Antonio Vilalta

New Dermoscopic Pattern in Actinic Keratosis and Related Conditions

T HE LESIONS SHOWN IN THIS ARTICLE ARE from the upper lip of an 85-year-old woman (Figure 1, inset), the malar of a 67-year-old man (Figure 2, inset), and the forehead of a 56-year-old man (Figure 3, inset). They correspond to actinic keratosis (AK) (case 1), lichenoid AK (case 2), and squamous cell carcinoma that developed on an AK (case 3). Polarized contact dermoscopy of all 3 lesions revealed a pattern called a rosette sign (Figures 1-3, arrows), a term coined by Lester Cowell, MD, and is characterized by 4 white points arranged as a 4-leaf clover (Figure 4) mainly localized inside the follicular openings. Histologically, the rosette sign may correspond to changes of orthokeratosis and parakeratosis (flag sign) (Figure 5 [case shown in Figure 3]). It is occasionally seen in AK and related conditions and could help in their diagnosis. It does not appear in nonpolarized contact dermoscopic images and may therefore represent a tissue and polarized light phenomenon.

Rapid Diagnosis of Two Facial Papules Using Ex Vivo Fluorescence Confocal Microscopy: Toward a Rapid Bedside Pathology

An application of interest is the rapid diagnosis of ambiguous lesions under dermoscopy located where in vivo reflectance confocal microscopy (RCM) can not be performed. We report two papules on the face referred for Mohs micrographic surgery (MMS) as basal cell carcinomas (BCCs). Noninvasive RCM diagnosis could not be performed because of the difficult location (nose tip and jaw). A shave biopsy was performed in both cases. The two samples underwent rapid diagnosis with FCM; in each case, we obtained a 10by 10-mm fluorescence confocal mosaic with high cellular morphologic resolution that enabled us to provide a precise diagnosis in less than 5 minutes. The present report represents a first step toward a rapid bedside pathology.

Angiolymphoid hyperplasia with eosinophilia of the nail bed and bone : successful treatment with radiation therapy

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare entity characterized by the presence of one or several papules or nodules in the skin. Histopathology of ALHE shows a marked proliferation of blood vessels with distinctive large endothelial cells and variable inflammatory infiltrates with eosinophils. We report a 32‐year‐old Caucasian woman with multiple nodules involving the skin, subcutaneous tissue and bone of the distal phalanx of the fingers that were treated successfully with orthovoltage radiation therapy (40 Gy/20 fractions) and without any side‐effects after 9 years of follow‐up.

Dermoscopy of Early Recurrent Basal Cell Carcinoma

Francisco Cuellar, MD; Antonio Vilalta, MD; Susana Puig, MD, PhD; Josep Palou, MD; Pedro Zaballos, MD; Josep Malvehy, MD, PhD; Unidad de Dermatologia Quirurgica, Barcelona (Drs Cuellar and Vilalta), Hospital Clinic, Institut de Investigacions Biomediques Cientifiques Agusti Pi I Suryer, Barcelona (Drs Cuellar, Vilalta, Palou, Puig, and Malvehy), and Hospital de Sant Pau i Santa Tecla, Tarragona (Dr Zaballos), Spain

High nevus counts confer a favorable prognosis in melanoma patients.

A high number of nevi is the most significant phenotypic risk factor for melanoma and is in part genetically determined. The number of nevi decreases from middle age onward but this senescence can be delayed in patients with melanoma. We investigated the effects of nevus number count on sentinel node status and melanoma survival in a large cohort of melanoma cases. Out of 2,184 melanoma cases, 684 (31.3%) had a high nevus count (>50). High nevus counts were associated with favorable prognostic factors such as lower Breslow thickness, less ulceration and lower mitotic rate, despite adjustment for age. Nevus count was not predictive of sentinel node status. The crude 5‐ and 10‐year melanoma‐specific survival rate was higher in melanomas cases with a high nevus count compared to those with a low nevus count (91.2 vs. 86.4% and 87.2 vs. 79%, respectively). The difference in survival remained significant after adjusting for all known melanoma prognostic factors (hazard ratio [HR] = 0.43, confidence interval [CI] = 0.21–0.89). The favorable prognostic value of a high nevus count was also seen within the positive sentinel node subgroup of patients (HR = 0.22, CI = 0.08–0.60). High nevus count is associated with a better melanoma survival, even in the subgroup of patients with positive sentinel lymph node. This suggests a different biological behavior of melanoma tumors in patients with an excess of nevi.

Dermoscopy structures as predictors of sentinel lymph node positivity in cutaneous melanoma.

Histological features such as Breslow thickness, ulceration and mitosis are the main criteria to guide sentinel lymph node biopsy (SLNB) in melanoma. Dermoscopy may add complementary information to these criteria.

Desmoplastic melanoma on the nose: electrochemotherapy as an alternative treatment to local advanced disease

Desmoplastic malignant melanoma (DMM) is a rare and usually misdiagnosed type of melanoma. Delayed detection at complicated anatomical locations can lead to the necessity of alternative therapies.

Prognostic role of the histological subtype of melanoma on the hands and feet in Caucasians

Acral melanoma (AM) is associated with a poor prognosis in part because of delayed diagnosis, but probably also because of other intrinsic characteristics of location. The aim of this study was to review the specific characteristics and outcome of AM in Caucasians. This was a cross-sectional retrospective clinical-pathological study of 274 patients identified with AM in the database of a referral unit in Europe from 1986 to 2010. The mean age of the patients was 56.6 (SD 17.7) years. 269 cases could be histologically classified and included in the study. In all, 222 (82.5%) were located on feet. According to melanoma subtype, 165 (61.3%) were acral lentiginous melanoma (ALM), 84 (31.2%) were superficial spreading melanoma (SSM), and 20 (7.5%) were nodular melanoma (NM). SSM patients were characterized by female predominance (77.4%), younger age, and classic melanoma-risk phenotype (fair skin and multiple nevi). Among the 198 invasive cases with a mean follow-up of 56.2 months, the mean (SD) Breslow’s thickness was 3.1 (3.6) mm, being 1.4 (1.4) mm in SSM, 3.5 (4.1) mm in ALM and 4.9 (2.9) mm in NM (P<0.001). Ulceration was present in 33.3%, 2.9% in SSM, 38.6% in ALM, and 76.9% in NM (P<0.001). A total of 29.3% relapsed (7.3% of SSM, 35% of ALM and 55% of NM) and 24.2% died because of AM. In multivariate analysis, age at diagnosis, Breslow, and histopathological subtype were independent prognostic factors for both disease-free and AM-specific survival. The ALM and NM subtypes presented poorer outcome after weighting Breslow and age (P=0.02). Histological subtype of AM could have an impact on biological behavior, ALM and NM subtypes presenting a poorer prognosis after adjusting for age and Breslow’s thickness.

Prognostic value of tyrosinase reverse transcriptase PCR analysis in melanoma sentinel lymph nodes: long‐term follow‐up analysis

Objective.  To determine the prognostic value of detecting tyrosinase transcripts in melanoma sentinel lymph nodes (SLNs).

Electroquimioterapia en metástasis cutáneas de melanoma: Experiencia en 31 casos

INTRODUCTION AND OBJECTIVES Electrochemotherapy is indicated for the treatment of unresectable cutaneous and subcutaneous tumors. The technique involves the synergistic use of electroporation of cell membranes to increase the cytotoxicity of anticancer drugs delivered to the tumor cells. The aim of this study was to analyze the clinical effectiveness and safety of electrochemotherapy in the treatment of unresectable locoregional recurrent or metastatic melanomas. MATERIAL AND METHODS We studied 31 patients treated between January 2007 and December 2012. The European Standard Operating Procedures of Electrochemotherapy (ESOPE) were applied in all cases. Treatment response was analyzed as overall patient response (mean response based on results for all lesions treated in a given patient). RESULTS Response was classified as partial in 49% of patients and complete in 23%. At 1 year, the level of response achieved had been maintained in 17 patients. Disease progression was observed in 28% of the series. Immediate local complications (pain, swelling, erythema) were mild and resolved within 48hours in most cases. Eight patients developed subsequent local complications, such as ulcers and secondary infections associated with necrosis of the lesions. These complications were brought under control with topical treatments. CONCLUSIONS Electrochemotherapy is a very effective, safe, and efficient treatment for advanced locoregional disease in patients with unresectable melanoma lesions.