When a clinical-dermoscopic correlation is warranted Juliana Marques-da-Costa, MD,a Alice Mota Buc¸ard, MD,b Simonetta Piana, MD,c Elvira Moscarella, MD,d Giuseppe Argenziano, MD,d and Caterina Longo, MD, PhDd Rio de Janeiro, Brazil, and Reggio Emilia, Italy
CLINICAL PRESENTATION A 64-year-old woman was seen because of the presence of a clinically suspicious, flat, pigmented lesion that had recently appeared on her left leg (Fig 1).
Fig 1. A solitary, pigmented, irregularly shaped, flat lesion 6 mm in diameter located on the left leg of a 64-year-old woman.
DERMOSCOPIC APPEARANCE Although clinically equivocal, the dermoscopic examination revealed a regular reticular, homogeneous pattern in the absence of any melanoma-specific criteria (Fig 2, A). Because of the suspicious clinical context coupled with benign dermoscopic morphology, short-term digital monitoring was scheduled. Six months later, the dermoscopic examination revealed asymmetrical growth and development of an atypical network (Fig 2, B).
From the Servic¸o de Dermatologia,a Hospital Naval Marcılio Dias, Rio de Janeiro; Servic¸o de Medicina InternaeSetor Dermatologia,b Hospital Federal de Ipanema, Rio de Janeiro; and the Pathology Unitc and Dermatology and Skin Cancer Unit,d Arcispedale S. Maria Nuova-IRCCS, Reggio Emilia. Publication of this article was supported by 3Gen. Supported in part by the Italian Ministry of Health (RF-20102316524 to IRCCS). Conflicts of interest: None declared.
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Correspondence to: Caterina Longo, MD, PhD, Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Viale Risorgimento, 80,42100 Reggio Emilia, Italy. E-mail: longo. [email protected]. J Am Acad Dermatol 2015;72:S16-8. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.04.031
J AM ACAD DERMATOL VOLUME 72, NUMBER 1
Marques-da-Costa et al S17
Fig 2. Dermoscopic images. A, The baseline dermoscopic examination revealed a regular reticular, homogeneous pattern. B, After 6 months, the lesion showed remarkable asymmetric growth and the appearance of an atypical network and irregular globules.
HISTOPATHOLOGY The lesion was excised, and subsequent histopathologic examination revealed a poorly demarcated proliferation of atypical melanocytes that were irregularly distributed and scattered along the epidermis or arranged in nests. Pagetoid spread was present throughout the entire lesion (Fig 3). These features were suggestive of melanoma in situ.
Fig 3. Histopathologic aspects. A, At low power magnification (320), the lesion is relatively large and poorly defined. B, At higher magnification (340), atypical melanocytes are irregularly distributed in single units or in small nests. Pagetoid spread is prominent. C, Atypical melanocytes, with abundant cytoplasm and angulated nuclei, are present at all epidermal levels. In the superficial dermis, a mild inflammatory infiltrate is evident (magnification 3100).
S18 Marques-da-Costa et al
J AM ACAD DERMATOL
JANUARY 2015
KEY MESSAGE The primary value of dermoscopy is to allow for the detection of suspicious features in melanomas that look otherwise clinically benign.1,2 However, the presence of benign dermoscopic features should not be a good reason to underestimate clear-cut suspicious clinical information. A solitary and newly appearing pigmented lesion on the leg of a middleaged woman should raise the index of suspicion independently of its dermoscopic appearance. In these cases, short-term follow-up is a valuable method to detect eventual early changes that should prompt obtaining a biopsy specimen while minimizing unnecessary excision of benign unchanged lesions.3,4
REFERENCES 1. Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions—a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001;2: 443-9. 2. Argenziano G, Cerroni L, Zalaudek I, Staibano S, Hofmann-Wellenhof R, Arpaia N, et al. Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol 2012;67:54-9. 3. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH. Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001;137:1583-9. 4. Kittler H, Guitera P, Riedl E, Avramidis M, Teban L, Fiebiger M, et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol 2006;142:1113-9.
CLINICAL PRESENTATION A 64-year-old woman was seen because of the presence of a clinically suspicious, flat, pigmented lesion that had recently appeared on her left leg (Fig 1).
Fig 1. A solitary, pigmented, irregularly shaped, flat lesion 6 mm in diameter located on the left leg of a 64-year-old woman.
DERMOSCOPIC APPEARANCE Although clinically equivocal, the dermoscopic examination revealed a regular reticular, homogeneous pattern in the absence of any melanoma-specific criteria (Fig 2, A). Because of the suspicious clinical context coupled with benign dermoscopic morphology, short-term digital monitoring was scheduled. Six months later, the dermoscopic examination revealed asymmetrical growth and development of an atypical network (Fig 2, B).
From the Servic¸o de Dermatologia,a Hospital Naval Marcılio Dias, Rio de Janeiro; Servic¸o de Medicina InternaeSetor Dermatologia,b Hospital Federal de Ipanema, Rio de Janeiro; and the Pathology Unitc and Dermatology and Skin Cancer Unit,d Arcispedale S. Maria Nuova-IRCCS, Reggio Emilia. Publication of this article was supported by 3Gen. Supported in part by the Italian Ministry of Health (RF-20102316524 to IRCCS). Conflicts of interest: None declared.
S16
Correspondence to: Caterina Longo, MD, PhD, Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Viale Risorgimento, 80,42100 Reggio Emilia, Italy. E-mail: longo. [email protected]. J Am Acad Dermatol 2015;72:S16-8. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.04.031
J AM ACAD DERMATOL VOLUME 72, NUMBER 1
Marques-da-Costa et al S17
Fig 2. Dermoscopic images. A, The baseline dermoscopic examination revealed a regular reticular, homogeneous pattern. B, After 6 months, the lesion showed remarkable asymmetric growth and the appearance of an atypical network and irregular globules.
HISTOPATHOLOGY The lesion was excised, and subsequent histopathologic examination revealed a poorly demarcated proliferation of atypical melanocytes that were irregularly distributed and scattered along the epidermis or arranged in nests. Pagetoid spread was present throughout the entire lesion (Fig 3). These features were suggestive of melanoma in situ.
Fig 3. Histopathologic aspects. A, At low power magnification (320), the lesion is relatively large and poorly defined. B, At higher magnification (340), atypical melanocytes are irregularly distributed in single units or in small nests. Pagetoid spread is prominent. C, Atypical melanocytes, with abundant cytoplasm and angulated nuclei, are present at all epidermal levels. In the superficial dermis, a mild inflammatory infiltrate is evident (magnification 3100).
S18 Marques-da-Costa et al
J AM ACAD DERMATOL
JANUARY 2015
KEY MESSAGE The primary value of dermoscopy is to allow for the detection of suspicious features in melanomas that look otherwise clinically benign.1,2 However, the presence of benign dermoscopic features should not be a good reason to underestimate clear-cut suspicious clinical information. A solitary and newly appearing pigmented lesion on the leg of a middleaged woman should raise the index of suspicion independently of its dermoscopic appearance. In these cases, short-term follow-up is a valuable method to detect eventual early changes that should prompt obtaining a biopsy specimen while minimizing unnecessary excision of benign unchanged lesions.3,4
REFERENCES 1. Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions—a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001;2: 443-9. 2. Argenziano G, Cerroni L, Zalaudek I, Staibano S, Hofmann-Wellenhof R, Arpaia N, et al. Accuracy in melanoma detection: a 10-year multicenter survey. J Am Acad Dermatol 2012;67:54-9. 3. Menzies SW, Gutenev A, Avramidis M, Batrac A, McCarthy WH. Short-term digital surface microscopic monitoring of atypical or changing melanocytic lesions. Arch Dermatol 2001;137:1583-9. 4. Kittler H, Guitera P, Riedl E, Avramidis M, Teban L, Fiebiger M, et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol 2006;142:1113-9.
