Alessia Barisani

Nail apparatus melanoma: Is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

The Prognosis of Nail Apparatus Melanoma: 20 Years of Experience from a Single Institute

Introduction and Objectives: Nail apparatus melanoma (NAM) is an uncommon tumor, especially in Caucasians. The prognosis of patients affected by NAM was analyzed and correlated with the histopathological criteria and the surgical management of the tumors. Materials and Methods: We collected data regarding NAM referred to the Skin Cancer Unit of the Dermatology Department of the University of Bologna, from 1992 to January 2012. Results: Out of 1,327 melanoma cases diagnosed between 1992 and 2012, 42 patients were affected by NAM (2.93%). All the patients were Caucasian. Two deceased patients with insufficient medical records and 1 woman with a personal history of breast cancer were excluded. Thirty-nine cases entered this study: 24 were women (67%) and 15 men (33%). The mean age at diagnosis of NAM was 57.3 years (range 29-88 years). Statistical analyses showed that prognosis was significantly correlated with the Breslow thickness (≥/<2 mm; p = 0.02), regression (p < 0.0001) and ulceration (p = 0.04). Regarding surgical management, Kaplan-Meiers test pointed out that performing functional surgery compared to disarticulation did not correlate with a better prognosis of patients (p = 0.08). Conclusions: In our experience, the surgical management (disarticulation with respect to functional surgical excision) did not influence the prognosis of NAM patients. The latter was affected by the histopathological characteristics (Breslow thickness, regression and mitoses) and location (fingers vs. foot).

The Role of Photodynamic Therapy in the Treatment of Vulvar Intraepithelial Neoplasia

Background: vulvar intraepithelial neoplasia is a non-invasive precursor lesion found in 50–70% of patients affected by vulvar squamous cell carcinoma. In the past, radical surgery was the standard treatment for vulvar intraepithelial neoplasia, however, considering the psychological and physical morbidities related to extensive surgery, several less aggressive treatment modalities have been proposed since the late 1970s. Photodynamic therapy is an effective and safe treatment for cutaneous non-melanoma skin cancer, with favorable cosmetic outcomes. Methods: in the present paper, the results of selected studies on photodynamic therapy in the treatment of vulvar intraepithelial neoplasia are reported and discussed. Results: Overall, complete histological response rates ranged between 20% and 67% and symptom response rates ranged between 52% and 89% according to different studies and case series. Conclusions: the real benefit of photodynamic therapy in the setting of vulvar intraepithelial neoplasia lies in its ability to treat multi-focal disease with minimal tissue destruction, preservation of vulvar anatomy and excellent cosmetic outcomes. These properties explain why photodynamic therapy is an attractive option for vulvar intraepithelial neoplasia treatment.

Spitz nevi: diverse clinical, dermatoscopic and histopathological features in childhood

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.

Autoantibody serum levels and intensity of pruritus in bullous pemphigoid

Bullous pemphigoid (BP) is an autoimmune bullous disease characterised by immunoglobulin G (IgG) autoantibodies to BP180 and BP230 [1]. Autoantibodies against BP180 have proved to play a critical role in the pathogenesis of BP, whereas autoantibodies against BP230 are thought not to be involved [2, 3]. Pruritus represents an important symptom in BP. Several authors investigated the association between serum levels of autoantibodies and disease severity [1-8], however, only few studies evaluated [...]

A dermatoscopic portrait of morphological changes of vulvar melanosis over time

Vulvar melanotic macules or vulvar melanosis (VM) may present as single or multiple asymmetric macules, of different size and colors, with a predilection for the mucosal surfaces of the vulva. Vulvar melanosis has a favorable prognosis and, although new lesions may develop over time, morphological changes of VM during follow-up have scarcely been documented. Here we describe the clinical, dermatoscopic and pathological features of VM in a 35-year-old Caucasian female. Her medical history was signifi cant for four spontaneous abortions within the previous four years. She was not taking any medications, including estrogens and progestins, and her family history was unremarkable with regard to gynecological and cutaneous tumors, including melanoma. The patient had irregular pigmented macules on the internal aspects of both labia minora (Figure 1 a). Two punch biopsies were performed. Histopathology demonstrated prominent hyperpigmentation of basal keratinocytes with scattered dermal melanophages and a slightly increased number of melanocytes (Figure 1 b), confi rming the diagnosis of VM. Dermatoscopy showed a ring-like pattern (Figure 1 c) associated with a fi nger-like pattern (Figure 1 d, blue circle; Figure 1 e, detail). Refl ectance confocal microscopy (RCM) of the area corresponding to the ring-like pattern showed dermal papillae rimmed by bright, monomorphic cells corresponding to hyperpigmented keratinocytes (Figure 1 f). Immunohistochemistry with Melan A staining showed a slight increase in the number of melanocytes (Figure 2 ). The patient was followed up with clinical examination and photography for more than fi ve years (Figure 3 ). Compared to the baseline evaluation (Figure 3 a), VM was stable at + 26 months (Figure 3 b), but had become paler in evaluations at + 32 months (Figure 3 c) and + 48 months (Figure 3 d). At + 56 months, the lesion on the internal aspect of the right labium minor was paler and diminished in size (Figure 3 e), and at the 66-month follow-up, only a residual small, brown hyperpigmented macule was present on the internal aspect of the left labium minor (Figure 3 f). Figure 4 shows a comparison between the clinical and dermatoscopic appearance at baseline (Figure 4 a, c) and at + 48 months (Figure 4 b, d); at the 48-month follow-up, a ring-like pattern is still evident, although the rings are less demarcated and a diffuse erythematous background is visible. In accordance with the patient’s wishes, the small residual lesion on the internal aspect of her left labium minor was excised. Histopathology confi rmed a VM. The patient is still being followed up and no further signs of VM have been found so far.

Ein großer Tumor und livid-erythematöse Plaques

Ein 55-jähriger Mann stellte sich mit einer seit zwei Monaten bestehenden Hämatom-artigen großen Masse auf seinem Unterleib vor (Abbildung 1 ). Die klinische Untersuchung ergab eine große violette abdominale Plaque (6 cm im Durchmesser), die von einem erythematösen Halo und zahlreichen erythematös-violetten Papeln und Knötchen im Gesicht, am Rumpf und den Extremitäten umgeben war (Abbildung 2 ). Keine der Läsionen war juckend oder schmerzhaft, wegen ihres plötzlichen Auftretens aber besorgniserregend und veranlassten den Patienten, einen Arzt aufzusuchen. Nach seinem Bericht traten weder Fieber, noch Müdigkeit oder Gewichtsverlust auf. Bluttests zeigten einen Anstieg des Lactatdehydrogenase-Spiegels (> 500 U/L) und des ESR (> 40 mm); die Leukozytenzahl, die Elektrophorese und alle anderen Parameter befanden sich im Normalbereich. HIV-, Hepatitisund Syphilistests waren negativ.

Pachyonychia of the toenail in a child

A 9-year-old Caucasian girl presented for evaluation of a solitary pachyonychia of the third right toenail. Her parents reported that the nail plate had thickened progressively since she was two years old. The patients family history was negative for onychodystrophy and nail diseases. The fi rst abnormality that they noticed was yellow discoloration of the nail plate, followed by progressive thickening over time and a tendency toward transverse hypercurvature. Clinical examination showed a yellowish, thickened nail plate with a subungual hemorrhage of the third right toe (Figure 1 a). A frontal view of the nails free margin revealed prominent thickening of the nail plate with a rough surface and small ovoid cavities (Figure 1 b). In 2013 the patient underwent podiatry treatment (nail removal), which was followed by regrowth of the lesion. A fungal culture performed in 2014 demonsPachyonychia of the toenail in a child Case for Diagnosis

Multiple pigmented lesions of the glans penis after circumcision

A 54-year-old man was referred to us for evaluation of multiple pigmented lesions of the glans penis. The patient had undergone circumcision one week earlier and was otherwise healthy. He reported that he had never noticed any local pigmented lesions before. The largest lesion had a maximum diameter of 12 mm and was surrounded by numerous smaller lesions (Figure 1 ); its central portion was slightly raised and palpable, with a smooth surface and well-defi ned borders. The mucosal tissue surrounding the pigmented lesions appeared normal.

Vulvar intraepithelial neoplasia and vulvar squamous cell carcinoma: Differential dermoscopic features in a case series, and a progression model

Vulvar squamous cell carcinoma (SCC) is the most common vulvar malignancy, and about 60% of cases arise after menopause. Vulvar SCC is usually associated with a pre-existing vulvar intraepithelial neoplasia (VIN), in particular differentiated VIN (DVIN), which is often associated with vulvar lichen sclerosus (VLS). We propose some dermoscopic features of DVIN and vulvar SCC and a dermoscopic progression model. Figure 1a shows a DVIN in the context of VLS, with a central erosion. Dermoscopy of DVIN revealed a pink to red, structureless background (Fig. 1b), with red areas (upper part) due to superficial erosions and vascular structures (lower part) consisting of curvy, short serpentine and some dotted vessels. Figure 2a shows a microinvasive vulvar SCC appearing as a whitish hyperkeratotic plaque with a rough surface and erosions. Dermoscopy of this lesion (Fig. 2b) showed a whitish background with polymorphous vessels (curvy, dotted, linear–irregular, and also some hairpin-shaped vessels) Fig. 2c is of an invasive vulvar SCC, presenting as a whitish plaque with an ulcerated area; dermoscopy (Fig. 2d) showed a white background due to hyperkeratosis surrounding the ulcerated area, and a number of highly polymorphous vessels, with curvy and linear–irregular vessels detectable centrally (Fig. 1d) and hairpin vessels at the periphery (Fig. 1e). DVIN is characterized by a differentiated histopathological morphology, with premature keratinizing differentiation leading to squamous whorls and keratin pearls, often arising in the context of VLS, as in our case. DVIN, microinvasive SCC and invasive SCC are very closely related entities. We tried to define a progression model linking them, similar to the progression model from actinic keratosis (AK) to intraepidermal carcinoma and invasive SCC proposed by Zalaudek et al. According to that model, most AKs are characterized by a red pseudo-network (‘strawberry’) pattern, while during the progression to intraepidermal carcinoma, yellow opaque structures and dotted vessels become evident. White structureless areas and dotted or hairpin vessels characterize the transition to SCC, and in minimally invasive SCC, a central mass of keratin and hairpin vessels are seen. Finally, linear–irregular vessels, keratinization and ulceration characterize invasive SCC. In our case series, the red colour was predominant in DVIN, then the white colour became more evident during the progression to microinvasive SCC and invasive SCC (except in ulcerated areas), and these findings appear to be in line with the aforementioned model. Moreover, in DVIN, mainly curvy and short-serpentine vessels were seen, as previously described, while in microinvasive vulvar SCC, curvy, dotted, linear–irregular and some hairpin vessels were observed. In invasive SCC, the vessels appeared highly polymorphous (hairpin vessels peripherally, curvy and linear–irregular vessels centrally) together with ulceration. The observation of different colours and vascular patterns (leading to hairpin and linear–irregular vessels in the later stages) may aid the differential diagnosis