Sara Bassoli

The Impact of In Vivo Reflectance Confocal Microscopy on the Diagnostic Accuracy of Lentigo Maligna and Equivocal Pigmented and Nonpigmented Macules of the Face.

Limited studies have reported the in vivo reflectance confocal microscopy (RCM) features of lentigo maligna (LM). A total of 64 RCM features were scored retrospectively and blinded to diagnosis in a consecutive series of RCM sampled, clinically equivocal, macules of the face (n=81 LM, n=203 benign macules (BMs)). In addition to describing RCM diagnostic features for LM (univariate), an algorithm was developed (LM score) to distinguish LM from BM. This comprised two major features each scoring +2 points (nonedged papillae and round large pagetoid cells > 20 microm), and four minor features; three scored +1 point each (three or more atypical cells at the dermoepidermal junction in five 0.5 x 0.5 mm(2) fields, follicular localization of atypical cells, and nucleated cells within the dermal papillae), and one (negative) feature scored -1 point (a broadened honeycomb pattern). A LM score of > or = 2 resulted in a sensitivity of 85% and specificity of 76% for the diagnosis of LM (odds ratio (OR) for LM 18.6; 95% confidence interval: 9.3-37.1). The algorithm was equally effective in the diagnosis of amelanotic lesions and showed good interobserver reproducibility (87%). In a test set of 29 LMs and 44 BMs, the OR for LM was 60.7 (confidence interval: 11.9-309) (93% sensitivity, 82% specificity).

In Vivo Confocal Microscopic and Histopathologic Correlations of Dermoscopic Features in 202 Melanocytic Lesions

OBJECTIVES To identify in vivo microscopic substrates of the dermoscopic patterns of melanocytic lesions and to correlate them with histopathologic features. DESIGN Before excision, lesion areas that showed characteristic dermoscopic patterns were imaged by dermoscopy and confocal microscopy and directly correlated with histopathologic features. SETTING Departments of Dermatology of the University of Modena and Reggio Emilia and Hospital Clínico of Barcelona, between July 2006 and March 2007. Patients Patients with 202 melanocytic lesions, corresponding to 76 melanomas, 114 nevi, and 12 Spitz or Reed nevi. MAIN OUTCOME MEASURES Correlation of dermoscopic patterns in melanocytic lesions with confocal microscopic findings and conventional histopathologic findings. RESULTS Characteristic architectural and cytologic substrates were identified in vivo with the use of confocal microscopy and correlated with histopathologic features. Pigment network atypia was evidenced through confocal microscopy as a disarrangement of dermoepidermal junction architecture and cellular atypia. Pigmented globules consisted of cell clusters, corresponding to melanocytic nests identified on histopathologic analysis. Black dots correlated with intraepidermal reflective spots or with large pagetoid cells in nevi and melanoma, respectively. Blue structures usually consisted of numerous pleomorphic cells, corresponding to malignant melanocytes and inflammatory cells in melanomas, whereas plump bright cells, corresponding to melanophages on histopathologic analysis, characterized benign lesions. Within regression, a retiform distribution of collagen fibers, which sometimes intermingled with melanophages and rarely with nucleated cells, was observable. CONCLUSIONS The knowledge of the cytologic and architectural aspects of the different dermoscopic patterns, as they appear by in vivo confocal microscopy, may guide the user to the identification of specific substrates in melanocytic lesions and consequently the interpretation of the dermoscopic features.

In Vivo Microscopic Features of Nodular Melanomas Dermoscopy, Confocal Microscopy, and Histopathologic Correlates

OBJECTIVE To characterize nodular melanoma (NM) using dermoscopy, in vivo reflectance-mode confocal microscopy, and histopathologic analysis. DESIGN Consecutive pure NMs and superficial spreading melanomas (SSMs) with nodular or blue areas were studied using dermoscopy and confocal microscopy, and a correlation with histopathologic findings was performed. MATERIALS Ten NMs, 10 SSMs with a nodular area, and 10 SSMs with a blue palpable but not yet nodular area. MAIN OUTCOME MEASURE Confocal differences within the nodular component between pure NMs and SSMs with a nodular area, hypothesizing different biological behaviors. RESULTS Whereas NMs had predominantly nonspecific global dermoscopic patterns, SSMs exhibited a multicomponent pattern and higher dermoscopic scores. Globules, blue-white veil, atypical vessels, and structureless areas were frequent in NMs and in nodular areas from SSMs. At confocal microscopy, NMs exhibited few pagetoid cells within a typical epidermal architecture in the superficial layers in most cases, differing from SSMs frequently characterized by epidermal disarrangement and pagetoid infiltration. At the dermoepidermal junction, dermal papillae were rarely seen in nodular areas both from NMs and from SSMs, frequently substituted by nonaggregated atypical cells distributed in sheetlike structures. In the upper dermis, all groups exhibited plump bright cells, dense dishomogeneous cell clusters, and atypical nucleated cells, whereas cerebriform clusters were characteristic of NMs. Conclusion Distinctive dermoscopic and confocal features seen in NMs compared with SSMs are helpful in making the diagnosis and suggest different biological behavior.

New insights into nevogenesis: In vivo characterization and follow-up of melanocytic nevi by reflectance confocal microscopy

BACKGROUND Development of melanocytic nevi is a complex process. OBJECTIVE The aim of the study was to characterize the in vivo confocal microscopy patterns and histopathologic correlates of melanocytic nevi. In addition, for the first time, confocal follow-up of characteristic nevi was performed documenting histologic changes in nevi. METHODS For the correlation study, 33 melanocytic nevi showing characteristic dermatoscopic patterns were studied by confocal microscopy. For the follow-up study 20 nevi were monitored for 12 to 18 months. RESULTS Reticular nevi showed two different confocal patterns, ringed and meshwork, mostly corresponding to lentiginous and nested junctional patterns, respectively. Globular nevi presented large junctional clusters, whereas cobblestone nevi were constituted by dermal dense melanocytic clusters. Homogeneous nevi did not show distinctive confocal and histopathologic findings. Nevi with a rim of globules presented a meshwork pattern with junctional clusters at the periphery. At the confocal follow-up study all lesions showed limited dynamic changes resulting in stable dermatoscopic and confocal patterns, but 3 globular nevi with junctional nests at baseline evolved into reticular-meshwork pattern nevi with peripheral rim of globules-junctional nests. LIMITATIONS Longer confocal follow-up of more melanocytic nevi is required to confirm this theory and to validate our preliminary findings. CONCLUSIONS A model explaining the nevus classification and patterns of evolution of nevi observed in the study was proposed.

Reflectance confocal microscopy and features of melanocytic lesions: An internet-based study of the reproducibility of terminology

OBJECTIVE To test the interobserver and intraobserver reproducibility of the standard terminology for description and diagnosis of melanocytic lesions in in vivo confocal microscopy. DESIGN A dedicated Web platform was developed to train the participants and to allow independent distant evaluations of confocal images via the Internet. SETTING Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy. PARTICIPANTS The study population was composed of 15 melanomas, 30 nevi, and 5 Spitz/Reed nevi. Six expert centers were invited to participate at the study. Intervention Evaluation of 36 features in 345 confocal microscopic images from melanocytic lesions. MAIN OUTCOME MEASURE Interobserved and intraobserved agreement, by calculating the Cohen kappa statistics measure for each descriptor. RESULTS High overall levels of reproducibility were shown for most of the evaluated features. In both the training and test sets there was a parallel trend of decreasing kappa values as deeper anatomic skin levels were evaluated. All of the features, except 1, used for melanoma diagnosis, including roundish pagetoid cells, nonedged papillae, atypical cells in basal layer, cerebriform clusters, and nucleated cells infiltrating dermal papillae, showed high overall levels of reproducibility. However, less-than-ideal reproducibility was obtained for some descriptors, such as grainy appearance of the epidermis, junctional thickening, mild atypia in basal layer, plump bright cells, small bright cells, and reticulated fibers in the dermis. Conclusion The standard consensus confocal terminology useful for the evaluation of melanocytic lesions was reproducibly recognized by independent observers.

Prediction of Survival in Patients With Thin Melanoma: Results From a Multi-Institution Study

PURPOSE Cutaneous melanoma incidence is increasing. Most new cases are thin (≤ 1 mm) with favorable prognoses, but survival is nonetheless variable. Our aim was to investigate new prognostic factors and construct a nomogram for predicting survival in individual patients. PATIENTS AND METHODS Data from 2,243 patients with thin melanoma were retrieved from prospectively maintained databases at six centers. Kaplan-Meier survival and crude cumulative incidences of recurrence were estimated, and competing risks were taken into account. Multivariable Cox regression was used to investigate survival predictors. RESULTS Median follow-up was 124 months (interquartile range, 106 to 157 months); 12-year overall survival was 85.3% (95% CI, 83.4% to 87.2%). Median times to local, regional, and distant recurrence were 79, 78, and 107 months, respectively. Relapse was significantly related to age, Breslow thickness, mitotic rate (MR), ulceration, lymphovascular invasion (LVI), and regression; incidence was lower and subgroup differences were less marked for distant metastasis than for regional relapse. The worst prognosis categories were age older than 60 years, Breslow thickness more than 0.75 mm, MR ≥ 1, presence of ulceration, presence of LVI, and regression ≥ 50%. Breslow thickness more than 0.75 mm, MR ≥ 1, presence of ulceration, and LVI (all P = .001) were significantly associated with sentinel node positivity. Age, MR, ulceration, LVI, regression, and sentinel node status were independent predictors of survival and were used to construct a nomogram to predict 12-year overall survival. The nomogram was well calibrated and had good discriminative ability (adjusted Harrell C statistic, 0.88). CONCLUSION Our findings suggest including LVI and regression as new prognostic factors in the melanoma staging system. The nomogram appears useful for risk stratification in clinical management and for recruiting patients to clinical trials.

Dermoscopic Island: A New Descriptor for Thin Melanoma

OBJECTIVES To determine the frequency and the features of the dermoscopic island (DI) in melanocytic lesions and to assess its specificity for the diagnosis of melanoma. Dermoscopy improves the diagnostic accuracy of melanoma, but only a few dermoscopic descriptors specific for thin melanomas have been identified. We defined a new descriptor, the dermoscopic island, a well-circumscribed area showing a uniform dermoscopic pattern that differs from the rest of the pigmented lesion. DESIGN Dermoscopic images of 96 in situ melanomas, 266 invasive melanomas, and 612 dermoscopic atypical nevi were evaluated to establish the presence and the main pattern of the DI. Also, clinical and histologic characteristics were analyzed. SETTING Dermoscopic images were collected from lesions excised between 2003 and 2008 at the Department of Dermatology, University of Modena and Reggio Emilia. MAIN OUTCOME MEASURES Specificity and odds ratio for melanoma; dermoscopic and histologic characteristics of lesions with a DI. RESULTS The DI was present in 10.4% of in situ melanomas, 4.1% of invasive melanomas, and 3.1% of dermoscopic atypical nevi. The odds ratio for melanoma was 1.922, and specificity was 96.9%. Invasive melanomas with a DI were thinner than those lacking this descriptor. In addition, more than half of the melanomas with a DI arose on a nevus. The DI appeared mainly reticular on a reticular background. CONCLUSION The DI is characteristic of thin melanoma arising in a nevus; thus, it can be considered a potential early sign of transformation of a nevus into a melanoma.

Multiphoton laser microscopy and fluorescence lifetime imaging for the evaluation of the skin.

Multiphoton laser microscopy is a new, non-invasive technique providing access to the skin at a cellular and subcellular level, which is based both on autofluorescence and fluorescence lifetime imaging. Whereas the former considers fluorescence intensity emitted by epidermal and dermal fluorophores and by the extra-cellular matrix, fluorescence lifetime imaging (FLIM), is generated by the fluorescence decay rate. This innovative technique can be applied to the study of living skin, cell cultures and ex vivo samples. Although still limited to the clinical research field, the development of multiphoton laser microscopy is thought to become suitable for a practical application in the next few years: in this paper, we performed an accurate review of the studies published so far, considering the possible fields of application of this imaging method and providing high quality images acquired in the Department of Dermatology of the University of Modena.

Reticular grey-blue areas of regression as a dermoscopic marker of melanoma in situ.

Background  By dermoscopy, regression structures are substantially defined by the presence of white and blue areas in the lesion image. As fibrosis and melanosis are often seen in malignant melanoma (MM), the presence of dermoscopic signs of regression may represent a clue for the diagnosis of malignancy.

Diagnosis of BCC by multiphoton laser tomography

Multiphoton Laser Tomography (MPT) is a non‐linear optical technique that gives access to morphology and structure of both cells and extracellular matrix of the skin through the combination of autofluorescence imaging and second harmonic generation (SHG). The aim of this study was to identify MPT descriptors on ex vivo specimens of basal cell carcinoma (BCC) to assess the sensitivity and specificity of these criteria for the diagnosis of BCC and its differentiation from other skin tumours, inflammatory diseases and healthy skin.