Case report
Dermoscopy of skin metastases from breast cancer and of the orange peel type (“peau d’orange”): a report of two cases Gra_zyna Kami nska-Winciorek1, MD, PhD, and Jerzy Wydma nski1,2, MD, PhD
1 The Centre for Cancer Prevention and Treatment, Katowice, Poland, and 2 Department of Conventional and Intraoperative Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology Gliwice Branch, Gliwice, Poland
Correspondence _ Grazyna Kaminska-Winciorek, MD, PhD The Centre for Cancer Prevention and Treatment, ul. Fliegera 16, Katowice, Poland E-mail: [email protected] Conflicts of interest: None. doi: 10.1111/ijd.12094
Introduction To date, no results of any dermoscopy of breast cancer metastases of the orange peel type (peau d’orange) have yet been published. Dermoscopy is a safe, worthwhile, and efficient diagnostic method – not only in the case of diagnosing melanocytic skin tumors but also in reference to the observation of non-melanocytic ones, especially those characterized by pink nodular lesions.1 A number of literary references exist concerning dermoscopic reports, with their diagnostic steps being based on vascular structures in skin non-melanocytic tumors. However, only a limited number of dermoscopic images of metastic nodules of solid tumors have been published so far.2 All types of cancer may metastasize to the skin, with the frequency of occurrence ranging from 0.2 to 9% among autopsies carried out on patients with cancer.3 Skin metastases may occur synchronously or metachronously with the diagnosis of the primary tumor. They usually signify symptoms of advanced cancer. Occasionally, skin metastases may represent an initial manifestation of an occult internal carcinoma.2 The incidence of skin metastases depends on the type of primary tumor and on the patient’s gender. Breast and lung cancer are the most common primary types of cancer that metastasize to the skin, both among men as well as women. Large intestine cancer, melanoma, head and neck cancer, ª 2013 The International Society of Dermatology
kidney cancer, stomach cancer, and ovarian cancer have also regularly been known to metastasize to the skin.3 The clinical diagnosis is not clear. Skin lesions occur as a non-painful, single or multiple, hard or flexible, tiny, pinkish nodule without any specific clinical diagnostic criteria. In such cases, dermoscopy may provide a useful method for the differentiation between the diagnosis of metastasis to the skin and non-neoplastic dermatological diseases. Objective The aim of the study was to present the clinical and dermoscopic features of skin metastasis from breast cancer clinically presenting as multiple skin nodules and an edema of the skin of the breast, known as the orange peel sign (peau d’orange), in the course of that malignancy. Case reports The authors report two cases of dermoscopy in skin metastasis of breast cancer with pink lesion nodules and manifestations of the orange peel sign. In both cases, clinical and dermoscopic examination had been performed. Dermoscopic images from each lesion were obtained using a lens (Dermatoscope delta 20; Heine, Herrsching, Germany) mounted on a Nikon D700 camera on immersion with ultrasonographic gel. International Journal of Dermatology 2013
1
2
Case report
ska-Winciorek et al. Kamin
Dermoscopy of skin metastases from breast cancer
Case 1 A 65-year-old woman presented with a 4-month history of a tumor on the left breast. Clinical examination revealed an edema of the skin with dimpling pits (peau d’orange) of the breast with multiple satellite skin nodules confined to the same breast, in addition to a large, palpable mass with regional adenopathy (Fig. 1). Microscopic examination revealed an invasive lobular carcinoma. An ultrasound examination of the liver, chest x-rays, and bone scan all produced negative results for the presence of metastases. The patient has been diagnosed with a clinical stage IIIB (T4bN2aM0) left breast carcinoma. Dermoscopic examination of the skin metastases demonstrated regularly distributed, irregular, linear arborizing vessels with a tendency for vascular polymorphism (Fig. 2). Figures 3 and 4 present dermoscopic images manifesting the aforementioned orange peel sign. Case 2
Figure 2 Dermoscopy of the skin metastases. Regularly distributed, linear, irregular and arborizing vessels with a tendency to vascular polymorphism. Dermoscopy in this case showed a vascular, irregularly branched arrangement. Two nodules also exhibit loosely distributed, dotted (red dots) vascular structures, especially on the lesion’s edge. Vascular system resembles a cobweb
This case involves a 58-year-old female patient with triple-negative right breast cancer of clinical stage IIIB (T4dN0M0). The first symptom of the disease was a palpable breast tumor, with an accompanying satellite skin nodule found near the nipple. Owing to family reasons, the patient refused treatment for a period of four months. Progression of the disease caused growth of the tumor to a size of 8 cm, with multiple skin nodules and the orange peel sign (Fig. 5). Dermoscopic examination of the skin nodules manifested arborizing telangiectasia (Fig. 6).
Figure 3 Dermoscopic image of the skin of an orange peel sign. Regularly distributed umbilicated, brownish, 1 mm diameter pits over skin are present
Results Dermoscopy
Figure 1 Patient with locally advanced non-inflammatory left breast cancer, with multiple satellite skin nodules as metastases from breast cancer into the skin (black arrows) and the orange peel sign (peau d’orange) (red arrows) at the time of diagnosis International Journal of Dermatology 2013
Vascular structures Dermoscopy of the metastatic skin nodules from both breast cancers in the cases presented above has shown the presence of two predominant types of vascular structures (Figs. 2 and 6). The first of these is an irregular, linear morphology. The second one is the arborizing morphology in the form of both a linear straight and a linear serpentine. Dotted morphology (dots) was also observed in the form of tiny red points, densely aligned, and peripherally positioned next to each other. A combination of two ª 2013 The International Society of Dermatology
ska-Winciorek et al. Kamin
Figure 4 Dermoscopic image of the orange peel sign near the metastatic skin nodule. Linear, irregularly distributed, small fissure-like structures with linear skin depressions are shown
Dermoscopy of skin metastases from breast cancer
Case report
Figure 6 Dermoscopic image of the skin metastases together with the orange peel sign. In the center, the small metastatic nodule with linear irregular and arborizing vessels resembling cobweb are seen with small, umbilicated, brownish pits with orange peel effect located peripherally
Discussion
Figure 5 Patient with right inflammatory breast cancer with multiple skin metastases from breast cancer (black arrows) and the orange peel effect (red arrows)
or more vascular types in metastatic breast cancer indicates the polymorphous type of vascular structures. All vascular structures are distributed along with confluent, whitish depigmentation. The vascular arrangement is rather irregularly branched, resembling a cobweb. Orange peel (“peau d’orange”) Dermoscopy reveals the presence of several brownish, umbilicated pits, 1 mm in diameter. These resemble the umbilicus (Figs. 3 and 6). This is one of the most predominant dermoscopic features of the orange peel sign. During dermoscopy of numerous advanced fibrosing skin lesions, umbilicated pits with a tendency for forming linear fissure-like structures with small, lateral depressions were also found (Fig. 4).
ª 2013 The International Society of Dermatology
Dermoscopic analysis of skin tumors has mainly been focused on pigmented and vascular structures, especially in the case of basal cell carcinoma, spindle cell carcinoma, keratoacanthoma, and melanoma. The dermoscopic vascular patterns accompanying a variety of non-melanocytic non-pigmented skin tumors, such as sebaceous hyperplasia, seborrheic keratosis, clear cell acanthoma, Bowen’s disease, or nodular cystic basal cell carcinoma are highly specific, allowing ready diagnosis in the vast majority of cases.4 Recently, several different morphological types of vessels have been found to possess a direct association with pigmented or non-pigmented skin tumors.4,5 The structures of arborizing and glomerular vessels revealed diagnostic specificity for basal cell carcinoma and Bowen’s disease, and irregularly distributed, linear structures were helpful in differentiating melanoma from spindle cell carcinoma.4–6 Irregular, linear, dotted, and polymorphous/atypical vessels are the most frequent vascular structures characterizing melanoma.7 Kreusch has reported that dotted vessels could also be present in melanocytic and non-melanocytic lesions, as well as in both benign and malignant tumors, including melanoma. This is because vascular dots are considered only tumoral vessels, which supply a solid tumor whose borders can be recognized at clinical examination.6,8 Few publications exist concerning the dermoscopy of metastatic tumors, especially the metastatic solid tumor. To date, only dermoscopic features of metastatic melanoma have ever been described.9 Previously, de Giorgi et al.2 described a dermoscopic pattern of cutaneous meta-
International Journal of Dermatology 2013
3
4
Case report
ska-Winciorek et al. Kamin
Dermoscopy of skin metastases from breast cancer
static thyroid cancer, which revealed the presence of atypical and polymorphous vascular structures within the pink, solitary erythematous lesion. Cutaneous metastasis from breast carcinoma is rather commonly observed. Clinical manifestations of cutaneous metastasis have been found as nodular, inflammatory, and sclerodermoid lesions.10 It usually occurs as a collection of numerous, tiny reddish nodules, without a tendency for ulceration, manifesting sclerodermoid skin changes known as the orange peel sign. Any dermoscopic description of metastatic breast cancer is very rarely found in professional literature. To the authors’ best knowledge, supported by meticulous literary analysis (PubMed), only one report on the use of dermoscopy has ever been published. Only in one case of nodular hyperpigmented metastatic breast cancer have the occurring dermoscopic changes been observed in the form of peripheral globules and a blue–white veil characterized, mimicking a melanoma.11 The case report includes no mention of any dermoscopic effects resembling the discussed orange peel characteristics. In both presented cases, dermoscopy of metastatic skin nodules from the existing breast cancer manifests two predominant types of vascular structures. The first is the irregular linear morphology, which may be characterized as linear straight – in new terminology, a linear serpentine defined as a linear, irregularly shaped and sized vascular structure. The second one takes the form of arborizing morphology as a linear straight and linear serpentine, both of which reflect bright red stem vessels of large diameter, branching irregularly into finer terminal capillaries. Dotted morphology (dots) as tiny red dots, densely aligned to each other and distributed peripherally, has also been observed in the dermoscopy of skin metastases from breast cancer. The combination of two or more vascular types in metastatic breast cancer indicates a polymorphous type of vascular structure. In the presented case, the diagnosis of skin metastasis seems to present itself as a relatively easy task. Patients with breast cancer require differentiation between skin metastasis and dermatological disease many years following treatment to rule out or diagnose a skin tumor. An edema of the skin of the breast, known as the orange peel sign (peau d’orange), can be caused by the infiltration or obstruction of lymphatic drainage of the breast or breast skin. Skin dimpling may occur because of a tumor invading the Cooper’s ligament. Dermoscopy of the area characterizing itself with the manifestation of the orange peel effect reveals the presence of several dimpling pits, all resembling the umbilicus. It also possesses a tendency for forming linear, fissure-like structures in the immediate vicinity of satellite metastatic skin nodules. The prognostic value of the density and diameter of these vessels found in skin metastases is yet to be
International Journal of Dermatology 2013
investigated. Dermoscopy also allows for an easy assessment of vessels during treatment and the possibility for efficient monitoring while treatment is in progress. Conclusion In conclusion, dermoscopy is a valuable method, which may be facilitated in performing additional diagnostics, especially in the case of recognition of a metastatic breast cancer invasion on to the skin. However, further research and observation are still needed. References 1 Kaminska-Winciorek G, Spiewak R. [Basic dermoscopy of melanocytic lesions for beginners]. Postepy Hig Med Dosw (Online) 2011; 65: 501–508. 2 de Giorgi V, Alfaioli B, Massi D, et al. Solitary cutaneous metastasis as the first sign of relapse of thyroid carcinoma: a clinical, dermoscopic-pathologic case study. Dermatol Surg 2009; 35: 523–526. 3 Bijan S. Cancer of the skin. In: DeVita VT, Hellman S, Rosenberg SA eds. Cancer: Principles and Practice of Oncology. Philadelphia: J.B. Lippincott Company, 1993: 1567–1611. 4 Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose non-pigmented skin tumours: a review of vascular structures seen with dermoscopy: part II. Non-melanocytic skin tumours. J Am Acad Dermatol 2010; 63: 377–386. 5 Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose non-pigmented skin tumours: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumours. J Am Acad Dermatol 2010; 63: 361–374. 6 Sakakibara A, Kamijima M, Shibata S, et al. Dermoscopic evaluation of vascular structures of various skin tumours in Japanese patients. J Dermatol 2010; 37: 316–322. 7 Argenziano G, Zalaudek I, Corona R, et al. Vascular structures in skin tumours: a dermoscopy study. Arch Dermatol 2004; 140: 1485–1489. 8 Kreusch JF. Vascular patterns in skin tumours. Clin Dermatol 2002; 20: 248–254. 9 Bories N, Dalle S, Debarbieux S, et al. Dermoscopy of fully regressive cutaneous melanoma. Br J Dermatol 2008; 158: 1224–1229. 10 Brownstein MH, Helwig EB. Spread of tumours to the skin. Arch Dermatol 1973; 107: 80–86. 11 Wyatt AJ, Agero AL, Delgado R, et al. Cutaneous metastatic breast carcinoma with melanocyte colonization: a clinical and dermoscopic mimic of malignant melanoma. Dermatol Surg 2006; 32: 949–954.
ª 2013 The International Society of Dermatology
Dermoscopy of skin metastases from breast cancer and of the orange peel type (“peau d’orange”): a report of two cases Gra_zyna Kami nska-Winciorek1, MD, PhD, and Jerzy Wydma nski1,2, MD, PhD
1 The Centre for Cancer Prevention and Treatment, Katowice, Poland, and 2 Department of Conventional and Intraoperative Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology Gliwice Branch, Gliwice, Poland
Correspondence _ Grazyna Kaminska-Winciorek, MD, PhD The Centre for Cancer Prevention and Treatment, ul. Fliegera 16, Katowice, Poland E-mail: [email protected] Conflicts of interest: None. doi: 10.1111/ijd.12094
Introduction To date, no results of any dermoscopy of breast cancer metastases of the orange peel type (peau d’orange) have yet been published. Dermoscopy is a safe, worthwhile, and efficient diagnostic method – not only in the case of diagnosing melanocytic skin tumors but also in reference to the observation of non-melanocytic ones, especially those characterized by pink nodular lesions.1 A number of literary references exist concerning dermoscopic reports, with their diagnostic steps being based on vascular structures in skin non-melanocytic tumors. However, only a limited number of dermoscopic images of metastic nodules of solid tumors have been published so far.2 All types of cancer may metastasize to the skin, with the frequency of occurrence ranging from 0.2 to 9% among autopsies carried out on patients with cancer.3 Skin metastases may occur synchronously or metachronously with the diagnosis of the primary tumor. They usually signify symptoms of advanced cancer. Occasionally, skin metastases may represent an initial manifestation of an occult internal carcinoma.2 The incidence of skin metastases depends on the type of primary tumor and on the patient’s gender. Breast and lung cancer are the most common primary types of cancer that metastasize to the skin, both among men as well as women. Large intestine cancer, melanoma, head and neck cancer, ª 2013 The International Society of Dermatology
kidney cancer, stomach cancer, and ovarian cancer have also regularly been known to metastasize to the skin.3 The clinical diagnosis is not clear. Skin lesions occur as a non-painful, single or multiple, hard or flexible, tiny, pinkish nodule without any specific clinical diagnostic criteria. In such cases, dermoscopy may provide a useful method for the differentiation between the diagnosis of metastasis to the skin and non-neoplastic dermatological diseases. Objective The aim of the study was to present the clinical and dermoscopic features of skin metastasis from breast cancer clinically presenting as multiple skin nodules and an edema of the skin of the breast, known as the orange peel sign (peau d’orange), in the course of that malignancy. Case reports The authors report two cases of dermoscopy in skin metastasis of breast cancer with pink lesion nodules and manifestations of the orange peel sign. In both cases, clinical and dermoscopic examination had been performed. Dermoscopic images from each lesion were obtained using a lens (Dermatoscope delta 20; Heine, Herrsching, Germany) mounted on a Nikon D700 camera on immersion with ultrasonographic gel. International Journal of Dermatology 2013
1
2
Case report
ska-Winciorek et al. Kamin
Dermoscopy of skin metastases from breast cancer
Case 1 A 65-year-old woman presented with a 4-month history of a tumor on the left breast. Clinical examination revealed an edema of the skin with dimpling pits (peau d’orange) of the breast with multiple satellite skin nodules confined to the same breast, in addition to a large, palpable mass with regional adenopathy (Fig. 1). Microscopic examination revealed an invasive lobular carcinoma. An ultrasound examination of the liver, chest x-rays, and bone scan all produced negative results for the presence of metastases. The patient has been diagnosed with a clinical stage IIIB (T4bN2aM0) left breast carcinoma. Dermoscopic examination of the skin metastases demonstrated regularly distributed, irregular, linear arborizing vessels with a tendency for vascular polymorphism (Fig. 2). Figures 3 and 4 present dermoscopic images manifesting the aforementioned orange peel sign. Case 2
Figure 2 Dermoscopy of the skin metastases. Regularly distributed, linear, irregular and arborizing vessels with a tendency to vascular polymorphism. Dermoscopy in this case showed a vascular, irregularly branched arrangement. Two nodules also exhibit loosely distributed, dotted (red dots) vascular structures, especially on the lesion’s edge. Vascular system resembles a cobweb
This case involves a 58-year-old female patient with triple-negative right breast cancer of clinical stage IIIB (T4dN0M0). The first symptom of the disease was a palpable breast tumor, with an accompanying satellite skin nodule found near the nipple. Owing to family reasons, the patient refused treatment for a period of four months. Progression of the disease caused growth of the tumor to a size of 8 cm, with multiple skin nodules and the orange peel sign (Fig. 5). Dermoscopic examination of the skin nodules manifested arborizing telangiectasia (Fig. 6).
Figure 3 Dermoscopic image of the skin of an orange peel sign. Regularly distributed umbilicated, brownish, 1 mm diameter pits over skin are present
Results Dermoscopy
Figure 1 Patient with locally advanced non-inflammatory left breast cancer, with multiple satellite skin nodules as metastases from breast cancer into the skin (black arrows) and the orange peel sign (peau d’orange) (red arrows) at the time of diagnosis International Journal of Dermatology 2013
Vascular structures Dermoscopy of the metastatic skin nodules from both breast cancers in the cases presented above has shown the presence of two predominant types of vascular structures (Figs. 2 and 6). The first of these is an irregular, linear morphology. The second one is the arborizing morphology in the form of both a linear straight and a linear serpentine. Dotted morphology (dots) was also observed in the form of tiny red points, densely aligned, and peripherally positioned next to each other. A combination of two ª 2013 The International Society of Dermatology
ska-Winciorek et al. Kamin
Figure 4 Dermoscopic image of the orange peel sign near the metastatic skin nodule. Linear, irregularly distributed, small fissure-like structures with linear skin depressions are shown
Dermoscopy of skin metastases from breast cancer
Case report
Figure 6 Dermoscopic image of the skin metastases together with the orange peel sign. In the center, the small metastatic nodule with linear irregular and arborizing vessels resembling cobweb are seen with small, umbilicated, brownish pits with orange peel effect located peripherally
Discussion
Figure 5 Patient with right inflammatory breast cancer with multiple skin metastases from breast cancer (black arrows) and the orange peel effect (red arrows)
or more vascular types in metastatic breast cancer indicates the polymorphous type of vascular structures. All vascular structures are distributed along with confluent, whitish depigmentation. The vascular arrangement is rather irregularly branched, resembling a cobweb. Orange peel (“peau d’orange”) Dermoscopy reveals the presence of several brownish, umbilicated pits, 1 mm in diameter. These resemble the umbilicus (Figs. 3 and 6). This is one of the most predominant dermoscopic features of the orange peel sign. During dermoscopy of numerous advanced fibrosing skin lesions, umbilicated pits with a tendency for forming linear fissure-like structures with small, lateral depressions were also found (Fig. 4).
ª 2013 The International Society of Dermatology
Dermoscopic analysis of skin tumors has mainly been focused on pigmented and vascular structures, especially in the case of basal cell carcinoma, spindle cell carcinoma, keratoacanthoma, and melanoma. The dermoscopic vascular patterns accompanying a variety of non-melanocytic non-pigmented skin tumors, such as sebaceous hyperplasia, seborrheic keratosis, clear cell acanthoma, Bowen’s disease, or nodular cystic basal cell carcinoma are highly specific, allowing ready diagnosis in the vast majority of cases.4 Recently, several different morphological types of vessels have been found to possess a direct association with pigmented or non-pigmented skin tumors.4,5 The structures of arborizing and glomerular vessels revealed diagnostic specificity for basal cell carcinoma and Bowen’s disease, and irregularly distributed, linear structures were helpful in differentiating melanoma from spindle cell carcinoma.4–6 Irregular, linear, dotted, and polymorphous/atypical vessels are the most frequent vascular structures characterizing melanoma.7 Kreusch has reported that dotted vessels could also be present in melanocytic and non-melanocytic lesions, as well as in both benign and malignant tumors, including melanoma. This is because vascular dots are considered only tumoral vessels, which supply a solid tumor whose borders can be recognized at clinical examination.6,8 Few publications exist concerning the dermoscopy of metastatic tumors, especially the metastatic solid tumor. To date, only dermoscopic features of metastatic melanoma have ever been described.9 Previously, de Giorgi et al.2 described a dermoscopic pattern of cutaneous meta-
International Journal of Dermatology 2013
3
4
Case report
ska-Winciorek et al. Kamin
Dermoscopy of skin metastases from breast cancer
static thyroid cancer, which revealed the presence of atypical and polymorphous vascular structures within the pink, solitary erythematous lesion. Cutaneous metastasis from breast carcinoma is rather commonly observed. Clinical manifestations of cutaneous metastasis have been found as nodular, inflammatory, and sclerodermoid lesions.10 It usually occurs as a collection of numerous, tiny reddish nodules, without a tendency for ulceration, manifesting sclerodermoid skin changes known as the orange peel sign. Any dermoscopic description of metastatic breast cancer is very rarely found in professional literature. To the authors’ best knowledge, supported by meticulous literary analysis (PubMed), only one report on the use of dermoscopy has ever been published. Only in one case of nodular hyperpigmented metastatic breast cancer have the occurring dermoscopic changes been observed in the form of peripheral globules and a blue–white veil characterized, mimicking a melanoma.11 The case report includes no mention of any dermoscopic effects resembling the discussed orange peel characteristics. In both presented cases, dermoscopy of metastatic skin nodules from the existing breast cancer manifests two predominant types of vascular structures. The first is the irregular linear morphology, which may be characterized as linear straight – in new terminology, a linear serpentine defined as a linear, irregularly shaped and sized vascular structure. The second one takes the form of arborizing morphology as a linear straight and linear serpentine, both of which reflect bright red stem vessels of large diameter, branching irregularly into finer terminal capillaries. Dotted morphology (dots) as tiny red dots, densely aligned to each other and distributed peripherally, has also been observed in the dermoscopy of skin metastases from breast cancer. The combination of two or more vascular types in metastatic breast cancer indicates a polymorphous type of vascular structure. In the presented case, the diagnosis of skin metastasis seems to present itself as a relatively easy task. Patients with breast cancer require differentiation between skin metastasis and dermatological disease many years following treatment to rule out or diagnose a skin tumor. An edema of the skin of the breast, known as the orange peel sign (peau d’orange), can be caused by the infiltration or obstruction of lymphatic drainage of the breast or breast skin. Skin dimpling may occur because of a tumor invading the Cooper’s ligament. Dermoscopy of the area characterizing itself with the manifestation of the orange peel effect reveals the presence of several dimpling pits, all resembling the umbilicus. It also possesses a tendency for forming linear, fissure-like structures in the immediate vicinity of satellite metastatic skin nodules. The prognostic value of the density and diameter of these vessels found in skin metastases is yet to be
International Journal of Dermatology 2013
investigated. Dermoscopy also allows for an easy assessment of vessels during treatment and the possibility for efficient monitoring while treatment is in progress. Conclusion In conclusion, dermoscopy is a valuable method, which may be facilitated in performing additional diagnostics, especially in the case of recognition of a metastatic breast cancer invasion on to the skin. However, further research and observation are still needed. References 1 Kaminska-Winciorek G, Spiewak R. [Basic dermoscopy of melanocytic lesions for beginners]. Postepy Hig Med Dosw (Online) 2011; 65: 501–508. 2 de Giorgi V, Alfaioli B, Massi D, et al. Solitary cutaneous metastasis as the first sign of relapse of thyroid carcinoma: a clinical, dermoscopic-pathologic case study. Dermatol Surg 2009; 35: 523–526. 3 Bijan S. Cancer of the skin. In: DeVita VT, Hellman S, Rosenberg SA eds. Cancer: Principles and Practice of Oncology. Philadelphia: J.B. Lippincott Company, 1993: 1567–1611. 4 Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose non-pigmented skin tumours: a review of vascular structures seen with dermoscopy: part II. Non-melanocytic skin tumours. J Am Acad Dermatol 2010; 63: 377–386. 5 Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose non-pigmented skin tumours: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumours. J Am Acad Dermatol 2010; 63: 361–374. 6 Sakakibara A, Kamijima M, Shibata S, et al. Dermoscopic evaluation of vascular structures of various skin tumours in Japanese patients. J Dermatol 2010; 37: 316–322. 7 Argenziano G, Zalaudek I, Corona R, et al. Vascular structures in skin tumours: a dermoscopy study. Arch Dermatol 2004; 140: 1485–1489. 8 Kreusch JF. Vascular patterns in skin tumours. Clin Dermatol 2002; 20: 248–254. 9 Bories N, Dalle S, Debarbieux S, et al. Dermoscopy of fully regressive cutaneous melanoma. Br J Dermatol 2008; 158: 1224–1229. 10 Brownstein MH, Helwig EB. Spread of tumours to the skin. Arch Dermatol 1973; 107: 80–86. 11 Wyatt AJ, Agero AL, Delgado R, et al. Cutaneous metastatic breast carcinoma with melanocyte colonization: a clinical and dermoscopic mimic of malignant melanoma. Dermatol Surg 2006; 32: 949–954.
ª 2013 The International Society of Dermatology
