Correspondence
50
No. of referrals
Skin 40
Lymphadenopathy Miscellaneous
30
CNS
20
Soft tissue Head/neck
10
Bone
0 2009
2010
Referral type by year
2011
Over 3 years, total TWR referrals to the children’s hospital increased by 19% each year (91, 108 and 128 for 2009, 2010 and 2011, respectively) with the annual increase in the rate of malignant melanoma referrals being much higher at 60% and 67% (15, 24 and 40 cases, respectively) (Fig. 1). Accounting for the rise in melanoma referrals, the remaining TWR referrals increased only by 11% and 5% (76, 84 and 88, respectively) per year. Controlling for the annual rise, the increase seen in melanoma referrals remained statistically significant (P = 0.01), showing that the rise was independent of, and in addition to, any temporal increase in overall referrals. Of the 76 suspected melanoma cases, (54%) were referred because of lesion enlargement, and in the majority of cases, this was accompanied by at least one other change in either colour, border or pigment regularity. The presentation of childhood melanoma is often atypical. Compared with melanoma in adults, it is less likely to present as a ‘changing mole’, and more likely to manifest as an amelanotic and/or nodular lesion that imitates a pyogenic granuloma or Spitz naevus.4,5 Our data suggest that minor morphological changes have a low discriminatory value, and may lead to unnecessary paediatric skin cancer referrals. We suggest that developing a new referral proforma, not based on the adult melanoma model, could help to enhance diagnostic accuracy and reduce over-referral of benign lesions. Increasing size or appearance of new melanocytic naevi should not form the major criteria for lesion referral even if combined with secondary morphological change (e.g. border, colour), especially for prepubescent children. A greater degree of clinical suspicion should be conferred on clinically amelanotic and/or nodular lesions (e.g. resembling a pyogenic granuloma or Spitz naevus) and acknowledged in the referral proforma. This approach should ideally be informed by longitudinal studies that accurately define the normal evolution of moles in children, with particular regard to pigmented lesion changes at puberty.
206
Clinical and Experimental Dermatology (2015) 40, pp204–212
Figure 1 Number of 2-week referrals by
type from 2009 to 2011.
L. Newell,1 L. Shaw1 and R. Bragonier2 1 Department of Dermatology, Bristol Royal Infirmary, Marlborough St, Bristol, BS2 8HW, UK; and 2Department of Paediatrics, Bristol Children’s Hospital, Bristol, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 11 April 2014
References 1 National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. http: //publications.nice.org.uk/referral-guidelines-forsuspected -cancer-cg27 2 Cox NH, Madan V, Sanders T. The U.K. skin cancer ‘two-week rule’ proforma: assessment of potential modifications to improve referral accuracy. Br J Dermatol 2008; 158: 1293–8. 3 Cox NH. Evaluation of the U.K. 2-week referral rule for skin cancer. Br J Dermatol 2004; 150: 291–8. 4 Schaffer JV. Pigmented lesions in children: when to worry. Curr Opin Pediatr 2007; 19: 430–40. 5 Strouse JJ, Fears TR, Tucker MA et al. Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol 2005; 23: 4735–41.
Paraneoplastic leucocytoclastic vasculitis heralding a solid-organ tumour doi: 10.1111/ced.12423 A 54-year-old woman presented with a 2-week history of an asymptomatic purpuric rash affecting her lower legs. She had a recent history of a sore throat but no other systemic symptoms. She had a history of a deep vein thrombosis and pulmonary embolism following a
ª 2014 British Association of Dermatologists
Correspondence
(a)
(a)
(b) (b)
Figure 1 (a) A purpuric rash on the lower leg. (b) Histology
demonstrating moderate fibrinoid necrosis, in keeping with active small vessel leukocytoclastic vasculitis (haematoxylin and eosin, original magnification 9100).
fractured ankle 15 years previously. Her only medications were occasional paracetamol, ibuprofen and echinacea. On physical examination, a purpuric vasculitic rash was seen, affecting the lower legs (Fig 1a). Peripheral blood tests revealed a normal full blood count and biochemistry, and negative for antinuclear and doublestranded DNA antibodies, anticentromere antibodies and extractable nuclear antigen. Urinalysis was negative. A throat swab grew commensals only. The clinical diagnosis was small vessel vasculitis, possibly triggered by the recent sore throat. Skin biopsy was declined because of the risk of poor healing. The patient experienced recurrent flares over the next 18 months, which were triggered by physical or emotional stress, exercise or prolonged standing. Her erythrocyte sedimentation rate (ESR) was elevated at 23 mm/h (normal range 1–15 mm/h) 12 months after initial presentation. A small polyclonal increase in IgA (5.04 g/L; normal 0.8–4.0 g/L) was also noted, which persisted.
ª 2014 British Association of Dermatologists
Figure 2 (a) Axial contrast enhanced computed tomography
scan showing bilateral pelvic mass lesions (arrows) measuring approximately 80 mm in diameter (right) and 60 mm in diameter (left) and large volume ascites (asterisk). (b) Axial contrast enhanced computed tomography scan showing multiple peritoneal nodules (arrow) measuring up to 10 mm in diameter in keeping with peritoneal metastases.
Other repeat immunological tests were negative or normal, including antineutrophil cytoplasmic antibodies, rheumatoid factor, complement C3 and C4, and cryoglobulins. Serology tests for hepatitis B and C viruses and for parvovirus were negative. A skin biopsy was subsequently taken, which demonstrated active necrotizing small vessel leucocytoclastic vasculitis (LCV) (Fig. 1b). Topical steroids and elastic hosiery gave limited benefit. Dapsone was declined because of the potential side-effects. Over 2 years after developing the LCV, the patient was referred by her general practitioner to gynaecology with a 2-month history of otherwise asymptomatic abdominal distension, raised ESR (57 mm/h) and markedly elevated carcinoma antigen (CA)-125 (9100 KU/L;
Clinical and Experimental Dermatology (2015) 40, pp204–212
207
Correspondence
range 0–30 KU/L). Abdominal CT demonstrated bilateral ovarian masses, large volume ascites, peritoneal metastases and an enlarged right inguinal lymph node (Fig. 2a, b). Histology and immunohistochemistry confirmed primary ovarian adenocarcinoma. She was commenced on palliative chemotherapy with good symptomatic response. A prothrombotic tendency in cancer is well recognised, and thrombotic paraneoplastic conditions such as migratory thrombophlebitis (Trousseau syndrome) and recurrent venous thrombosis are widely accepted phenomena. However, cutaneous LCV is only infrequently reported in conjunction with internal malignancies. Most cases described in the literature are related to haematological malignancies (lymphomas and leukaemias).1 In a review, only 37 of 200 cases of malignancy-related LCV were associated with solid-organ tumours; most frequently lung (non-small cell), prostate, colon, breast and renal cancer.1 There has been only one other published report of ovarian carcinoma presenting with LCV.2 In that case, persistence of microscopic haematuria and proteinuria despite improvement of skin lesions with oral corticosteroid treatment led to incidental discovery of an ovarian mass on renal ultrasonography. That patient’s LCV resolved without recurrence following curative surgery for the ovarian carcinoma. It is important to note that LCV can manifest prior to, as in our patient, concurrently with or following the diagnosis of malignancy. One should therefore consider the possibility of underlying haematological or solid-organ neoplasms in cases of persistent or recurrent leucocytoclastic vasculitis of otherwise unexplained aetiology.
Acknowledgements We thank Dr Ferekh Salim for providing the radiological images and accompanying legends. S. Ayob and A. J. G. McDonagh Dermatology Department, Royal Hallamshire Hospital, Sheffield, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 27 March 2014
Dermoscopic features of molluscum contagiosum based on white structures and their correlation with histopathological findings doi: 10.1111/ced.12444 The best known dermoscopic pattern of molluscum contagiosum (MC) consists of crown vessels at the periphery of the lesion with a radial distribution.1 However, crown arrangements are thought to be characteristic not only of MC but also of naevus sebaceous, sebaceous adenoma, and especially sebaceous hyperplasia.2–5 In addition, a radial arrangement was identified in sebaceous hyperplasia.1 These results indicate that vascular characteristics are insufficient to differentiate MC from sebaceous tumours. In this study, we aimed to characterize the dermoscopic features of centrally located white structures of MC, and to investigate their histopathological correlation. The dermoscopic images of 258 cytologically or histologically proven MC lesions were assessed by two physicians. The frequency of each dermoscopic feature, and the intraobserver and interobserver agreement of the classification of the white structures were determined. Following selection of MC papules with typical white structures
Table 1 Vascular structures seen by dermoscopy in the 258 lesions of molluscum contagiosum. Frequency Vascular structures
n
%
Single vascular pattern Crown Punctiform Radial Mixed vascular pattern Crown + radial Crown + punctiform Radial + punctiform Not visible
158/258 128/258 19/258 11/258 77/258 56/258 13/258 8/258 23/258
61.2 49.6 7.4 4.3 29.8 21.7 5.0 3.1 8.9
Table 2 White structures seen by dermoscopy in the 258 lesions of molluscum contagiosum.
References 1 Kurzrock R, Cohen PR, Markowitz A. Clinical manifestations of vasculitis in patients with solid tumors. A case report and review of the literature. Arch Intern Med 1994; 154: 334–40. 2 Stashower ME, Rennie TA, Turiansky GW et al. Ovarian cancer presenting as leukocytoclastic vasculitis. J Am Acad Dermatol 1999; 40: 287–9.
208
Clinical and Experimental Dermatology (2015) 40, pp204–212
Frequency Type of white structure
n
%
Roundish Polylobular Fourleaf clover-like Nonspecific Not visible
88/258 69/258 58/258 36/258 7/258
34.1 26.7 22.5 14.0 2.7
ª 2014 British Association of Dermatologists
50
No. of referrals
Skin 40
Lymphadenopathy Miscellaneous
30
CNS
20
Soft tissue Head/neck
10
Bone
0 2009
2010
Referral type by year
2011
Over 3 years, total TWR referrals to the children’s hospital increased by 19% each year (91, 108 and 128 for 2009, 2010 and 2011, respectively) with the annual increase in the rate of malignant melanoma referrals being much higher at 60% and 67% (15, 24 and 40 cases, respectively) (Fig. 1). Accounting for the rise in melanoma referrals, the remaining TWR referrals increased only by 11% and 5% (76, 84 and 88, respectively) per year. Controlling for the annual rise, the increase seen in melanoma referrals remained statistically significant (P = 0.01), showing that the rise was independent of, and in addition to, any temporal increase in overall referrals. Of the 76 suspected melanoma cases, (54%) were referred because of lesion enlargement, and in the majority of cases, this was accompanied by at least one other change in either colour, border or pigment regularity. The presentation of childhood melanoma is often atypical. Compared with melanoma in adults, it is less likely to present as a ‘changing mole’, and more likely to manifest as an amelanotic and/or nodular lesion that imitates a pyogenic granuloma or Spitz naevus.4,5 Our data suggest that minor morphological changes have a low discriminatory value, and may lead to unnecessary paediatric skin cancer referrals. We suggest that developing a new referral proforma, not based on the adult melanoma model, could help to enhance diagnostic accuracy and reduce over-referral of benign lesions. Increasing size or appearance of new melanocytic naevi should not form the major criteria for lesion referral even if combined with secondary morphological change (e.g. border, colour), especially for prepubescent children. A greater degree of clinical suspicion should be conferred on clinically amelanotic and/or nodular lesions (e.g. resembling a pyogenic granuloma or Spitz naevus) and acknowledged in the referral proforma. This approach should ideally be informed by longitudinal studies that accurately define the normal evolution of moles in children, with particular regard to pigmented lesion changes at puberty.
206
Clinical and Experimental Dermatology (2015) 40, pp204–212
Figure 1 Number of 2-week referrals by
type from 2009 to 2011.
L. Newell,1 L. Shaw1 and R. Bragonier2 1 Department of Dermatology, Bristol Royal Infirmary, Marlborough St, Bristol, BS2 8HW, UK; and 2Department of Paediatrics, Bristol Children’s Hospital, Bristol, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 11 April 2014
References 1 National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. http: //publications.nice.org.uk/referral-guidelines-forsuspected -cancer-cg27 2 Cox NH, Madan V, Sanders T. The U.K. skin cancer ‘two-week rule’ proforma: assessment of potential modifications to improve referral accuracy. Br J Dermatol 2008; 158: 1293–8. 3 Cox NH. Evaluation of the U.K. 2-week referral rule for skin cancer. Br J Dermatol 2004; 150: 291–8. 4 Schaffer JV. Pigmented lesions in children: when to worry. Curr Opin Pediatr 2007; 19: 430–40. 5 Strouse JJ, Fears TR, Tucker MA et al. Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol 2005; 23: 4735–41.
Paraneoplastic leucocytoclastic vasculitis heralding a solid-organ tumour doi: 10.1111/ced.12423 A 54-year-old woman presented with a 2-week history of an asymptomatic purpuric rash affecting her lower legs. She had a recent history of a sore throat but no other systemic symptoms. She had a history of a deep vein thrombosis and pulmonary embolism following a
ª 2014 British Association of Dermatologists
Correspondence
(a)
(a)
(b) (b)
Figure 1 (a) A purpuric rash on the lower leg. (b) Histology
demonstrating moderate fibrinoid necrosis, in keeping with active small vessel leukocytoclastic vasculitis (haematoxylin and eosin, original magnification 9100).
fractured ankle 15 years previously. Her only medications were occasional paracetamol, ibuprofen and echinacea. On physical examination, a purpuric vasculitic rash was seen, affecting the lower legs (Fig 1a). Peripheral blood tests revealed a normal full blood count and biochemistry, and negative for antinuclear and doublestranded DNA antibodies, anticentromere antibodies and extractable nuclear antigen. Urinalysis was negative. A throat swab grew commensals only. The clinical diagnosis was small vessel vasculitis, possibly triggered by the recent sore throat. Skin biopsy was declined because of the risk of poor healing. The patient experienced recurrent flares over the next 18 months, which were triggered by physical or emotional stress, exercise or prolonged standing. Her erythrocyte sedimentation rate (ESR) was elevated at 23 mm/h (normal range 1–15 mm/h) 12 months after initial presentation. A small polyclonal increase in IgA (5.04 g/L; normal 0.8–4.0 g/L) was also noted, which persisted.
ª 2014 British Association of Dermatologists
Figure 2 (a) Axial contrast enhanced computed tomography
scan showing bilateral pelvic mass lesions (arrows) measuring approximately 80 mm in diameter (right) and 60 mm in diameter (left) and large volume ascites (asterisk). (b) Axial contrast enhanced computed tomography scan showing multiple peritoneal nodules (arrow) measuring up to 10 mm in diameter in keeping with peritoneal metastases.
Other repeat immunological tests were negative or normal, including antineutrophil cytoplasmic antibodies, rheumatoid factor, complement C3 and C4, and cryoglobulins. Serology tests for hepatitis B and C viruses and for parvovirus were negative. A skin biopsy was subsequently taken, which demonstrated active necrotizing small vessel leucocytoclastic vasculitis (LCV) (Fig. 1b). Topical steroids and elastic hosiery gave limited benefit. Dapsone was declined because of the potential side-effects. Over 2 years after developing the LCV, the patient was referred by her general practitioner to gynaecology with a 2-month history of otherwise asymptomatic abdominal distension, raised ESR (57 mm/h) and markedly elevated carcinoma antigen (CA)-125 (9100 KU/L;
Clinical and Experimental Dermatology (2015) 40, pp204–212
207
Correspondence
range 0–30 KU/L). Abdominal CT demonstrated bilateral ovarian masses, large volume ascites, peritoneal metastases and an enlarged right inguinal lymph node (Fig. 2a, b). Histology and immunohistochemistry confirmed primary ovarian adenocarcinoma. She was commenced on palliative chemotherapy with good symptomatic response. A prothrombotic tendency in cancer is well recognised, and thrombotic paraneoplastic conditions such as migratory thrombophlebitis (Trousseau syndrome) and recurrent venous thrombosis are widely accepted phenomena. However, cutaneous LCV is only infrequently reported in conjunction with internal malignancies. Most cases described in the literature are related to haematological malignancies (lymphomas and leukaemias).1 In a review, only 37 of 200 cases of malignancy-related LCV were associated with solid-organ tumours; most frequently lung (non-small cell), prostate, colon, breast and renal cancer.1 There has been only one other published report of ovarian carcinoma presenting with LCV.2 In that case, persistence of microscopic haematuria and proteinuria despite improvement of skin lesions with oral corticosteroid treatment led to incidental discovery of an ovarian mass on renal ultrasonography. That patient’s LCV resolved without recurrence following curative surgery for the ovarian carcinoma. It is important to note that LCV can manifest prior to, as in our patient, concurrently with or following the diagnosis of malignancy. One should therefore consider the possibility of underlying haematological or solid-organ neoplasms in cases of persistent or recurrent leucocytoclastic vasculitis of otherwise unexplained aetiology.
Acknowledgements We thank Dr Ferekh Salim for providing the radiological images and accompanying legends. S. Ayob and A. J. G. McDonagh Dermatology Department, Royal Hallamshire Hospital, Sheffield, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 27 March 2014
Dermoscopic features of molluscum contagiosum based on white structures and their correlation with histopathological findings doi: 10.1111/ced.12444 The best known dermoscopic pattern of molluscum contagiosum (MC) consists of crown vessels at the periphery of the lesion with a radial distribution.1 However, crown arrangements are thought to be characteristic not only of MC but also of naevus sebaceous, sebaceous adenoma, and especially sebaceous hyperplasia.2–5 In addition, a radial arrangement was identified in sebaceous hyperplasia.1 These results indicate that vascular characteristics are insufficient to differentiate MC from sebaceous tumours. In this study, we aimed to characterize the dermoscopic features of centrally located white structures of MC, and to investigate their histopathological correlation. The dermoscopic images of 258 cytologically or histologically proven MC lesions were assessed by two physicians. The frequency of each dermoscopic feature, and the intraobserver and interobserver agreement of the classification of the white structures were determined. Following selection of MC papules with typical white structures
Table 1 Vascular structures seen by dermoscopy in the 258 lesions of molluscum contagiosum. Frequency Vascular structures
n
%
Single vascular pattern Crown Punctiform Radial Mixed vascular pattern Crown + radial Crown + punctiform Radial + punctiform Not visible
158/258 128/258 19/258 11/258 77/258 56/258 13/258 8/258 23/258
61.2 49.6 7.4 4.3 29.8 21.7 5.0 3.1 8.9
Table 2 White structures seen by dermoscopy in the 258 lesions of molluscum contagiosum.
References 1 Kurzrock R, Cohen PR, Markowitz A. Clinical manifestations of vasculitis in patients with solid tumors. A case report and review of the literature. Arch Intern Med 1994; 154: 334–40. 2 Stashower ME, Rennie TA, Turiansky GW et al. Ovarian cancer presenting as leukocytoclastic vasculitis. J Am Acad Dermatol 1999; 40: 287–9.
208
Clinical and Experimental Dermatology (2015) 40, pp204–212
Frequency Type of white structure
n
%
Roundish Polylobular Fourleaf clover-like Nonspecific Not visible
88/258 69/258 58/258 36/258 7/258
34.1 26.7 22.5 14.0 2.7
ª 2014 British Association of Dermatologists
