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Liu H, Jiang H, Shan Q. Reflectance confocal microscopy versus dermoscopy for the diagnosis of cutaneous melanoma: a head-to-head comparative meta-analysis. Melanoma Res 2024; 34:355-365. [PMID: 38847651 DOI: 10.1097/cmr.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
This meta-analysis aimed to evaluate the comparative diagnostic performance of reflectance confocal microscopy (RCM) and dermoscopy in detecting cutaneous melanoma patients. An extensive search was conducted in the PubMed and Embase databases to identify available publications up to December 2023. Studies were included if they evaluated the diagnostic performance of RCM and dermoscopy in patients with cutaneous melanoma. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool. A total of 14 articles involving 2013 patients were included in the meta-analysis. The overall sensitivity of RCM was 0.94 [95% confidence interval (CI), 0.87-0.98], while the overall sensitivity of dermoscopy was 0.84 (95% CI, 0.71-0.95). These results suggested that RCM has a similar level of sensitivity compared with dermoscopy ( P = 0.15). In contrast, the overall specificity of RCM was 0.76 (95% CI, 0.67-0.85), while the overall specificity of dermoscopy was 0.47 (95% CI, 0.31-0.63). The results indicated that RCM appears to have a higher specificity in comparison to dermoscopy ( P < 0.01). Our meta-analysis indicates that RCM demonstrates superior specificity and similar sensitivity to dermoscopy in detecting cutaneous melanoma patients. The high heterogeneity, however, may impact the evidence of the current study, further larger sample prospective research is required to confirm these findings.
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Affiliation(s)
- Huasheng Liu
- Departments of Burn Plastic and Cosmetic Surgery
| | - Hong Jiang
- Departments of Burn Plastic and Cosmetic Surgery
| | - Qianqian Shan
- Gynecology and Obstetric, Liaocheng People's Hospital, Liaocheng, China
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Huisman BW, Pagan L, Ulrich M, Rissmann R, Damman J, Piek JMJ, Niemeyer-van der Kolk T, van Poelgeest MIE. Reflectance confocal microscopy as a non-invasive imaging tool in vulvar high-grade squamous intraepithelial lesions and lichen sclerosus: A descriptive morphological study in patients and healthy volunteers. Exp Dermatol 2023; 32:1734-1743. [PMID: 37486173 DOI: 10.1111/exd.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023]
Abstract
Incorrect and delayed diagnosis of vulvar high-grade squamous intraepithelial neoplasia (vHSIL) and lichen sclerosus (LS) increases malignant progression risks and negatively impacts prognosis and quality of life. There is a need to improve diagnosis and monitoring. Reflectance confocal microscopy is a non-invasive imaging tool that visualizes skin structures at cellular resolution. The objectives were to explore feasibility and patient acceptability of vulvar RCM imaging and to identify RCM characteristics that are discriminative for vulvar HSIL and LS. This was a prospective, cross-sectional, observational clinical trial in patients with vHSIL and LS compared to healthy volunteers. RCM images and vulvar tissue samples were obtained. Five (5) patients with vHSIL, 10 patients with LS and 10 healthy volunteers were enrolled. In total, 100 image series of vulvar skin were obtained, including lesional and nonlesional sites. The RCM technique was considered acceptable for application by patients and healthy controls. Healthy vulvar skin was characterized by a homogenous, normal honeycomb patterned epidermis and a clear epidermal-dermal junctions. Vulvar HSIL and LS displayed an atypical honeycomb pattern of the epidermis and lymphocytic influx with presence of melanophages. Distinct features specifically observed in LS included the presence of hyalinised vessels and sclerotic areas in the dermis. RCM is a non-invasive imaging technique that is feasible and clinically acceptable to apply on vulvar skin, both in patients with premalignant lesions and healthy controls. Recognition and validation of disease-specific characteristics could make reflectance confocal microscopy a clinical tool to non-invasively aid identification of vulvar premalignancies.
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Affiliation(s)
- Bertine W Huisman
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisa Pagan
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Ulrich
- CMB Collegium Medicum Berlin GmbH/Dermatology Office, Berlin, Germany
| | - Robert Rissmann
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Jeffrey Damman
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jurgen M J Piek
- Department of Obstetrics and Gynaecology and Catharina Cancer Institute, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | - Mariette I E van Poelgeest
- Centre for Human Drug Research, Leiden, The Netherlands
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Molecular Features of Preinvasive and Invasive Vulvar Neoplasms. J Low Genit Tract Dis 2023; 27:40-46. [PMID: 36083687 DOI: 10.1097/lgt.0000000000000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Neoplasms arising from the vulva are uncommon and comprise various subtypes. Given the recent advancements in the molecular aspects of oncologic pathology and how they have impacted cancer treatment, an understanding of recent innovations in the molecular features of vulvar lesions is important. MATERIALS AND METHODS Systematic literature search was performed on PubMed, Google Scholar, and Scopus databases for molecular and genetic characteristics of vulvar neoplasms. Peer-reviewed literature published in English is included. RESULTS Squamous cell carcinoma (SCC) and its precursors are the predominant neoplasm at this site. Human papillomavirus (HPV) plays a crucial role in the pathogenesis of some of these lesions. Human papillomavirus-associated SCC follows the carcinogenic pathway driven by viral proteins E6 and E7 while HPV-independent SCC shows a high incidence of mutation of TP53 and CDKN2A genes. Mutations in the genes involving the PI3K-Akt pathway play an important role in the pathogenesis of both types of SCC. Among other vulvar malignancies, melanoma, and vulvar Paget disease (VPD) pose a significant clinical challenge and have unique molecular characteristics. Compared with dermal cutaneous melanoma, vulvar melanoma shows a higher rate of mutation of cKIT and NRAS genes and a lower rate of mutations in BRAF . Less than 20% of VPD shows amplification of ERBB2 and seldom shows mutation in genes involving the PI3K-Akt pathway. CONCLUSIONS Several potentially targetable molecular pathways have emerged as they have been shown to be involved in the tumorigenesis of SCC, melanoma, and VPD.
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Wohlmuth C, Wohlmuth-Wieser I. Vulvar Melanoma: Molecular Characteristics, Diagnosis, Surgical Management, and Medical Treatment. Am J Clin Dermatol 2021; 22:639-651. [PMID: 34125416 PMCID: PMC8421300 DOI: 10.1007/s40257-021-00614-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 12/13/2022]
Abstract
Ten percent of all women have pigmented vulvar lesions. Fortunately, most of these are benign but 1% of all melanomas in women affect the vulva. While the mortality rate of cutaneous melanoma has dropped by 7% annually during the last 5 years, the prognosis of vulvar melanoma remains dismal: the 5-year overall survival rate is 47% compared with 92% for cutaneous melanoma. The current evidence suggests that this likely results from a combination of delayed diagnosis and different tumor biology, treatment strategies, and treatment response. Although many landmark trials on checkpoint inhibitors included mucosal and vulvar melanomas, the results were often not reported separately. Post-hoc analyses indicate overall response rates between 19 and 37% for checkpoint inhibitors. A recently published retrospective study on vulvar melanomas suggests an objective response in 33.3% with a similar safety profile to cutaneous melanoma. Tyrosine kinase inhibitors may be considered in recurrent disease if a c-KIT mutation is present.
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Affiliation(s)
- Christoph Wohlmuth
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Iris Wohlmuth-Wieser
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Navarrete-Dechent C, Cordova M, Sahu A, Liopyris K, Rishpon A, Chen C, Rajadhyaksha M, Busam KJ, Marghoob AA, Chen CSJ. Optical imaging guided- 'precision' biopsy of skin tumors: a novel approach for targeted sampling and histopathologic correlation. Arch Dermatol Res 2021; 313:517-529. [PMID: 32844312 PMCID: PMC10185006 DOI: 10.1007/s00403-020-02126-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/02/2020] [Accepted: 08/08/2020] [Indexed: 01/25/2023]
Abstract
Dermoscopy and reflectance confocal microscopy (RCM) are two noninvasive, optical imaging tools used to facilitate clinical diagnosis. A biopsy technique that produces exact correlation with optical imaging features is not previously reported. To evaluate the applications of a novel feature-focused 'precision biopsy' technique that correlates clinical-dermoscopy-RCM findings with histopathology. This was a prospective case-series performed during August 2017 and June 2019 at a tertiary care cancer. We included consecutive patients requiring a precise dermoscopy-RCM-histopathologic correlation. We performed prebiopsy dermoscopy and both wide probe and handheld RCM of suspicious lesions. Features of interest were isolated with the aid of paper rings and a 2 mm punch biopsy was performed in the dermoscopy- or RCM-highlighted area. Tissue was processed either en face or with vertical sections. One-to-one correlation with histopathology was obtained. Twenty-three patients with 24 lesions were included in the study. The mean age was 64.6 years (range 22-91 years); there were 16 (69.6%) males, 14 (58.3%) lesions biopsied were on head and neck region. We achieved tissue-conservation diagnosis in 100% (24/24), 13 (54.2%) were clinically equivocal lesions, six (25%) were selected for 'feature correlation' of structures on dermoscopy or RCM, and five (20.8%) for 'correlation of new/unknown' RCM features seen on follow-up. The precision biopsy technique described herein is a novel method that facilitates direct histopathological correlation of dermoscopy and RCM features. With the aids of optical imaging devices, accurate diagnosis may be achieved by minimally invasive tissue extraction.
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Affiliation(s)
- Cristian Navarrete-Dechent
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
- Department of Dermatology, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Miguel Cordova
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Aditi Sahu
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Konstantinos Liopyris
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Ayelet Rishpon
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Curtis Chen
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Milind Rajadhyaksha
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashfaq A Marghoob
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA
| | - Chih-Shan Jason Chen
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 800 Veterans Memorial Highway, 2nd floor Hauppauge, New York, NY, 11788, USA.
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De Pascalis A, Perrot JL, Tognetti L, Rubegni P, Cinotti E. Review of Dermoscopy and Reflectance Confocal Microscopy Features of the Mucosal Melanoma. Diagnostics (Basel) 2021; 11:diagnostics11010091. [PMID: 33429900 PMCID: PMC7827612 DOI: 10.3390/diagnostics11010091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/22/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023] Open
Abstract
Mucosal melanoma is a rare tumor with aggressive biological behavior and poor prognosis. Diagnosis is often performed at an advanced stage when the lesions become symptomatic. Although dermoscopy and reflectance confocal microscopy (RCM) are widely used techniques for the diagnosis of cutaneous tumors, their use for mucosal lesions is not well established, probably because the latter are rarer. The objective of this study was to evaluate current literature on these imaging techniques for mucosal melanoma. We searched in PubMed and Cochrane databases all studies up to October 2020 dealing with dermoscopy, RCM, and mucosal melanoma. We found that the most relevant dermoscopic features were structureless pattern and/or the presence of multiple colors. RCM examination mainly showed numerous basal hyper-reflective dendritic cells and loss of normal architecture of the papillae of the lamina propria. Although diagnostic algorithms have been proposed for both techniques, the limit of these methods is the absence of large studies and of standardized and shared diagnostic criteria.
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Affiliation(s)
- Andrea De Pascalis
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, 53100 Siena, Italy; (L.T.); (P.R.); (E.C.)
- Correspondence: ; Tel.: +39-0577-585428; Fax: +39-0577-585484
| | - Jean Luc Perrot
- Department of Dermatology, University Hospital of Saint-Etienne, 42000 Saint-Etienne, France;
| | - Linda Tognetti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, 53100 Siena, Italy; (L.T.); (P.R.); (E.C.)
| | - Pietro Rubegni
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, 53100 Siena, Italy; (L.T.); (P.R.); (E.C.)
| | - Elisa Cinotti
- Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, S. Maria alle Scotte Hospital, 53100 Siena, Italy; (L.T.); (P.R.); (E.C.)
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Lopez S, Guerrisi R, Brusadelli C, Bogani G, Ditto A, Raspagliesi F. The role of sentinel lymph node mapping in lower genital tract melanoma. ACTA ACUST UNITED AC 2020; 72:384-390. [PMID: 32744452 DOI: 10.23736/s0026-4784.20.04628-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Vulvar and vaginal melanomas are rare cancers of the female genital tract and account for 1% to 3% of all melanomas diagnosed in women. Due to the rarity of the disease, few data are available on the clinical and pathologic features of these cancers. Furthermore, treatment options are generally based on extrapolations of the information available for the more common cutaneous counterparts. Surgery represents the mainstay of treatment for lower genital tract melanoma. Moreover, the role of sentinel lymph node (SLN) assessment is controversial because no prospective data are available. EVIDENCE ACQUISITION Data were collected from Medline, Embase, Web of Sciences and Scopus databases. On July 10, 2020, we used the search comprising the terms "vulvar melanoma," "genital melanoma" and "vulvovaginal melanoma" including only studies in which SLN biopsy was performed. EVIDENCE SYNTHESIS Ten retrospective studies have been found. No randomized trials have been reported. The studies included 132 patients while only 63 (47%) undergone SLN. 99mTC with or without blue dye followed by ultrastaging was highly accurate and is currently the gold standard. Mean detection rate was 98.3%. No clear evidence supported the execution of back lymphadenectomy (after SLN mapping), in fact, extrapolating data from cutaneous melanomas of other sites, completion of lymphadenectomy does not confer a melanoma-specific survival advantage. CONCLUSIONS Although the small amount of available data, sentinel lymph node procedure is feasible and capable of identifying patients who have occult lymph node metastases. However, the potential role of the sentinel lymph node procedure as an alternative method of lymph node staging in patients with vulvar or vaginal melanoma needs further investigation.
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Affiliation(s)
- Salvatore Lopez
- Unit of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy - .,Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy -
| | - Rocco Guerrisi
- Unit of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy
| | - Claudia Brusadelli
- Unit of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy
| | - Giorgio Bogani
- Unit of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy
| | - Antonino Ditto
- Unit of Gynecological Oncology, National Cancer Institute of Milan, Milan, Italy
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Lacarrubba F, Borghi A, Verzì AE, Corazza M, Stinco G, Micali G. Dermoscopy of genital diseases: a review. J Eur Acad Dermatol Venereol 2020; 34:2198-2207. [PMID: 32531092 DOI: 10.1111/jdv.16723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/20/2020] [Indexed: 12/15/2022]
Abstract
The male and female external genital regions are anatomical areas in which various types of skin disorders may occur. Although most of these conditions can be diagnosed by means of clinical examination and an accurate medical history, in most cases further investigations with time-consuming and/or invasive procedures are needed in order to reach the correct diagnosis. Dermoscopy, as a modern non-invasive tool, is able to better diagnose pigmented and non-pigmented skin tumours along with various inflammatory and infectious skin and appendage disorders. The aim of this paper was to provide a review of the use of dermoscopy in genital disorders based on published data and to include personal experience gained from real life, focusing on any possible gender difference and whether disease mucosal/semimucosal dermoscopy features may differ from those observed on the skin. In conclusion, genital dermoscopy should always be considered during clinical inspection in order to enhance the diagnosis or to rule out those conditions that may look similar but that show a different dermoscopy pattern, thus narrowing down the differential diagnoses and avoiding unnecessary invasive investigations.
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Affiliation(s)
- F Lacarrubba
- Dermatology Clinic, University of Catania, Catania, Italy
| | - A Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - A E Verzì
- Dermatology Clinic, University of Catania, Catania, Italy
| | - M Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - G Stinco
- Department of Experimental and Clinical Medicine, Institute of Dermatology, University of Udine, Udine, Italy
| | - G Micali
- Dermatology Clinic, University of Catania, Catania, Italy
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Vaccari S, Barisani A, Salvini C, Pirola S, Preti EP, Pennacchioli E, Iacobone AD, Patrizi A, Tosti G. Thin vulvar melanoma: a challenging diagnosis. Dermoscopic features of a case series. Clin Exp Dermatol 2020; 45:187-193. [PMID: 31389062 DOI: 10.1111/ced.14068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vulvar melanoma (VM) is rare and is often diagnosed late. Dermoscopy may aid in its recognition, differentiating VM from other more common vulvar lesions, such as melanosis and naevi. However, little is known about the dermoscopic features of thin VM. AIM To retrospectively analyse a series of histopathologically diagnosed thin VMs and to highlight their most suggestive dermoscopic features. METHODS A multicentre, retrospective study was conducted, including histopathologically proven thin VMs, either intraepidermal or with Breslow thickness ≤ 0.5 mm, diagnosed during the period 2016-2018. We particularly focused on their dermoscopic characteristics to highlight the most suggestive dermoscopic diagnostic clues. RESULTS In total, 14 cases of early-stage VM were included, in women with a mean age at diagnosis of 64.86 years. The most frequently affected sites were the labia minora. Of these, 11 cases were unifocal. Dermoscopy most often revealed structureless areas, grey globules and areas, irregular black-brown dots, blue and white structures, and red areas. CONCLUSIONS In our experience, early-stage VM often exhibits dermoscopic features that are more typical of thicker cutaneous melanomas. Dermoscopy may provide useful clues for the prompt diagnosis of thin VM.
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Affiliation(s)
- S Vaccari
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - A Barisani
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - C Salvini
- Unit of Dermatology, USL Toscana Centro-Prato Hospital, Prato, Italy
| | - S Pirola
- Pathology Division, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - E P Preti
- Unit of Preventive Gynecology, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - E Pennacchioli
- Melanoma Division, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - A D Iacobone
- Unit of Preventive Gynecology, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - A Patrizi
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - G Tosti
- Melanoma Division, IRCCS Istituto Europeo di Oncologia, Milan, Italy
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