Lentigo Maligna of the Face: The Importance of Clinical, Dermoscopic, and Histological Correlation

Citation:  Serrão Fensterseifer G, Lodi AP, Lima Dantas M, Boff AL, Lovatto L. Lentigo maligna of the face: the importance of clinical, dermoscopic, and histological correlation. Dermatol Pract Concept. 2019;9(4): 292-294. DOI: https://doi.org/10.5826/dpc.0904a08 Accepted: July 21, 2019; Published: October 31, 2019 Copyright: ©2019 Serrão Fensterseifer et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author:  Dr. Giovana Serrão Fensterseifer, Rua Professor Annes Dias, 135-Hospital Santa Clara, Santa Casa Porto Alegre, Brazil. Email: gfensterseifer@gmail.com

In vivo reflectance confocal microscopy of equivocal melanocytic lesions detected by digital dermoscopy follow-up

BACKGROUND

Digital follow-up is a useful method for the detection of melanoma in atypical mole syndrome patients. The combination of digital follow-up (DFU) and reflectance confocal microscopy (RCM) could be useful to increase the accuracy in the classification of equivocal lesions in atypical mole syndrome patients.

OBJECTIVES

To assess the impact of RCM analysis on sensitivity and specificity of digital follow-up in a high-risk melanoma setting.

METHODS

Retrospective study with dermoscopy and RCM of consecutive equivocal atypical melanocytic lesions exhibiting changes in digital dermoscopy in a referral centre.

RESULTS

Sixty-four lesions from 51 patients were included. Thirteen changing lesions (20.3%) corresponded to eight melanomas in situ and five invasive melanomas with Breslow less than 1 mm. Fifty-one lesions corresponded to melanocytic naevus with variable atypia. Total dermoscopy scores were not different between naevus and melanoma neither in the baseline (mean 5.06 and 5.24; P = 0.37) nor in the follow-up dermoscopic control (mean 5.44 and 5.55; P = 0.37). The only significant dermoscopic feature associated with melanoma in multivariate analysis was the presence of streaks after follow-up (P = 0.027; OR = 3.6; CI 1.50-8.70). The confocal microscopy evaluation (by means both the Modena and Barcelona methods) showed a sensitivity and specificity for the diagnosis of melanoma of 100% and 69% respectively. Based on our experience, the combination of RCM and DFU could have avoided 35 of 51 nevi excised.

CONCLUSIONS

Reflectance confocal microscopy evaluation of equivocal lesions detected by DFU improved the accuracy in the detection of melanoma. The combination of dermoscopy, DFU and confocal microscopy in equivocal lesions can be useful to dramatically reduce the number of excisions of benign lesions in atypical mole syndrome patients.

Ex vivo dermoscopy for biobank-oriented sampling of melanoma

IMPORTANCE

In the era of targeted therapy for cancer, translational research identifying molecular targets in melanoma offers novel opportunities for potential new treatments.

OBJECTIVES

To describe a method for sampling fresh tissue from primary melanoma and to test whether the area of maximal thickness can be identified with dermoscopy to ensure it remains available for routine histopathological diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Tumors clinically suspicious for melanoma with diameter exceeding 5 mm were included. Dermoscopy-guided sampling was performed using a 2-mm to 3-mm punch through not the thickest part of the tumor. In vivo and ex vivo dermoscopic images obtained were available to the diagnosing pathologist. Melanoma samples were obtained in a referral melanoma unit.

MAIN OUTCOMES AND MEASURES

In study 1, Breslow thickness in 10 melanomas was compared between sampled tissue and the remaining specimen to confirm that the area of maximal thickness remained available for the histopathological diagnosis. In study 2, forty-three additional melanomas were sampled for biobanking prospectively. Agreement between 2 independent observers on dermoscopic identification of the thickest part of the melanoma was studied.

RESULTS

In study 1, the area of maximal Breslow thickness in all 10 melanomas was not sampled and remained in the main specimen. In study 2, sampling was performed by one of the investigators. Concordance was 93% between 2 independent observers for the dermoscopic selection of the thickest portion of the melanoma. Pathologists asserted that the sampling procedure did not compromise their ability to evaluate melanoma specimens. A limitation is that this is a single-center study. Each case required joint evaluation by expert dermoscopists and dermatopathologists.

CONCLUSIONS AND RELEVANCE

In applying the dermoscopy-guided sampling protocol, we make the following 5 recommendations: Samples should only be obtained from areas that will not interfere with the pathologist's diagnosis and prognostic information. Sampling should not be obtained from tumors for which one suspects that the histopathological evaluation may prove difficult. Sampling should not be performed on small melanomas; we recommend a minimum diameter of 10 mm. All the dermoscopy-guided sampling should be documented with images, available to pathologists and clinicians, and reflected in the pathology report. Finally, the frozen biobank samples should be made available for routine hematoxylin-eosin histopathological evaluation until the final pathology report is produced. Ex vivo dermoscopy may serve to guide the procurement of small samples from primary melanoma for fresh tissue biobanking without compromising the histopathological evaluation.

Dermoscopic clues in the diagnosis of amelanotic and hypomelanotic malignant melanoma

The clinical identification of amelanotic malignant melanoma (AMM) and hypomelanotic malignant melanoma (HMM) becomes difficult due to the lack of pigmentation and to the diverse clinical presentations. Dermoscopy is very useful in these cases, increasing the level of suspicion of malignancy. We report 4 cases of amelanotic malignant melanoma and hypomelanotic malignant melanoma with characteristic dermoscopic findings. Dermoscopy under polarized light demonstrates vascular polymorphism, globules and milky-red areas, in addition to chrysalis and multiple blue-gray dots.

Characterization of 1152 lesions excised over 10 years using total-body photography and digital dermatoscopy in the surveillance of patients at high risk for melanoma

BACKGROUND

The combined use of total-body photography and digital dermatoscopy, named "two-step method of digital follow-up," allowed the detection of incipient melanoma as a result of dermatoscopic or macroscopic changes during follow-up.

OBJECTIVE

We sought to assess dermatoscopic features and dynamic changes leading to excision of melanocytic lesions during our 10-year experience of monitoring patients at high risk for melanoma.

METHODS

We analyzed 1152 lesions excised during the surveillance of 618 patients at high risk for melanoma from 1999 to 2008.

RESULTS

A total of 779 excised lesions had been previously recorded: 728 were removed because of dermatoscopic changes during follow-up and 51 were removed even though no significant change was noted. The remaining 373 excised lesions were new or undetected on previous total-body photography. A total of 98 melanomas were detected, 60 in the monitored lesions, and 38 among the "new" lesions. The most frequent dermatoscopic changes detected were asymmetric enlargement in almost 60% (n = 418), focal changes in structure in 197 (27%) and in pigmentation in 122 (17%), the latter two being more frequently seen in melanomas than in nevi (both P < .001). No significant differences were detected between dermatoscopic or histopathological characteristics of the melanomas in each group, with a considerable proportion of melanomas misclassified as benign in both groups (26.3% and 38.3%, respectively).

LIMITATIONS

The dermatoscopy pattern of stable lesions and the histopathology of lesions not removed were not included in the study.

CONCLUSION

The most frequent dermatoscopic features associated with melanoma were focal change in pigmentation or structure. Melanomas detected by dermatoscopic changes were remarkably similar to those detected in total-body photography. Almost 40% of melanomas diagnosed in individuals at high risk corresponded to lesions that were not under dermatoscopic surveillance.

Early stages of melanoma on the limbs of high-risk patients: clinical, dermoscopic, reflectance confocal microscopy and histopathological characterization for improved recognition

Early stages of 36 melanomas on limbs were morphologically characterised. Most occurred in high-risk patients (multiple and/or familial melanoma) attending a referral unit for melanoma and pigmented lesions. None of the tumours was clinically suspicious for melanoma (mean diameter of 4.3 mm). The tumours were classified into four dermoscopic groups: (i) prominent network (n = 16); (ii) delicate network (n = 5); (iii) hypo-pigmentation with dotted vessels (n = 10); and (iv) diffuse light pigmentation with perifollicular pigmentation (n = 5). Confocal microscopy performed in 12 cases allowed the identification of atypical, single cells within epidermal layers. Histopathology showed marked large atypical cells in a pagetoid spreading pattern in most cases. Significant associations were detected between the third dermoscopic group and naevoid histological appearance and delay in detection, and between the fourth group and lentigo-maligna-like features. Dermoscopy allowed an increase in the suspicious threshold in these difficult melanomas in high-risk patients and enabled the subclassification of early melanomas on the limbs, with a correct confocal and histopathological correlation. Although the biological behaviour of these incipient tumours remains uncertain, the most appropriate treatment seems to be recognition and proper excision.

Case for diagnosis: umbilical metastasis of pancreatic carcinoma (Sister Mary Joseph's Nodule)

A 56-year-old man was hospitalized with a history of diffuse abdominal pain. Cutaneous examination revealed an erythematous to violaceous, infiltrative nodule of the umbilicus. Histologic examination demonstrated poorly differentiated adenocarcinoma. Abdominal tomography showed advanced pancreatic cancer with metastatic involvement of the liver and the diagnosis of pancreatic adenocarcinoma with umbilical metastasis -- Sister Mary Joseph's nodule.

Dermatoses em pacientes infectados pelo HIV com a contagem de linfócitos CD4

OBJETIVO: Correlacionar a prevalência das doenças dermatológicas entre pacientes infectados pelo HIV com a contagem de linfócitos CD4. MÉTODOS: Estudo de série de casos realizado na região de Caxias do Sul, Estado do Rio Grande do Sul. Os dados foram coletados por meio da revisão de prontuários de pacientes com infecção pelo HIV internados em hospital público (198 pacientes, período de março de 1998 a junho de 2002) ou atendidos no ambulatório central universitário (40 pacientes, período de março a junho de 2002). As variáveis analisadas foram: idade, sexo, contagem de linfócitos CD4, carga viral e doenças dermatológicas apresentadas pelo paciente. Os testes estatísticos utilizados foram o Teste t de Student, o de Spearman e o do qui-quadrado. RESULTADOS: A freqüência de doença dermatológica foi de 67,2% entre os pacientes hospitalizados e de 75,0% entre os pacientes ambulatoriais. Candidíase oral foi a doença dermatológica mais prevalente. Na população hospitalar, a média de células CD4 foi menor entre os pacientes com doença dermatológica dos sem doença dermatológica (142,34 células/mm³ vs 512,35 células/mm³, respectivamente; p=0,018). O mesmo fenômeno foi observado na população ambulatorial (138,88 células/mm³ e 336,21 células/mm³, respectivamente; p=0,001). Verificou-se, em ambas as populações, uma correlação negativa entre a contagem de CD4 e o número total de doenças dermatológicas apresentadas pelo paciente (p=0,000, população hospitalar; p=0,000, população ambulatorial). CONCLUSÕES: As doenças dermatológicas são altamente prevalentes entre os pacientes infectados pelo HIV, sendo que a freqüência e o número dessas manifestações correlacionam-se bem com o status imunológico do paciente e com a progressão da doença.

Freqüência de aconselhamento para prevenção de câncer da pele entre as diversas especialidades médicas em Caxias do Sul

FUNDAMENTOS: O câncer da pele é a forma mais comum de câncer atualmente, apesar de ser um dos mais preveníveis. Não foram encontrados dados na literatura nacional quanto à freqüência de orientação para prevenção desse tipo de câncer de acordo com as diversas especialidades médicas. OBJETIVOS: O objetivo do trabalho foi verificar a freqüência de aconselhamento para prevenção de câncer da pele entre as diversas especialidades médicas em uma amostra da população de Caxias do Sul. MÉTODOS: Trata-se de um estudo transversal. Foram entrevistadas e examinadas 499 pessoas que procuraram atendimento na área de dermatologia em ações comunitárias realizadas em Caxias do Sul de janeiro a julho de 2002. RESULTADOS: Apenas 31,9% (n=159; IC 27,8 - 36,2) das pessoas entrevistadas já haviam recebido aconselhamento pela classe médica para prevenção de câncer da pele. Os pacientes de alto risco com o maior potencial para intervenção, ou seja, pacientes com idade inferior a 20 anos, receberam orientação em freqüência menor do que os pacientes com 20 anos ou mais (26,5% versus 42,5%, respectivamente; p = 0,03). A especialidade de dermatologia foi responsável por mais da metade dos aconselhamentos para prevenção de câncer da pele na população estudada. CONCLUSÃO: A freqüência de aconselhamento para prevenção de câncer da pele pelos profissionais da saúde é baixa, mesmo para os pacientes de alto risco. A orientação também varia de acordo com a especialidade consultada, tendo apenas a especialidade de dermatologia apresentado alta freqüência de aconselhamento.

Kabuki make-up syndrome

The Kabuki Make-up Syndrome is a rare congenital anomaly, characterized by five fundamental features, the " Pentad of Niikawa": dysmorphic facies, skeletal anomalies; dermatoglyphic abnormalities, mild to moderate mental retardation, postnatal growth deficiency. Orthopaedic aspects include scoliosis, malformation of spinal column and ribs, delay in skeletal maturation, congenital deslocation of the hip and patelar dislocation, among others.With the purpose of drawing attention to this diagnostic, the case of five years old brazilian female patient is presented.It´s convenient to present this case to focus on the existance of this syndrome and all its complexity and, therefore, provide help for future diagnosis.