New findings in non-invasive imaging of cutaneous endometriosis: Dermoscopy, high-frequency ultrasound and reflectance confocal microscopy

BACKGROUND

Cutaneous endometriosis (CE) is rare and its dermoscopic features were reported only in 3 patients. The aim of this study was to examine a case of pigmented CE with multiple non-invasive imaging techniques, to compare the obtained images with histopathology and to define their utility in an early diagnosis of the disease.

CASE REPORT

We performed dermoscopy, high-frequency ultrasound (HFUS), in vivo and ex vivo reflectance confocal microscopy (RCM) of a pigmented CE arising on the caesarean scar of a phototype IV patient, along with histologic studies. Dermoscopy showed a greyish background and a brownish pigmentation. HFUS shows well-demarcated anechoic areas corresponding to ectopic endometrial tissue at histopathologic examination. RCM and OCT only showed the alterations of the epidermis.

CONCLUSION

High-frequency ultrasound could represent a very useful tool for an early diagnosis of CE and its usefulness could be tested in patients with unusual cyclical pain, even before skin lesion appearance. RCM allowed the visualization of skin surface modification due to underlying endometriosic tissue. Dermoscopy showed a new aspect that was probably related to the mix of blood extravasation (ie, greyish background) and epidermal pigmentation (ie, brown pigmentation).

Benign and malignant collision tumors of melanocytic skin lesions with hemangioma: Dermoscopic and reflectance confocal microscopy features

BACKGROUND

Though the combination/collision of nevi or lentigo simplex and hemangiomas is frequent, the malignant collision tumor melanoma-hemangioma is exceptional and can sometime clinically simulate a benign collision. To date, a series of collision tumors of hemangiomas associated with either benign or malignant melanocytic skin lesions (MSL) has yet to be studied by non-invasive imaging and clinico-pathologic correlates.

METHODS

We present 10 cases of patients with collision tumors of hemangioma with different MSL including: 2 in situ lentigo-maligna melanoma, 1 invasive melanoma, 5 melanocytic nevi, and 2 lentigo simplex. The clinical aspect along with the dermoscopic and reflectance confocal microscopy (RCM) features is described and compared with histopathologic findings.

RESULTS

Dermoscopic examination allows to recognize a dark ring in malignant collision melanoma-hemangioma and a jelly ring sign in benign collision of nevi/lentigo simplex-hemangioma. These peculiar features were confirmed by RCM and histopathologic findings.

CONCLUSION

Two simple dermoscopic clues confirmed by RCM features can be proposed to help distinguish between benign and malignant collisions tumors.

Reflectance confocal microscopy identification of subclinical basal cell carcinomas during and after vismodegib treatment

BACKGROUND

Recently, it has been shown that reflectance confocal microscopy (RCM) could identify subclinical basal cell carcinoma (BCC) during vismodegib treatment of locally advanced BCC.

OBJECTIVES

To evaluate specificity and sensitivity of clinical, dermoscopic and RCM examination for BCC in patients with multiple BCCs treated by vismodegib.

METHODS

Ninety four BCCs had 710 clinical, dermoscopic and RCM examinations during 72 weeks of vismodegib treatment. Thirty-eight were biopsied at the end of the treatment. Sensitivity and specificity for these 38 lesions were calculated. BCC diagnoses of clinical, dermoscopic and RCM examination on all the 710 investigations were compared using chi-square test.

RESULTS

Reflectance confocal microscopy was extremely more sensitive than dermoscopy and clinical examination and slightly less specific (sensitivity of 95%, 35% and 33% and specificity of 81%, 88% and 86% for RCM, dermoscopy and clinical examination, respectively) for the identification of residual BCC in the 38 biopsied cases. Considering all the 710 observations, RCM correctly diagnosed more BCCs than dermoscopy and clinical examination.

CONCLUSION

Reflectance confocal microscopy is a non-invasive technique that can detect subclinical residual BCC during and after vismodegib treatment helping the clinician to identify incomplete tumour regression.

Prediction of a nail polish colour applied on a nail

OBJECTIVE

The colour of a nail polish varies according to the nail on which it is applied. The objective of this study was to predict the colour of the nail polish on a given nail and to study how the colour varies depending on the nail polish thickness.

METHODS

Six nail polishes were applied in one, two and three layers on the nails of one subject, thus forming eighteen samples. The spectral reflectances of the eighteen nail polishes applied on the nails with different thicknesses were obtained by spectrophotometry. The spectral reflectances of the nails without polish were also measured using the same technique. The thicknesses of nail polishes were measured by high-definition optical coherence tomography (HD-OCT). Then, to determine the physical parameters of the nail polish itself, we applied the six nail polishes on an opacity drawdown chart and we measured the spectral reflectance and the thickness of each patch using spectrophotometry and HD-OCT, respectively. The Kubelka-Munk theory was used to get the predicted spectral reflectance of the nail polish applied on the nail according to the polish thickness by knowing the parameter of the polish itself and the spectral reflectance of the nail. The predicted spectral reflectances were finally compared with those measured directly on the nails.

RESULTS

The predicted spectral reflectances were rather close to measured ones. Consequently, knowing the colour of the nail without polish and the optical parameters of the nail polish itself, we can estimate the colour of the nail polish applied on the nail depending on its thickness.

CONCLUSION

Our study showed that the Kubelka-Munk theory can be used to predict the nail polish colour. The ability to predict the real colour of a nail polish applied on a nail could help a nail polish manufacturer to improve his polish formulae in order to obtain a precise colour.

Mucosal melanoma: clinical, histological and c-kit gene mutational profile of 86 French cases

BACKGROUND

Mucosal melanomas are rare and highly aggressive tumours. Few studies evaluated mucosal melanomas of locations other than the head and neck region, and other than those of the Asian population.

OBJECTIVES

The objective of this study was to analyse the clinical and histological features, as well as the mutational status of c-kit and b-raf gene of mucosal melanoma in any localization in a French series.

METHODS

We investigated clinical (sex, age, performance status, survival, treatment of the patients and lack of pigmentation of the tumours) and histopathological features (ulceration, Breslow's index, mitotic rate), as well as the mutational status of c-kit and b-raf of 86 mucosal melanomas diagnosed in 15 years in four French University Hospitals.

RESULTS

Most melanomas affected women (72%) and the genital region (46.5%). A fifth of melanomas were amelanotic. 81% of melanomas had a Breslow's index ≥1, whereas all glans melanomas, and most vulvar melanomas had a Breslow index ≤1 mm. Overall survival was 54% at 3 years; 11.6% of the 43 tested mucosal melanomas were c-kit-mutated while the 15 tested genital melanomas were not. The c-kit gene mutation did not influence the overall survival. Age ≥ 50, amelanotic type and performance status ≥1 were not poor prognostic factors in our series.

CONCLUSION

This study confirmed that mucosal melanomas are rare and could be difficult to diagnose being often amelanotic and in hidden sites. Most melanomas were thick at the diagnosis, but glans and vulvar melanomas were thinner probably because of their greater visibility. The frequency of the c-kit mutation varied depending on the initial tumour site. In our series, the prognosis was poor, independently from c-kit mutations and the patient's general health and age. The presence of metastasis at diagnosis was associated with a worse prognosis indicating the importance of an early diagnosis.

[The role of reflectance confocal microscopy in the diagnosis of secondary syphilis of the vulva and anus: A first case report]

PATIENTS AND METHODS

Herein we report the case of an 18-year-old pregnant patient presenting with plantar and ano-genital lesions of syphilis, pharyngitis, erythematosus and scalynasolabial intertrigo and angular cheilitis.

REFLECTANCE CONFOCAL MICROSCOPY

In vivo reflectance confocal microscopy examination (Vivascope 3000^®; Caliber Inc, Rochester, NY, USA, distributed in France by Mavig, Munich) of ano-genital lesions enabled us to identify hyper-reflective elongated rods in the papillary dermis suggesting spirochetes. The diagnosis was confirmed by TPHA and VDRL as well as immunohistological examination.

COMMENTS

We identified for the first time rod shaped structures in ano-genital lesions of secondary syphilis, regularly alternating hyper-reflective and non-reflective areas corresponding to helix-shaped treponemes visualized by darkfield microscopy, which may not be confused with other cell structures.

New-onset vitiligo and progression of pre-existing vitiligo during treatment with biological agents in chronic inflammatory diseases

BACKGROUND

The development of vitiligo during treatment with biological agents is an unusual event and only a few isolated cases have been reported.

OBJECTIVES

To describe the clinical characteristics and evolution of patients developing new-onset vitiligo following initiation of a biological agent for chronic inflammatory disease; and also to report the clinical course of pre-existing vitiligo under biological therapy.

METHODS

This nationwide multicentre, retrospective study, carried out between July 2013 and January 2015, describes the characteristics of a large series of 18 patients (psoriasis N = 8, inflammatory rheumatic diseases N = 8, ulcerative colitis N = 1, uveitis N = 1) who developed new-onset vitiligo while receiving a biological agent.

RESULTS

TNFα inhibitors were the most common biological agent involved (13/18) while anti-IL-12/23 and anti-IL-17 agents or abatacept were less common (4/18 and 1/18 respectively). Mean duration of biological agent exposure before vitiligo onset was 13.9 ± 16.5 months. Outcome was favourable for most patients (15/17) while maintaining the biological agent. Data were also collected for 18 patients (psoriasis N = 5, inflammatory rheumatic diseases N = 10, inflammatory bowel diseases N = 2, SAPHO N = 1) who had pre-existing vitiligo when treatment with a biological agent started (TNFα inhibitors N = 15, ustekinumab N = 1, rituximab N = 1, tocilizumab N = 1). Vitiligo progressed in seven patients and was stable or improved in eight cases.

CONCLUSION

Vitiligo may thus emerge and/or progress during treatment with various biological agents, mainly TNFα inhibitors and could be a new paradoxical skin reaction. De novo vitiligo displays a favourable outcome when maintaining the biological agent, whereas the prognosis seems worse in cases of pre-existing vitiligo.

Reflectance confocal microscopy of mucosal pigmented macules: a review of 56 cases including 10 macular melanomas

BACKGROUND

Although most mucosal pigmented macules are benign, it can be clinically challenging to rule out an early melanoma. Reflectance confocal microscopy (RCM) is a noninvasive imaging technique useful in discriminating between benign and malignant skin lesions.

OBJECTIVES

To describe the confocal aspects of benign and malignant mucosal pigmented macules with histopathological correlations.

METHODS

We retrospectively reviewed the confocal images of 56 labial or genital pigmented macules including 10 macular melanomas. According to the retrospective nature of the study, we evaluated the recorded images chosen by the physicians that performed the RCM examination for each case.

RESULTS

In benign macules, the most frequently observed pattern was a ringed pattern characterized by round or polycyclic papillae, with a hyper-reflective basal layer; another pattern was characterized by sparse bright dendritic cells in the basal layer, the basal epithelial cells being otherwise less reflective. Roundish cells, a high density of dendritic cells with atypias and intraepithelial bright cells were clues to the presence of malignancy.

CONCLUSIONS

Reflectance confocal microscopy seems to be a valuable tool to noninvasively differentiate benign from malignant mucosal pigmented macules and target biopsies in cases of equivocal features.

Reflectance confocal microscopy for mucosal diseases

Non-invasive, real-time microscopic imaging using in vivo reflectance confocal microscopy (RCM) has been demonstrated to be a useful tool for the evaluation of skin diseases and in particular for skin neoplasms. Recently, the RCM devices dedicated to the skin have also been applied to perform "virtual biopsies" of the oral, genital and ocular mucosa. In fact, mucosa is a sensitive area where non invasive imaging techniques are of high interest in order to spare biopsies and excisions. Mucosa is particularly suitable for RCM because of its thin or absent cornified layer and its thin epithelium that allows a deeper penetration of the laser with the consequent possibility of exploring deeper tissue levels. Besides, being useful for the diagnosis, RCM may be helpful to identify the area to be biopsied in case of large or multifocal lesions and may be regarded as a complementary technique for non invasive assessment of treatment efficacy. The RCM features of healthy mucosa are described and a revision of the literature of the mucosal diseases that can be diagnosed by RCM has been performed.

Reflectance confocal microscopy in infectious diseases

In vivo reflectance confocal microscope (RCM) is a high-resolution non-invasive imaging technique that was initially focused on the diagnosis of skin cancers. A rising number of other indications have been later described for the diagnosis and management of inflammatory and infectious dermatological disorders. RCM can identify cutaneous parasites that are not visible to naked eye such as Sarcoptes scabiei and Demodex folliculorum and it allows to better identify the different body parts of bigger parasites such as ticks. Fungal filaments can also be identified as elongated bright structures in the cutaneous upper layers. RCM cannot observe virus directly. However, the cytopathic effect associated with some virus can be recognized. In addition of being helpful for the diagnosis and follow-up after treatment, thanks to its non-invasiveness, RCM allows pathophysiological studies.

Reflectance confocal microscopy features of acral lentiginous melanoma: a comparative study with acral nevi

BACKGROUND

Acral lentiginous melanoma (ALM) can be difficult to differentiate from acral nevus. Reflectance confocal microscopy (RCM) is widely used for the diagnosis of melanocytic tumours, but the RCM features of ALM and acral nevus have not been described yet.

OBJECTIVE

To determine the RCM features of ALM and acral nevus, and their correlation with clinical and histological characteristics.

METHODS

Retrospective study of 17 cases of ALM and 26 acral nevi.

RESULTS

Pagetoid cells were present in all ALMs with a visible epidermis and in three nevi. A proliferation of atypical melanocytes at the dermal-epidermal junction (DEJ) and/or in the dermis was visible in nine ALMs but not in nevi. The histopathological examination of initial skin biopsies was unable to diagnose ALM in four cases, differing from RCM that could identify malignant tumour cells by exploring the whole lesions.

CONCLUSION

Reflectance confocal microscopy can help in the differentiation of ALM and acral nevus, and to guide the biopsy.

In vivo confocal microscopic substrate of grey colour in melanosis

BACKGROUND

Melanosis is the most common cause of mucosal pigmentation and can be clinically difficult to differentiate from early melanoma (MM). Dermoscopy can help in the distinction between melanosis and MM, but in some instances, melanoses may exhibit overlapping features with MM such as the presence of grey colour.

OBJECTIVE

We sought to evaluate whether reflectance confocal microscopy (RCM) can help to better understand the dermoscopic features of melanoses in order to assist clinicians in their diagnosis.

METHODS

All melanoses diagnosed between June 2011 and December 2014 in the Departments of Dermatology of the University of Saint-Etienne (France) and of Modena and Reggio Emilia (Italy), for which dermoscopic and RCM images were available, were included. Twenty-two lesions were biopsied to confirm the clinical diagnosis, whereas the others did not present any change at a follow-up of at least 6 months. The correlation between dermoscopic and RCM features were evaluated by the Spearman's rho correlation coefficient.

RESULTS

55 melanoses were studied: 31 of the oral mucosa and 24 of the genital mucosa. 49% (n = 27) of melanoses exhibited a grey colour under dermoscopy. The grey colour correlated with the presence of melanophages under RCM (ρ = 0.424, P = 0.002).

CONCLUSION

Our findings highlight that the presence of the grey colour on dermoscopy, considered as an alerting feature, is common in melanoses and it is related to the presence of melanin-laden inflammatory cells in the papillary dermis on RCM. When it is present as a 'pure' feature not associated to other colours than brown or to atypical dermoscopical structures, it could be related to the diagnosis of melanosis.