Genital lentiginosis: a clinical and histopathologic study

Pigmentary complications after non-medical male circumcision

BACKGROUND

A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely.

METHODS

This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test.

RESULTS

69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest.

CONCLUSION

Pigmentary complications after male circumcision are not rare and its management is challenging.

The Skin in Cowden Syndrome

Cowden syndrome (CS) is an autosomal dominant condition caused by mutations in the phosphatase and tensin homolog (PTEN) gene, and is characterized by multiple hamartomas and a predisposition to malignant tumors. Characteristic skin lesions include trichilemmomas, acral keratosis, mucocutaneous neuromas, oral papillomas, and penile macules, and are often the first clues to the underlying diagnosis. Here, we discuss the mucocutaneous manifestations of CS, differential diagnoses of genetic causes of each cutaneous finding, genetic analyses for patients with skin manifestations, management of patients with CS, and potential new targeted therapies for CS.

Clinical and Dermoscopic Features of Vulvar Melanosis Over the Last 20 Years

Importance

Vulvar melanosis is a common pigmentary change that accounts for most pigmented vulvar lesions. It presents as single or multiple asymptomatic macules or patches of varying size and color that may be asymmetric with poorly defined borders. The differential diagnosis of melanocytic lesions includes melanoma, which creates anxiety for patients and the physicians who diagnose the condition and treat the patients.

Objective

To evaluate the clinical and dermoscopic features of vulvar melanosis and their changes over time.

Design, Setting, and Participants

In this cohort study, patients with vulvar melanosis were recruited and followed up in the Department of Dermatology, University of Florence, Florence, Italy, between January 1, 1998, and June 30, 2019. Data on patient characteristics and on both the clinical and dermoscopic features of the vulvar lesions were collected. Each lesion was photographed clinically and dermoscopically at initial evaluation and at annual follow-up visits.

Main Outcomes and Measures

The clinical, dermoscopic, and histopathologic features of vulvar melanosis and their changes over time.

Results

This cohort study included 129 women (mean age at diagnosis, 46 years [range, 19-83 years]) with vulvar melanosis. A total of 87 patients (67%) with vulvar melanotic lesions were premenopausal, and 84 patients (65%) had received some type of hormone therapy. The most frequent location for vulvar melanosis was the labia minora (55 [43%]), followed by the labia majora (33 [26%]). In 39 of 129 cases (30%), the lesions increased in size and changed color after initial evaluation but ultimately stabilized. No malignant evolution was documented in any patient during a median follow-up of 13 years (range, 5-20 years).

Conclusions and Relevance

This study suggests that vulvar melanosis was a benign entity, and changes in lesions over time did not signify malignant transformation. An association between hormonal status and vulvar melanosis may be hypothesized.

Video image of genital melanosis provides strong evidence to support identification of a sexual offender

A man in his thirties was suspected of committing a sexual offense against a young girl. A video on his mobile telephone provided the only evidence. Photographs obtained from the video showed male genitalia in two views, with the penis in both views exhibiting unique pigmentation. We appraised this case with the cooperation of dermatologists, who diagnosed the pigmentation as male genital melanosis, a relatively rare disease, which matched that on the suspected perpetrator's penis. Photographs obtained from the video were thus decisive evidence of sexual offense and identified the perpetrator.

Review of 189 Consecutive Female Genital Skin and Mucosal Biopsies Submitted to an Academic Dermatopathology Practice

OBJECTIVES

To describe consecutive vulvar biopsy cases and to create an educational template for pathology trainees and practicing pathologists.

METHODS

We reviewed 189 consecutive biopsies from the female genital area skin and mucosa. We classified them based on etiologies and examined limited clinical information.

RESULTS

We classified diagnoses as squamous intraepithelial neoplasia (21.5%), melanocytic neoplasia (17.9%), lichenoid dermatoses (15.9%), nonlichenoid dermatoses (11.3%), infectious (6.2%), reparative (4.6%), or miscellaneous (22.6%). The miscellaneous diagnoses included common entities (polyps and cysts) and rarer entities (calcinosis cutis, adnexal neoplasms, or basal cell carcinoma) and nonspecific descriptive diagnoses. Clinicians most often included the actual diagnosis in their differential for melanocytic lesions (83%) and least often for inflammatory lesions (32%). However, some cases included a clinical description without a differential diagnosis (14%) or no helpful clinical information (4%). The distribution of whether correct diagnoses were included in the clinical differential was similar between submitting physicians and midlevel providers.

CONCLUSIONS

Understanding squamous and melanocytic pathology and the various lichenoid and other inflammatory diagnoses is critical for signing out female genital tract skin pathology. The cases examined in this report can serve as an educational template for trainees and practicing pathologists.

PTEN Hamartoma Tumor Syndrome: A Clinical Overview

The phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS) is a grouping of related genetic disorders that has been linked to germline mutations in the PTEN gene. These disorders include Cowden syndrome (CS), Bannayan–Riley–Ruvalcaba syndrome, adult Lhermitte–Duclos disease, and autism spectrum disorders associated with macrocephaly. The majority of the clinical information available on PHTS, however, is related to individuals diagnosed with CS. There is still much to be learned about this disorder, since diagnostic criteria for CS were only established in 1996, before the identification of the PTEN gene, and were based primarily on features seen in cases reported in the existing literature. More recently, however, data from several large series of patients have shown that a number of the clinical features associated with PTEN mutations are either more or less common than previously reported. In addition, we now know that only about 30–35% of patients meeting clinical diagnostic criteria for Cowden syndrome actually have a detectable PTEN mutation. Thus, our understanding of PTEN-related diseases and their management has evolved significantly over time. The United States National Comprehensive Cancer Network (NCCN) has produced and regularly updates practice guidelines which include clinical diagnostic criteria as well as guidelines for PTEN testing and management of patients with mutations. This review will summarize the overall literature on PHTS as well as recent findings which are broadening our understanding of this set of disorders.

Evaluation of large clinically atypical vulvar pigmentation with RCM: atypical melanosis or early melanoma?

BACKGROUND

Vulvar melanosis can occasionally be clinically challenging by mimicking an early melanoma.

OBJECTIVE

To report our experience of initial evaluation and follow-up in this peculiar subset of vulvar melanosis using reflectance confocal microscopy (RCM).

METHODS

We retrospectively evaluated 18 consecutive cases referred for atypical vulvar pigmentation or for which melanoma was considered and that underwent both RCM examination and histopathological assessment. In 13 cases with available dermoscopic pictures, RCM classification was compared to dermoscopic diagnosis, and in all cases, the density of melanocytes was evaluated on biopsies using MelanA immunostaining.

RESULTS

Among the 18 atypical pigmented lesions, 17 vulvar melanosis and one melanoma were histologically determined. RCM concluded a benign vulvar melanosis in 10 of 17 cases, whereas dermoscopy did so in three of 12 cases. RCM identified the only early malignant lentiginous melanoma. In several cases of vulvar melanosis, RCM could identify foci of melanocytic hyperplasia in an otherwise benign pattern.

CONCLUSIONS

In this clinically and dermoscopically challenging subset of vulvar pigmentations, RCM appears relevant for initial extensive evaluation, especially to target initial biopsy sampling, and to perform non-invasive monitoring of foci of melanocytic hyperplasia.

A clinical, histologic, and follow-up study of genital melanosis in men and women

BACKGROUND

Genital melanosis may clinically mimic melanoma. Little is known about the potential risk for genital and nongenital melanoma in these patients.

OBJECTIVE

In this retrospective cohort study, we analyzed clinical and histologic data from patients with genital melanosis to better characterize these lesions and the risk they confer for genital and nongenital melanoma.

METHODS

In all, 41 patients were identified for a retrospective chart review and histologic analysis.

RESULTS

Genital melanosis can clinically mimic melanoma but the typical age of onset is younger than for genital melanoma. A majority of lesions were found to stabilize or regress over time. Five patients were found to have a history of melanoma, only 1 of which was in the genital region. Lesions from these patients were more likely to show melanocytes with suprabasal movement (P = .0101) and to have a higher melanocyte count (P < .0462).

LIMITATIONS

We present a relatively small cohort of patients with an average follow-up of only 30.5 months.

CONCLUSION

Patients with genital melanosis, and in particular those with any level of histologic atypia in the genital melanosis lesion, may require careful total body skin examinations for the possibility of melanoma in any body site.

Pigmented vulvar lesions

Pigmented lesions represent an enormous range of conditions, from benign to malignant tumors, and from infectious to post-inflammatory. Pigmented lesions are much less easily diagnosed on anogenital skin, and clinicians should have a low threshold for biopsy confirmation of diseases not classic in appearance.

Pigmented lesions of the vulva

Approximately one of every 10 women has a pigmented vulvar lesion. Given the risk of melanomas and pigmented vulvar intraepithelial neoplasia (squamous cell carcinoma in situ), proper evaluation of vulvar pigmented lesions is critical. Most vulvar lesions are benign; however, vulvar lesions grossly, dermoscopically, and histologically can appear atypical compared with pigmented lesions on the rest of the body. Thus, it is imperative to use not only a keen eye but also a low threshold for biopsy.

Dermoscopy of pigmented lesions on mucocutaneous junction and mucous membrane

BACKGROUND

The dermoscopic features of pigmented lesions on the mucocutaneous junction and mucous membrane are different from those on hairy skin. Differentiation between benign lesions and malignant melanomas of these sites is often difficult.

OBJECTIVE

To define the dermoscopic patterns of lesions on the mucocutaneous junction and mucous membrane, and assess the applicability of standard dermoscopic algorithms to these lesions.

PATIENTS AND METHODS

An unselected consecutive series of 40 lesions on the mucocutaneous junction and mucous membrane was studied. All the lesions were imaged using dermoscopy devices, analysed for dermoscopic patterns and scored with algorithms including the ABCD rule, Menzies method, 7-point checklist, 3-point checklist and the CASH algorithm.

RESULTS

Benign pigmented lesions of the mucocutaneous junction and mucous membrane frequently presented a dotted-globular pattern (25%), a homogeneous pattern (25%), a fish scale-like pattern (18.8%) and a hyphal pattern (18.8%), while melanomas of these sites showed a multicomponent pattern (75%) and a homogeneous pattern (25%). The fish scale-like pattern and hyphal pattern were considered to be variants of the ring-like pattern. The sensitivities of the ABCD rule, Menzies method, 7-point checklist, 3-point checklist and CASH algorithm in diagnosing mucosal melanomas were 100%, 100%, 63%, 88% and 100%; and the specificities were 100%, 94%, 100%, 94% and 100%, respectively.

CONCLUSION

The ring-like pattern and its variants (fish scale-like pattern and hyphal pattern) are frequently observed as well as the dotted-globular pattern and homogeneous pattern in mucosal melanotic macules. The algorithms for pigmented lesions on hairy skin also apply to those on the mucocutaneous junction and mucous membrane with high sensitivity and specificity.

Melanocytic nevi clinically simulating melanoma

Melanoma and other benign or malignant pigmented skin tumors can significantly overlap in their clinical and dermoscopical presentations. Thus, pigmented skin lesions may be misdiagnosed in a large number of cases. An extensive review of the published work provides numerous examples of benign lesions mimicking melanoma. Although a number of melanocytic nevi may have been identified as melanomas, information about their clinical appearance is limited. In this report, we present the clinical appearances of two melanocytic nevi on the vulva and the upper extremity that were difficult to diagnose clinically. Detecting melanoma at an early stage is of the utmost importance. However, more attention should be given to the diagnostic accuracy of benign pigmented skin lesions, which otherwise may be diagnosed and treated as melanoma.

[Atypical pigmented penile macules]

Two patients with pigmented lesions of the penis are described. The lesions consisted of asymptomatic, multifocal, irregular macules, with variegated pigmentation. The main differential diagnostic problem was with mucocutaneous melanoma. Histologic examination of the lesions showed basal layer hyperpigmentation. No cytologic atypia of melanocytes was detectable. The diagnosis in both cases was melanotic macules. Because of their atypical clinical appearance, genital melanotic macules are often misinterpreted as mucocutaneous melanoma. However histopathologic study solves the problem because genital melanotic macules show no melanocytic proliferation nor melanocytic atypia.

[Pigmented lesions of the genital mucosa]

Pigmented lesions of the genital mucosa are more frequent in women than in men. They represent a spectrum of different benign entities. A biopsy is always recommended when the diagnosis cannot be made with certainty on clinical examination and dermatoscopy. Differential diagnostic considerations include melanocytic nevi, blue nevi and syndromes featuring lentigines. Malignant melanomas of the penis and vulva are uncommon tumors which usually appear in elderly patients. They frequently present as painless palpable nodules at routine examination. The treatment consists of excision with histological control of the margins. An aggressive surgical approach has not been shown to prolong the poor 5-year survival. Cooperation with gynecologists and urologists is essential for the optimal management of such patients.

[Melanoma of the penis: 6 cases]

BACKGROUND

Melanomas of the penis are rare tumors of poor prognosis.

METHODS

Six cases of melanoma of the penis, followed between 1975 and 2002, were retrospectively reviewed. We collected the data on epidemiological, clinical and pathologic factors, treatment and follow-up.

RESULTS

The mean age was 44 years. The time to diagnosis was 2 years. Two patients had general predisposing factors for melanoma, and 3 patients local predisposing factors. Two patients had partial penectomy and 4 patients had conservative excision. One patient had local recurrence, and another had metastatic course resulting in death. Five patients out of 6 were alive and disease free at time of the study, with a 24 month follow-up.

DISCUSSION

The identified risk factors for the development of penile melanoma are melanosis and pre-existing nevus. Delayed diagnosis explains the usually bad prognosis. Classical surgical treatment used to be radical, but recently, conservative surgery has been proposed. For an early diagnosis, genital melanosis requires surgical excision, when technically feasible, and any atypical lesion of the penis should be submitted to a biopsy.

Dermoscopic Features of Mucosal Melanosis

BACKGROUND

Melanosis (lentiginosis, labial melanotic macula) is a benign pigmented lesion of mucosa characterized by pigmentation of basal keratinocytes with melanocytic normal or slightly increased in number. Melanosis, particularly when occurring on genitalia, can clinically mimic mucosal melanoma thus creating concern in both the patient and the physician.

OBJECTIVE

In this study dermoscopic features from a series of clinically equivocal (n=11) or clinically typical (n=10) mucosal melanosis were analyzed.

METHODS

All the women consecutively seen at the Vulva Clinic of the Department of Obstetrics and Gynecology, University of Florence, Italy, from May 1, 2002 to June 30, 2002, were examined.

RESULTS

Three major dermoscopic patterns were identified: (1) a "structureless" pattern, predominantly found in clinically equivocal vulvar melanosis, with a blue hue, associated with the presence of melanophages in the upper dermis, present in the majority of these lesions; (2) a "parallel pattern," often found in clinically typical melanotyc macules of the lips and penis; and (3) a "reticular-like" pattern associated with clinically equivocal melanosis occurring at peculiar sites such as the areola (all the three cases occurred at that site) or, rarely, on the lip.

CONCLUSIONS

Dermoscopy can play a role in the noninvasive classification of mucosal melanosis. The risk of misclassification with melanoma is probably dependent on dermoscopy pattern shown by the lesion. Prospective studies including early melanomas are needed to establish diagnostic performance of dermoscopy in pigmented lesions of the mucosa.

Genital lentigines and melanocytic nevi with superimposed lichen sclerosus: a diagnostic challenge

BACKGROUND

Benign pigmented lesions of the genitalia, such as genital lentigines and melanocytic nevi, often show clinical and histopathologic features highly suggestive of malignant melanoma (MM). Superimposed changes of lichen sclerosus (LS) may cause real concern and lead to an erroneous diagnosis of MM.

OBJECTIVE

This study was performed to assess clinicopathologic characteristics of genital lentigines and melanocytic nevi with associated LS.

METHODS

We performed a retrospective review of 5 cases.

RESULTS

Histopathologic sections of the 2 cases of genital lentigines with concurrent changes of LS showed a lichenoid lymphocytic infiltrate and pigment incontinence with melanophages in a fibrosed papillary dermis, features reminiscent of completely regressed MM. The 3 cases of genital melanocytic nevi and superimposed LS were sharply circumscribed, relatively symmetric, but revealed confluent nests varying in size and shape and pagetoid upward spread of melanocytic nests and single melanocytes. Changes of LS extended beyond the melanocytic proliferation.

CONCLUSION

Genital lentigines and melanocytic nevi with associated LS may show features that mimic MM.

Oral pigmentation

Oral pigmentation may be physiological or pathological in nature. It may represent a localized anomaly of limited significance or the presentation of potentially life-threatening multisystem disease. Evaluation of a patient with oral pigmentation requires a systematic approach with resource to appropriate investigations in certain circumstances. A full history of evolution of the pigmentary changes, as well as inquiring into family history, drug ingestion and systemic symptoms of concurrent disease are clearly important in the assessment. The duration, pattern, hue and distribution of colour changes can provide useful diagnostic clues. Special attention is given to newly appearing lesions, or those that have changed significantly in appearance, and biopsy may be needed to validate the clinical impression. This review should enable the reader to increase their familiarity with the assessment of oral pigmentation, the common causes of oral pigmentary change and the rarer disorders of pigmentation seen in this area. The systemic diseases that may give rise to oral pigmentation are detailed and the early signs of oral melanoma are highlighted, as well as the drugs which may cause pigmentary changes in this area and the different pattern of pigmentation they may induce.

Dermatoscopy in the diagnosis of pigmented skin lesions: a new semiology for the dermatologist

Dermatoscopy or epiluminescence microscopy (ELM), is a noninvasive method that enables clinicians to evaluate fully--by means of a magnified oil immersion diascopy--numerous morphological features, not visible with the naked eye, which enhance the diagnosis of nearly all pigmented skin lesions. In recent years, a burst of research activity in this topic has been carried out, dealing with different aspects, and new frontiers, of this technique. First, a continuous refinement of dermatoscopic terminology is undertaken, paying particular attention to the diagnostic performance of dermatoscopy at peculiar anatomical sites and to the building of different dermatoscopic algorithms aimed at a simplified diagnosis of melanoma, even for less experienced observers. Another point of interest concerns the possible role of dermatoscopy in the pre-operative assessment of melanoma thickness. Finally, promising data about the role of digital equipment in the follow up of melanocytic skin lesions as well as in the automated diagnosis of pigmented skin lesions have been recently reported. This paper should enable readers to become familiar with the procedure and terminology of ELM in the diagnosis of pigmented skin lesions encouraging a greater understanding of different methods (pattern analysis, algorithms) in the diagnosis of melanoma using ELM.

Primary malignant melanoma of the urethra: a clinicopathologic analysis of 15 cases

The clinical and pathologic features of 15 primary urethral melanomas occurring in patients (nine women and six men) age 44 to 96 years (mean age, 73 yrs) are described. In the men the tumor involved the distal urethra. In eight women it involved the distal urethra, usually the meatus; both the distal and proximal urethra were involved in one woman. The tumors were typically polypoid and ranged from 0.8 to 6 cm (mean, 2.6 cm) in maximum dimension. A vertical growth phase was present in all tumors, with a prominent nodular component in seven of them. A radial growth phase was seen in nine tumors. The depth of invasion ranged from 2 to 17 mm. The tumors had diffuse, nested, storiform, or mixed growth patterns. The neoplastic cells typically had abundant eosinophilic cytoplasm, large nuclei with prominent nucleoli, and brisk mitotic activity. Melanin pigment was seen in 12 tumors but was conspicuous in only six. At the time of diagnosis, 13 tumors were confined to the urethra and two patients had lymph node metastasis. Nine patients died of disease 13 to 56 months after initial diagnosis and treatment, and one patient had a local recurrence at 4 years and subsequently died of sepsis 1 year later. Three patients were alive and well at 11 months, 23 months, and 7 years. One patient died at the time of the initial operation, and one died of a ruptured aortic aneurysm at 3 years without evidence of melanoma at autopsy. Primary malignant melanomas of the urethra, one fifth of which are amelanotic, must be included in the differential diagnosis of a number of primary neoplasms that involve the urethra, including transitional cell carcinoma, sarcomatoid carcinoma, and sarcomas. Conventional prognostic factors, such as depth of invasion or tumor stage, do not seem to play as important a role in predicting survival as the mucosal location and the nodular growth present frequently in these tumors.

Melanoma in situ of the penis

Melanoma of the penis is rare and the prognosis is very poor. We report a case of melanoma in situ localized on the penile shaft. Melanoma in situ of the penis is extremely rare. We emphasize that early diagnosis of melanoma in situ will improve the prognosis of melanoma of the penis.

Penile lentiginosis. An ultrastructural study

This study on five patients has revealed more extensive alterations to melanocytes than previously reported, and emphasizes the fact that depigmentation is an essential element of the condition. In hyperpigmented areas, melanocytes were increased in number along the basal layer of the epithelium, were hyperactive, and in some cases contained bizarre melanosomes. In two cases there was suggestion of a defect in melanosome transfer to keratinocytes. Lymphocytes were closely apposed to melanocytes, and, in hypopigmented areas, were clearly involved in their disintegration. In depigmented areas, there was complete absence of melanocytes and of melanosomes in keratinocytes, and lymphocytes were present in the basal layer. In general, the appearances did not resemble melanoma in situ with spontaneous regression, although a second biopsy of one patient after one year did reveal features of melanocytes suggestive of an early stage of this condition. The study has provided no clear information as to the initial cause of the condition, but the manner of destruction of melanocytes suggests an immune reaction. Neither has it been of assistance in suggesting a more precise name for it.