Case Report: "Incognito" proteus syndrome

Proteus syndrome (PS) is a postnatal mosaic overgrowth disorder, progressive and disfiguring. It is clinically diagnosed according to the criteria reported by Biesecker et al.

We describe the case of a 49-year-old woman who presented with a 10-year history of pauci-symptomatic infiltrating plaque lesions on the sole and lateral margin of the left foot, which had been diagnosed as a keloid. The patient had a positive history for advanced melanoma and a series of subtle clinical signs, such as asymmetric face, scoliosis, multiple lipomas on the trunk, linear verrucous epidermal nevi, and hyperpigmented macules with a mosaic distribution. Even if the clinical presentation was elusive, she had enough criteria to be diagnosed with PS.

This case describes the first evidence, to the best of our knowledge, of pauci-symptomatic PS in adulthood, reports its rare association with advanced melanoma, and illustrates the importance of even minor cutaneous clinical signs, especially when atypical, in formulating the diagnosis of a complex cutaneous condition such as this.

Vascular Patterns in Cutaneous Ulcerated Basal Cell Carcinoma: A Retrospective Blinded Study Including Dermoscopy

The aim of this retrospective study was to determine the type and prevalence of vascular patterns in the ulcerated and non-ulcerated portions of histologically proven basal cell carcinomas (BCCs) and correlate them with other dermoscopic and clinical features, including the clinically supposed diagnosis. Three authors retrospectively collected 156 clinical and 156 dermoscopic digital images of ulcerated BCCs (histologically confirmed); each image was blindly evaluated by 2 other authors, who did not know the histological diagnosis. Seventeen lesions were completely ulcerated, while 139 lesions presented ulcerated and non-ulcerated portions. Correct clinical diagnosis was associated with the type of lesion, in particular 90.6% of partially ulcerated lesions were correctly diagnosed with clinical-dermoscopic examination, compared with 11.8% of totally ulcerated lesions (χ2 = 64.00, p = 0.000). Presence of arborizing pattern in the ulcerated portion was associated with a correct diagnosis (Fisher's exact test, p = 0.015). Correct diagnosis was also associated with absence of dotted pattern in the non-ulcerated area (χ2 = 16.18, p = 0.000); the absence of hairpin (χ2 = 6.08, p = 0.000) and glomerular patterns were associated with correct diagnosis in the ulcerated areas (χ2 = 18.64, p = 0.000). In case of completely ulcerated BCC the clinician lacks the means to correctly identify the correct nature of the lesion, and is driven towards an incorrect diagnostic conclusion.

Accuracy in melanoma detection: a 10-year multicenter survey

BACKGROUND

Early excision is the only strategy to reduce melanoma mortality, but unnecessary excision of benign lesions increases morbidity and healthcare costs.

OBJECTIVE

To assess accuracy in melanoma detection based on number-needed-to-excise (NNE) values over a 10-year period.

METHODS

Information was retrieved on all histopathologically confirmed cutaneous melanomas or melanocytic nevi that were excised between 1998 and 2007 at participating clinics. NNE values were calculated by dividing the total number of excised lesions by the number of melanomas. Analyses included changes in NNE over time, differences in NNE between specialized clinical settings (SCS) versus non-specialized clinical settings (NSCS), and patient factors influencing NNE.

RESULTS

The participating clinics contributed a total of 300,215 cases, including 17,172 melanomas and 283,043 melanocytic nevi. The overall NNE values achieved in SCS and NSCS in the 10-year period were 8.7 and 29.4, respectively. The NNE improved over time in SCS (from 12.8 to 6.8), but appeared unchanged in NSCS. Most of the effect on NNE in SCS was due to a greater number of excised melanomas. Higher NNE values were observed in patients younger than 40 years and for lesions located on the trunk.

LIMITATIONS

No data concerning the use of dermatoscopy and digital monitoring procedures were collected from the participating centers.

CONCLUSION

Over the 10-year study period, accuracy in melanoma detection improved only in specialized clinics maybe because of a larger use of new diagnostic techniques such as dermatoscopy.

Analytical and dimensional morphometry in early diagnosis cutaneous melanoma with dermoscopic images

OBJECTIVE

To give to the clinician an objective numerical assessment tool to evaluate melanomas so that a diagnosis can be reached with the assistance of computerized procedures.

STUDY DESIGN

The approach adopted for differential diagnosis of melanomas and nevi considers diverse morphologic characteristics intrinsic to the lesions, that is, shape, size, and symmetry in total independence of pigmentation, and proposes that this information can be evaluated quantitatively and separately by morphometric procedures with statistically valid independent numeric variables that guarantee objectivity and, from a method point of view, consistency.

RESULTS

The results show that the differential diagnosis on malignant and benign lesions is made on five variables, which all describe the fine irregularities of the contour and have a high significance in comparing melanomas to nevi.

CONCLUSION

The multivariate discriminant analysis demonstrates the ability of the analytic variables to discriminate 88% of the lesions, rising to 90% if two-dimensional variables are included.

Methyl-aminolevulinate photodynamic therapy for the treatment of actinic keratoses and non-melanoma skin cancers: a retrospective analysis of response in 462 patients

AIM

Topical photodynamic therapy (PDT) with methyl-aminolevulinate (MAL) is widely used for the management of actinic keratoses (AK) and non-melanoma skin cancers (NMSCs). The authors report the results of a retrospective chart review showing the cumulative four-year experience with MAL-PDT in a hospital outpatient setting.

METHODS

The medical records selected concerned all patients who completed the MAL-PDT regimen (one single session for AK and two sessions one week apart for NMSCs) and who underwent post-treatment assessments over a follow-up period of at least 12 months.

RESULTS

Present case series included a total of 462 patients: 210 patients with AK, 228 subjects with 348 basal cell carcinomas (BCCs), 213 of nodular type (nBCC) and 135 of superficial type (sBCC), 17 patients with Bowen's disease and seven with squamous cell carcinoma. On the whole, following a single session, complete clearance of AK was achieved in 79% of patients at three months and in 68.1% at 12 months. As concerns BCCs, regardless of the clinical type, a complete response was observed in 71% of lesions at three months, with a rate of recurrence at 12 months of 15%. The risk of both initial treatment failure and recurrence was higher for nBCCs than sBCCs. Our results, even if obtained in very few cases, indicate that Bowen's disease is very responsive to MAL-PDT, unlike microinvasive or invasive SCC. Treatment was generally well tolerated.

CONCLUSIONS

Our experience confirms that MAL-PDT is a valid approach to patients with AK, BCC and Bowen's disease, with an acceptable tolerability profile and a very low risk of complications.

VEGF concentration from plasma-activated platelets rich correlates with microvascular density and grading in canine mast cell tumour spontaneous model

Canine cutaneous mast cell tumour (CMCT) is a common cutaneous tumour in dog, with a higher incidence than in human. CMCT is classified in three subgroups, well and intermediately differentiated (G1 and G2), corresponding to a benign disease, and poorly differentiated (G3), corresponding to a malignant disease, which metastasize to lymph nodes, liver, spleen and bone marrow. In this study, we have evaluated serum (S), platelet-poor plasma (P-PP), plasma-activated platelet rich (P-APR) and cytosol vascular endothelial growth factor (VEGF) concentrations, microvascular density (MVD) and mast cell density (MCD) in a series of 86 CMCTs and we have correlated these parameters with each other, by means of ELISA detection of VEGF and immunohistochemistry. Results show that VEGF level from cytosol P-APR and MVD were significantly higher in G3 CMCTs as compared to G1 or G2 subgroups. Moreover, a significantly strong correlation among VEGF levels from P-PAR and cytosol, MVD and MCD was found in G3 subgroup. Because VEGF levels from P-APR well correlated with MVD and malignancy grade in CMCT, we suggest that VEGF might be secreted from MCs and it may be a suitable surrogate inter-species angiogenetic markers of tumour progression in CMCT. Finally, CMCT seems to be a useful model to study the role of MCs in tumour angiogenesis and inhibition of MCs degranulation or activation might be a new anti-angiogenic strategy worthy to further investigations.

Dermoscopic Features of Cutaneous Lymphangioma Circumscriptum

BACKGROUND

Cutaneous lymphangioma circumscriptum (CLC) is clinically characterized by clusters of translucent vesicles that may be filled by blood.

OBJECTIVE

To evaluate the dermoscopic features of CLC.

MATERIALS AND METHODS

Dermoscopic examination was performed in two cases presenting with discrete translucent and blood-tinged lesions.

RESULTS

Lesions filled with clear fluid were dermoscopically characterized by light brown lacunas surrounded by paler septa. Lesions tinged with blood were associated with different dermoscopic features depending on the amount of blood content: focal reddish areas inside the lagoons, pink diffuse coloration, reddish to violaceous lacunar structures.

CONCLUSIONS

On dermoscopy, CLC was characterized by a lacunar pattern. Lesions with a marked hematic content show dermoscopic findings indistinguishable from those of hemangioma.

Melanocytic nevus with atypical dermoscopic features at the site of radiodermatitis

BACKGROUND

Radiation therapy can cause acute and chronic damage of the skin.

OBJECTIVE

A 71-year-old woman presented with an atrophic and sclerotic plaque at a site previously treated with radiotherapy because of lung cancer. Inside the area affected by chronic radiodermatitis, she reported that a preexisting pigmentary lesion had gradually undergone morphologic changes after radiation therapy.

MATERIALS AND METHODS

On dermoscopy, the lesion showed features highly suspicious for malignant melanoma. The lesion was excised and examined histopathologically.

RESULTS

The histopathologic diagnosis was compound congenital melanocytic nevus associated with prominent dermal sclerosis and epidermal atrophy.

CONCLUSIONS

The existence of melanocytes within an atrophic and fibrotic area is a finding typically associated with recurrent or persistent melanocytic lesions. It is likely that the "pseudomelanoma" features of the lesion observed in our patient might have been secondary to the skin changes induced by radiation therapy.

Dermoscopic patterns of dermatofibroma

BACKGROUND

Clinical and dermoscopic aspects of dermatofibroma (DF) are usually typical. Systematic analysis of dermoscopic features of DFs has rarely been performed.

OBJECTIVE

To evaluate the dermoscopic patterns of DFs and, in selected cases, the change of these patterns over time.

METHODS

Dermoscopic examination was performed in 39 DFs belonging to 32 patients. In each case, the diagnosis was confirmed histopathologically.

RESULTS

We identified the following three dermoscopic patterns: isolated presence of the pigment network in 31% of cases; a peripheral pigment network associated with either globules and dots or with scale crusts, and sometimes also with a more or less evident white patch, in the central area in 13% of cases; and a peripheral pigment network with a central white area in 56% of cases.

CONCLUSION

The dermoscopic patterns observed in our case series may correspond to distinct sequential stages of formation, suggesting clues to understanding the pathogenesis of DF.

Unusual clinical presentation of regression in a congenital melanocytic nevus

BACKGROUND

Regression of congenital melanocytic nevi is usually accompanied by the halo phenomenon and is considered a rare event.

OBJECTIVE

A 15-year-old woman presented for the evaluation of multiple halo nevi. She had on her trunk a figure-of-eight pigmentary lesion, which had been developed after the coalescence of two distinct congenital melanocytic nevi. Close to the indentation between the two portions of the lesion, there was an achromic rounded area, extending from the perinevic skin to the nevus, causing its partial regression.

METHODS AND MATERIALS

Dermoscopic examination disclosed a globular and homogeneous pattern, which was irregularly present at the edge of the achromic area. The histopathologic diagnosis was compound congenital melanocytic nevus with an eccentric area of regression.

CONCLUSIONS

In our case, the presence of a regression area in the surrounding skin and the association with multiple halo nevi suggest a similarity with halo phenomenon, despite the atypical "halo," which was discontinuous and eccentric.