Giovanni Ghigliotti

Dermoscopic Evaluation of Amelanotic and Hypomelanotic Melanoma

OBJECTIVE To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. DESIGN A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. SETTING Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. RESULTS The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Dermoscopic evaluation of nodular melanoma

IMPORTANCE Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical. OBJECTIVE To determine the dermoscopy features of NM. DESIGN Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes. SETTING Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma. RESULTS Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM. CONCLUSIONS AND RELEVANCE When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

Total body skin examination for skin cancer screening in patients with focused symptoms

BACKGROUND The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Pigmented nodular melanoma: the predictive value of dermoscopic features using multivariate analysis

Nodular melanoma (NM), representing 10–30% of all melanomas, plays a major role in global mortality related to melanoma. Nonetheless, the literature on dermoscopy of NM is scanty.

Reticular erythematous mucinosis: a review of patients' characteristics, associated conditions, therapy and outcome in 25 cases

Reticular erythematous mucinosis (REM) is an uncommon disease, the nosology and specific characteristics of which are controversial because most reports deal with single cases or small series.

Usefulness of dermoscopy for the diagnosis of epidermal cyst: The 'pore' sign

Epidermal cyst can usually be diagnosed clinically as a roughly circular subcutaneous nodule of variable size, of firm consistency, covered by smooth, normal-coloured skin with a central punctum. However, it can be inflamed or, bluish, or may present with arborizing vessels, thus mimicking other skin lesions. The identification of the punctum, a pore corresponding to the follicle from which the cyst derives, gives a clue to the diagnosis. The pore is not always clinically evident (Fig. 1a), but dermoscopy can improve visualization (Fig. 1b). We aimed to assess whether dermoscopy can also help to distinguish the pore when it is not clinically visible. A prospective study was conducted on consecutive patients who presented with a roughly circular, firm, subcutaneous nodule. The age and sex of the patients, location of the nodule and presence of a central pore visible by clinical and/or dermoscopic (DermLite DL3, 3Gen, San Juan Capistrano, CA, USA) examination were recorded. In total, 83 patients (43 women and 40 men; mean age 50 18 years, range 17–90) presented with 83 subcutaneous nodules: 11 on the face, 7 on the neck, 57 on the trunk, and 8 on the arms. The pore was visible on clinical examination in 77.1% (64/83) of lesions, and was visible using dermoscopy in 90.0% (75/83) of cases. Specifically, clinical examination and dermoscopy respectively identified the pore in 45.5% and 63.6% of lesions on the face, 71.4% and 71.4% of those on the neck, 84.2% and 94.7% of those on the trunk, and 62.5% and 100% of those on the arm. The presence of a pore in a subcutaneous nodule allows a diagnosis of epidermal cyst to be made. In our study, the pore was clinically evident in the majority of cases (77.1%); however, using dermoscopy we could distinguish the pore in 57.9% (11/19) of the remaining cases. The pore appeared as a keratin-filled, roughly circular orifice, which was whitish, yellow, brown or black in colour. We also found that if the dermoscope was moved slightly in a horizontal plane to the skin, we could check if the mass of the cyst showed the ‘wobble sign’ that is, movement of the lesion with respect to the surrounding tissues, except for the pore, which represents the site of anchorage of the cyst to the overlying epidermis. The pore was less visible in facial lesions (63.6%), probably due to the fact that these were generally smaller and in an earlier phase of development. (a)

Multiple primary melanomas (MPMs) and criteria for genetic assessment: MultiMEL, a multicenter study of the Italian Melanoma Intergroup

BACKGROUND Multiple primary melanoma (MPM), in concert with a positive family history, is a predictor of cyclin-dependent kinase (CDK) inhibitor 2A (CDKN2A) germline mutations. A rule regarding the presence of either 2 or 3 or more cancer events (melanoma and pancreatic cancer) in low or high melanoma incidence populations, respectively, has been established to select patients for genetic referral. OBJECTIVE We sought to determine the CDKN2A/CDK4/microphthalmia-associated transcription factor mutation rate among Italian patients with MPM to appropriately direct genetic counseling regardless of family history. METHODS In all, 587 patients with MPM and an equal number with single primary melanomas and control subjects were consecutively enrolled at the participating centers and tested for CDKN2A, CDK4, and microphthalmia-associated transcription factor. RESULTS CDKN2A germline mutations were found in 19% of patients with MPM versus 4.4% of patients with single primary melanoma. In familial MPM cases the mutation rate varied from 36.6% to 58.8%, whereas in sporadic MPM cases it varied from 8.2% to 17.6% in patients with 2 and 3 or more melanomas, respectively. The microphthalmia-associated transcription factor E318K mutation accounted for 3% of MPM cases altogether. LIMITATIONS The study was hospital based, not population based. Rare novel susceptibility genes were not tested. CONCLUSION Italian patients who developed 2 melanomas, even in situ, should be referred for genetic counseling even in the absence of family history.

Dermoscopic diagnosis of amelanotic/hypomelanotic melanoma

Amelanotic/hypomelanotic melanoma (AHM) is a subtype including melanomas with little or no melanin pigmentation, amelanotic melanoma (AM); it represents 2-8 % of all melanomas.1-2 AM may be difficult to diagnose because of lack of pigmentation and symmetry: recently, germline mutations have been reported in the MC1R gene and to a certain extent also in the MITF gene.3 This article is protected by copyright. All rights reserved.

Trichoblastoma: is a clinical or dermoscopic diagnosis possible?

Trichoblastoma is a rare benign skin tumour that must be differentiated from basal cell carcinoma for its benign course and favourable outcome.

Pigmented fungiform papillae of the tongue: the first case in an Italian woman

nervous system (confusion, delirium, seizures) disturbances, hyperventilation, respiratory alkalosis, coma and death. Topical salicylic acid applied to intact skin in low to moderate doses normally causes minimal systemic effects, but if there is a break in the stratum corneum, as in warts, even application of low concentration preparations has been reported to result in measurable levels (8 mg/dL) of plasma salicylate. We hypothesize that the epidermal disruption caused by the cryotherapy permitted significant systemic absorption of salicylic acid. In a literature review of topical salicylic acid toxicity from 1966 to 2014, toxicity was linked to application in 13 cases of psoriasis, 8 cases of ichthyosis, 2 cases of tinea imbricata, 1 case of erythroderma and 1 case of seborrhoeic dermatitis. Salicylism from topical application of salicylic acid to viral warts has not been reported previously. In all of the previous cases, the salicylic acid preparation was applied over a large body surface area (BSA), often 50–80%. The lowest concentration and smallest BSA producing salicylism that we found reported was a 6% preparation used over 40% BSA. Lowerconcentration (1–2%) preparations have been found to cause salicylism in neonates when used over the whole body. Similar to our case, three previous cases reported symptoms of salicylism on the first day of treatment. In conclusion, we report a patient developing signs of salicylism within the first few hours of treatment with 26% salicylic acid preparation applied under occlusion to around 1% of her BSA. We believe this is the first reported case of salicylism from topical proprietary salicylic acid paint used in the treatment of viral warts on a small BSA.