italy
| | - Stefano Cavicchini
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milan, Italy
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10
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Moscarella E, Al Jalbout S, Piana S, Argenziano G, Lallas A, Longo C, Hofmann-Wellenhof R, Zalaudek I. The stars within the melanocytic garden: unusual variants of Spitz naevi. Br J Dermatol 2015; 172:1045-51. [DOI: 10.1111/bjd.13347] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2014] [Indexed: 11/28/2022]
Affiliation(s)
- E. Moscarella
- Dermatology and Skin Cancer Unit; Arcispedale Santa Maria Nuova IRCCS; Viale Risorgimento 80 42100 Reggio Emilia Italy
| | - S. Al Jalbout
- Department of Dermatology; University of Modena and Reggio Emilia; Modena Italy
| | - S. Piana
- Dermatology and Skin Cancer Unit; Arcispedale Santa Maria Nuova IRCCS; Viale Risorgimento 80 42100 Reggio Emilia Italy
| | - G. Argenziano
- Dermatology and Skin Cancer Unit; Arcispedale Santa Maria Nuova IRCCS; Viale Risorgimento 80 42100 Reggio Emilia Italy
| | - A. Lallas
- Dermatology and Skin Cancer Unit; Arcispedale Santa Maria Nuova IRCCS; Viale Risorgimento 80 42100 Reggio Emilia Italy
| | - C. Longo
- Dermatology and Skin Cancer Unit; Arcispedale Santa Maria Nuova IRCCS; Viale Risorgimento 80 42100 Reggio Emilia Italy
| | - R. Hofmann-Wellenhof
- Department of Dermatology and Venereology; Medical University of Graz; Graz Austria
| | - I. Zalaudek
- Department of Dermatology and Venereology; Medical University of Graz; Graz Austria
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11
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Malkan AD, Sandoval JA. Controversial tumors in pediatric surgical oncology. Curr Probl Surg 2014; 51:478-520. [PMID: 25524425 DOI: 10.1067/j.cpsurg.2014.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 11/17/2014] [Indexed: 12/13/2022]
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12
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Kravitz M. A Pragmatic Approach: Pediatric Spitz-like Lesions. J Nurse Pract 2013. [DOI: 10.1016/j.nurpra.2012.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cerrato F, Wallins JS, Webb ML, McCarty ER, Schmidt BA, Labow BI. Outcomes in pediatric atypical spitz tumors treated without sentinel lymph node biopsy. Pediatr Dermatol 2012; 29:448-53. [PMID: 22211716 DOI: 10.1111/j.1525-1470.2011.01699.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The diagnosis of atypical Spitz tumor (AST) in a pediatric patient conveys an uncertain potential for malignancy. Although pediatric melanoma is rare, AST may be treated aggressively with sentinel lymph node biopsy (SLNB) and subsequent completion lymphadenectomy. These procedures have unclear therapeutic benefit and potential morbidity. We aimed to collect outcomes on children with AST treated with excision alone to assist in the management of these lesions. We queried our institution's pathology database for AST specimens submitted between 1994 and 2009. A dermatopathologist reviewed pathology slides to confirm AST diagnosis. Clinical information was obtained from medical records, and outcomes surveys were administered to children with AST. Twenty-nine patients met AST diagnostic criteria and were included in this study. Mean age at first excision was 9.0 ± 4.2 (range 2.3-17.5), and 19 patients underwent more than one excision procedure to achieve clear margins. No patient had SLNB. Fourteen patients (48%) with mean follow-up time of 8.4 years (range 3.5-15.8) completed clinical outcomes surveys. Outcomes with mean follow-up time of 2.8 years (range 0.02-8.1 years) were obtained for 10 additional patients from medical records. There were no reports of recurrence, additional lesions, or metastases in these 24 patients. We report one of the largest series of children with AST treated using excision alone and who remain disease free after a significant follow-up period. Our data suggest that SLNB is not warranted in the routine management of pediatric AST. We recommend complete excision with clear margins and careful clinical follow-up.
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Affiliation(s)
- Felecia Cerrato
- Department of Plastic and Oral Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA
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Gulia A, Massone C. Advances in dermoscopy for detecting melanocytic lesions. F1000 MEDICINE REPORTS 2012; 4:11. [PMID: 22719794 PMCID: PMC3370664 DOI: 10.3410/m4-11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Over the last 30 years dermatological approaches to diagnosis and management of melanocytic lesions have been revolutionized by the introduction of dermoscopy. Continuous improvements are being made in applying the technique, mostly in melanoma diagnosis, follow-up of melanocytic lesions and nevogenesis. Identification of new dermoscopic criteria, such as the dermoscopic island and the blue-black color for thin and nodular melanoma, respectively, further add two new weapons in the dermoscopical armamentarium for diagnosis of otherwise featureless melanoma. Recent advances show that short-term, 3-month, follow-up is the optimum time interval to identify minimal changes in initially featureless melanomas. Nevertheless, long-term follow-up is still useful for the recognition of changes in melanomas with a very low-rate of growth. Dermoscopy greatly improves diagnosis and early excision of melanomas and reduces the number of unnecessary excisions.
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Affiliation(s)
- Andrea Gulia
- Department of Dermatology, University of L’AquilaL’AquilaItaly
- Department of Dermatology, Medical University of GrazGraz, Auenbruggerplatz 8, A-8036 GrazAustria
| | - Cesare Massone
- Department of Dermatology, Medical University of GrazGraz, Auenbruggerplatz 8, A-8036 GrazAustria
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Yoradjian A, Enokihara MMSES, Paschoal FM. Spitz nevus and Reed nevus. An Bras Dermatol 2012; 87:349-57; quiz 358-9. [DOI: 10.1590/s0365-05962012000300001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 04/04/2011] [Indexed: 11/22/2022] Open
Abstract
Spitz and Reed nevi, also called spindle and/or epithelioid cell nevi, are a special group of melanocytic lesions due to their peculiar clinical, dermoscopic and histopathological features. The study of these nevi is of great interest because both their nomenclature and classification are still a matter of discussion. Most importantly, the difficulty to differentiate them from melanoma can lead to inadequate therapies. In this context, dermoscopy, a link between clinical and anatomopathological examinations, appears as a helpful diagnostic tool whose accuracy can reach 93%. "Borderline" lesions are still a great challenge and object of research, including molecular studies. The present study explores the relevant characteristics of these nevi, with emphasis on dermoscopic findings, aiming at understanding their natural history, as well as discussing treatment and patient follow-up.
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Current world literature. Curr Opin Pediatr 2011; 23:492-7. [PMID: 21750430 DOI: 10.1097/mop.0b013e3283496fc1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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