Dermoscopy in the management of pigmented lesions of the oral mucosa

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.

Non-invasive intravital observation of lingual surface features using sliding oral mucoscopy techniques in clinically healthy subjects

To investigate intravital morphological features of the broader area of the lingual mucosa in clinically healthy subjects, and to attempt to evaluate subclinical conditions, we evaluated detailed intravital morphological features of the lingual mucosa using our newly developed oral contact mucoscopy techniques. Clinically healthy subjects (female: 19-22 years, average age: 20.27 years, and n = 28) were enrolled. A position indicator stain was placed on the lingual mucosal surface, and sliding images were captured and then reconstructed. In addition, the lingual mucosa was divided into six areas, and morphometry of the fungiform and filiform papillae was performed. The results were statistically analyzed. There were two morphological features among clinically healthy subjects involving the filiform papillae: the length of the papillae and the degree of biofilm (tongue coat) deposition. We defined a modified tongue coat index (mTCI) with scores ranging from 0 (tongue coating not visible) to 0.5, 1, 1.5, and 2 (thick tongue coating) for six sections of the tongue dorsum. No subjects received a score of 2. Significant differences were found in the mTCI between the six sections of the tongue dorsum, especially between the posterior areas and the lingual apex. The fungiform papillae of some subjects exhibited elongated morphological changes. Our findings suggest that magnified lingual dorsum examination of a broader area is especially important in accurate screening for subclinical or transient conditions of potential lingual mucosal diseases. For this purpose, our new oral mucoscopy and non-invasive intravital observational techniques were especially effective.

Osseous choristoma of the tongue: A case report with dermoscopic study

Osseous choristomas are rare benign lesions characterized by ectopic bone formation in the soft tissue of the head and neck region. Dermoscopy visualizes the morphological characteristics that are not observable by the naked eye, and may be used for the evaluation of calcification under the skin. The present study reports a case of an osseous choristoma arising in the tongue, and reveals the dermoscopic features of osseous choristoma from a surgical specimen. A 7-year-old boy was referred to the Department of Dentistry and Oral Surgery, with an asymptomatic pedunculated mass in the tongue. The lesion was removed completely with the adjacent normal tissue under general anesthesia. Dermoscopy of the surgical specimen revealed the hypovascular and homogeneous pattern of the lesion with round extruded whitish material. Based on dermoscopic findings, the presence of calcified hard tissue in the submucosa was verified by the dermatologist. Radiographic examination of the surgical specimen revealed the lesion contained a radiopaque trabeculated mass. Histologically, the lesion contained an osseous tissue, and the pathological diagnosis of osseous choristoma was made following consideration of the ectopic bony tissues that were localized away from the maxillo-mandibular bone. The postoperative course was uneventful with no signs of recurrence during the 36 months following surgery. To the best of the author's knowledge, this is the first report of evaluation of osseous choristoma using dermoscopy. The observation indicates the usefulness of dermoscopy for the diagnosis of oral ossified lesion in oral soft tissue.

Application of direct oral microscopy in evaluating mucosal margins around invasive oral squamous cell carcinoma

INTRODUCTION

Direct oral microscopy constitutes a novel, non-invasive diagnostic technique, which aids clinical examination of the oral cavity. The oral mucosa is examined at multiple magnifications and features such as sub-epithelial mucosal vessels, surface patterns, colour tone, transparency and the exact demarcation of mucosal lesions are estimated. The incidence of oral squamous cell carcinoma (OSCC) oscillates between 1.9% and 3.5%, which makes it the eighth most common carcinoma occurring around the world and in Poland. The 5-year survival rates oscillate between 20% and 30%.

AIM

The aim of the study was to evaluate clinically unchanged mucosal margins around OSCC by direct oral microscopy. The authors approached the question whether the borders of mucosal margins around OSCC established via direct oral microscopy differ from those established based on clinical examination.

MATERIAL AND METHODS

Fifteen patients diagnosed with OSCC were enrolled. Patients were first clinically examined to evaluate the extent of the tumour and to plan resection margins. Eventually, direct oral microscopy was performed to establish the width of the subclinically unchanged mucosal margins based on a standard picture of healthy oral mucosae, followed by comparison with those established by clinical evaluation.

RESULTS

Histopathologic results of biopsies from areas indicated by direct oral microscopy revealed dysplasia in 86.7% of patients, whereas biopsies from areas indicated by clinical examination revealed dysplasia only in 40% of individuals, resulting in the need for widening of mucosal margins.

CONCLUSIONS

Direct oral microscopy enables detection of dysplasia within clinically unaltered mucosal margins around OSCC, which results in more precise establishing of resection boundaries, contributing to improvement of resection totality.

A standard picture of healthy oral mucosae by direct oral microscopy

Introduction

Direct oral microscopy constitutes a novel technique of in vivo oral mucosae examination. The basic principles of this method derive from colposcopy and dermoscopy. The main goal of direct oral microscopy is the earliest possible detection of oral precancerous lesions in order to implement their treatment as quickly as possible and prevent malignant transformation.

Aim

To establish a standard picture of healthy oral mucosae with direct oral microscopy applying standard colposcopic criteria in order to create a reference point for further diagnosis of precancerous lesions.

Material and methods

Thirty patients of both genders with clinically unaltered oral mucosae were examined. For every individual, clinical examination with the naked eye was performed, followed by direct oral microscopy with colposcopic assessment criteria. Oral mucosae at various sites (lip, cheek, floor of mouth, ventral and lateral sides of the tongue, alveolar ridge and soft palate) were examined.

Results

Subepithelial blood vessel patterns, mucosal surface, colour tone and transparency were described for healthy oral mucosae. Moreover, cases with clinically unaltered oral mucosae where direct oral microscopy revealed subclinical alterations were described.

Conclusions

Direct oral microscopy with colposcopic assessment criteria enables establishment of a repeated picture of unaltered oral mucosae. The standard picture of healthy oral mucosae is an essential reference point for application of this technique to early diagnose potentially malignant oral mucosal lesions as well as apply their early treatment.

Dermoscopy of pigmented oral lesions

Dermoscopy is a noninvasive diagnostic technique that permits the visualization of morphologic features that are not visible to the naked eye. It is currently widely used for examination of pigmented skin lesions and early detection of cutaneous melanoma. Dermoscopy of mucous membranes is significantly less investigated and less popular among clinicians.This article reviews current knowledge about characteristic dermoscopy features of pigmented lesions of the oral mucous membranes and lips. It has to emphasized that a major advantage of dermoscopy is the capability to exclude melanoma and avoid unnecessary excisional biopsies and extensive surgery, often resulting in significant disfigurement of face and oral cavity.It has to be pointed out that there is a necessity to intensify research, which would result in clear-cut dermoscopy criteria for mucosal melanoma and the need for constructing thin, flexible dermoscopes suitable for investigation of oral mucous membranes.

Using dermoscopic criteria and patient-related factors for the management of pigmented melanocytic nevi

OBJECTIVE

To review recent dermoscopy studies that provide new insights into the evolution of nevi and their patterns of pigmentation as they contribute to the diagnosis of nevi and the management of pigmented melanocytic nevi.

DATA SOURCES

Data for this article were identified by searching the English and German literature by Medline and Journals@Ovid search for the period 1950 to January 2009.

STUDY SELECTION

The following relevant terms were used: dermoscopy, dermatoscopy, epiluminescence microscopy (ELM), surface microscopy, digital dermoscopy, digital dermatoscopy, digital epiluminescence microscopy, digital surface microscopy, melanocytic skin lesion, nevi, and pigmented skin lesions. There were no exclusion criteria.

DATA SYNTHESIS

The dermoscopic diagnosis of nevi relies on the following 4 criteria (each of which is characterized by 4 variables): (1) color (black, brown, gray, and blue); (2) pattern (globular, reticular, starburst, and homogeneous blue pattern); (3) pigment distribution (multifocal, central, eccentric, and uniform); and (4) special sites (face, acral areas, nail, and mucosa). In addition, the following 6 factors related to the patient might influence the pattern of pigmentation of the individual nevi: age, skin type, history of melanoma, UV exposure, pregnancy, and growth dynamics.

CONCLUSIONS

The 4 x 4 x 6 "rule" may help clinicians remember the basic dermoscopic criteria of nevi and the patient-related factors influencing their patterns. Dermoscopy is a useful technique for diagnosing melanocytic nevi, but the clinician should take additional factors into consideration to optimize the management of cases of pigmented lesions.

Dermoscopy report: Proposal for standardization

BACKGROUND

Dermoscopy can assist clinicians in the evaluation and diagnosis of skin tumors. Since dermoscopy is becoming widely accepted and used in the medical community, there is now the need for a standardized method for documenting dermoscopic findings so as to be able to effectively communicate such information among colleagues.

OBJECTIVES

Toward this end, the International Dermoscopy Society embarked on creating a consensus document for the standardization and recommended criteria necessary to be able to effectively convey dermoscopic findings to consulting physicians and colleagues.

METHODS

The Dermoscopy Report Steering Committee created an extensive list of dermoscopic criteria obtained from an exhaustive search of the literature. A preliminary document listing all the dermoscopic criteria that could potentially be included in a standardized dermoscopy report was elaborated and presented to the members of the International Dermoscopy Society Board in two meetings of the Society and subsequently discussed via Internet communications between members and the Steering Committee.

RESULTS

A consensus document including 10 points categorized as either recommended or optional and a template of the dermoscopy report were obtained. The final items included in the document are as follows: (1) patient's age, relevant history pertaining to the lesion, pertinent personal and family history (recommended); (2) clinical description of the lesion (recommended); (3) the two-step method of dermoscopy differentiating melanocytic from nonmelanocytic tumors (recommended); (4) the use of standardized terms to describe structures as defined by the Dermoscopy Consensus Report published in 2003. For new terms it would be helpful to provide a working definition (recommended); (5) the dermoscopic algorithm used should be mentioned (optional); (6) information on the imaging equipment and magnification (recommended); (7) clinical and dermoscopic images of the tumor (recommended); (8) a diagnosis or differential diagnosis (recommended); (9) decision concerning the management (recommended); (10) specific comments for the pathologist when excision and histopathologic examination are recommended (optional).

LIMITATIONS

The limitations of this study are those that are intrinsic of a consensus document obtained from critical review of the literature and discussion by opinion leaders in the field.

CONCLUSIONS

Although it may be acceptable for a consulting physician to only state the dermoscopic diagnosis, the proposed standardized reporting system, if accepted and utilized, will make it easier for consultants to communicate with each other more effectively.

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.