Atlas of Dermatoscopy Cases: Challenging and Complex Clinical Scenarios [1st ed.] 9783030436711, 9783030436728

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Horacio Cabo Aimilios Lallas Editors

Atlas of Dermatoscopy Cases Challenging and Complex Clinical Scenarios

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Atlas of Dermatoscopy Cases

Horacio Cabo  •  Aimilios Lallas Editors

Atlas of Dermatoscopy Cases Challenging and Complex Clinical Scenarios

Editors Horacio Cabo Dermatology University of Buenos Aires Buenos Aires Argentina

Aimilios Lallas First Department of Dermatology Aristotle University of Thessaloniki Thessaloniki Greece

ISBN 978-3-030-43671-1    ISBN 978-3-030-43672-8 (eBook) https://doi.org/10.1007/978-3-030-43672-8 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Dermatoscopy: A Silent Revolution in Medicine The triumphant march of dermatoscopy––from the little toy device of a rising generation of young, enthusiastic dermatoscopists in the 1980s to an accepted, evidence-based, integral part of any dermatological visit today––was silent, and it is still underway. Since there is no comparable imaging device that is as fast, reliable, lightweight, transportable, communicative, surprising, and applicable to every millimeter of skin, dermatoscopy remains a favorite. Each of us has our own reasons why we use and love dermatoscopy, and each of us knows that once we started using it, we would no longer trust our unaided eyes. Dermatoscopy, for me, is a true silent revolution in medicine for three reasons: First, it offers insights into a morphological dimension of the skin that always existed but for so long remained invisible to our unaided eyes. As Goethe said “The eyes only see what the mind knows”—it is true. Second, it made us better doctors. By looking though this lens, we can solve our patients’ problems quickly without needing further investigation. Third, in combination with our teachers’ charismatic examples, dermatoscopy sparked our enthusiasm for our daily work. The book in your hands is edited by two long-standing enthusiastic teachers and friends who I admire for their personality, professionality, and generous spirit. Reading this book, you will share their joy of diving into this always new dermatoscopic morphologic dimension. Iris Zalaudek Department of Dermatology University of Trieste, Trieste, Italy

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Preface

In 2018, we published the Comprehensive Atlas of Dermatoscopy Cases with Springer International Publishing AG. Following the success of that book, we were summoned again by Springer to produce this volume, Atlas of Dermatoscopy Cases: Challenging and Complex Clinical Scenarios. This book is also a collection of exemplary cases with high didactic value, highlighting how dermatoscopy improves our everyday work as clinicians. Similar to the previous book, the chapters are in a format that is easy to read, each case consisting of a short description of the clinical history, with the macroscopic and dermatoscopic images presented in a way that allows readers to exercise their diagnostic capacity. Immediately afterward, the dermatoscopic image is analyzed, and the most important clues leading to the correct diagnosis are highlighted, aiming to help readers improve their diagnostic skills. Finally, a few key points on the topic are discussed. Here again, the cases have been ordered not by diagnosis but according to clinical presentation and anatomic site, aiming to approximate as best as possible the real clinical scenario. We deeply thank all our friends and colleagues who contributed with their great cases, allowing us to create this beautiful collection. We also thank Springer for all their help and trust in us. We hope that you will find the book useful and that you will enjoy reading it. Buenos Aires, Argentina Thessaloniki, Greece 

Horacio Cabo Aimilios Lallas

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Contents

1 Ten Basic Rules: How Not to Miss a Melanoma������������������������������������������������������   1 Aimilios Lallas and Horacio Cabo 2 Flat Pigmented Lesions on the Scalp�������������������������������������������������������������������������   7 Horacio Cabo and Emilia N. Cohen Sabban 3 Palpable Pigmented Lesions on the Scalp�����������������������������������������������������������������   9 Flávia Vasques Bittencourt, Andzelka Ilieva, and Aimilios Lallas 4 Nodular Pigmented Lesions on the Scalp�����������������������������������������������������������������  11 Grazyna Kaminska-Winciorek, Pille Konno, and Aimilios Lallas 5 Flat Non-pigmented Lesions on the Scalp ���������������������������������������������������������������  15 Horacio Cabo and Emilia N. Cohen Sabban 6 Palpable Non-pigmented Lesions on the Scalp �������������������������������������������������������  17 Verce Todorovska and Aimilios Lallas 7 Nodular Non-pigmented Lesions on the Scalp���������������������������������������������������������  19 Rosario Peralta, Guisella Martínez, and Aimilios Lallas 8 Flat Pigmented Lesions on the Face �������������������������������������������������������������������������  23 Lídice Dufrechou Varela, Renato Marchiori Bakos, Cristian Navarrete-­Dechent, Pablo Uribe, Ashfaq A. Marghoob, Montserrat Arceu, and Aimilios Lallas 9 Palpable Pigmented Lesions on the Face �����������������������������������������������������������������  29 Emilia N. Cohen Sabban and Horacio Cabo 10 Nodular Pigmented Lesions on the Face�������������������������������������������������������������������  31 Raimonds Karls, Emilia N. Cohen Sabban, and Horacio Cabo 11 Flat Non-pigmented Lesions on the Face�����������������������������������������������������������������  35 Danica Tiodorovic, Enzo Errichetti, and Aimilios Lallas 12 Palpable Non-pigmented Lesions on the Face���������������������������������������������������������  39 Elizabeth Lazaridou, Mónica Ramos Álvarez, Sonia Rodriguez Saa, and Horacio Cabo 13 Nodular Non-pigmented Lesions on the Face����������������������������������������������������������  43 Ahmed Sadek, André Oliveira, Gabriel Salerni, María Belén Marín, Rodrigo Schwartz, and Horacio Cabo 14 Flat Pigmented Lesions on the Trunk�����������������������������������������������������������������������  53 Juan Sebastián Andreani Figueroa, Zoe Apalla, Sofía Nicoletti Russi, Renato Marchiori Bakos, Xavier Bosch-Amate, Cristina Carrera, Bohdan Lytvynenko, and Aimilios Lallas

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15 Palpable Pigmented Lesions on the Trunk���������������������������������������������������������������  61 Elizabeth Lazaridou, Emilia N. Cohen Sabban, Virginia Mariana González, Sergio Hirata, Pedro Diego Zaballos, and Horacio Cabo 16 Nodular Pigmented Lesions on the Trunk ���������������������������������������������������������������  77 Emilia N. Cohen Sabban, Horacio Cabo, Verce Todorovska, and Aimilios Lallas 17 Flat Non-pigmented Lesions on the Trunk���������������������������������������������������������������  83 Emilia N. Cohen Sabban and Horacio Cabo 18 Palpable Non-pigmented Lesions on the Trunk�������������������������������������������������������  85 Dimitrios Sgouros, Polytimi Sidiropoulou, Enzo Errichetti, Anna Elisa Verzì, Francesco Lacarrubba, Giuseppe Micali, Sonia Rodriguez Saa, Pedro Diego Zaballos, and Aimilios Lallas 19 Nodular Non-pigmented Lesions on the Trunk�������������������������������������������������������  91 Elizabeth Lazaridou, Pablo Uribe, Cristián Navarrete-­Dechent, Emilia N. Cohen Sabban, and Horacio Cabo 20 Flat Pigmented Lesions on the Upper Limb�������������������������������������������������������������  97 Bengu Nisa Akay, María Belén Marín, and Horacio Cabo 21 Palpable Pigmented Lesions on the Upper Limb����������������������������������������������������� 101 Ruzica Jurakic Toncic, Flávia Vasques Bittencourt, and Horacio Cabo 22 Nodular Pigmented Lesions on the Upper Limb����������������������������������������������������� 105 Zsuzsanna Lengyel and Horacio Cabo 23 Flat Non-pigmented Lesions on the Upper Limb���������������������������������������������������� 109 Cristián Navarrete-Dechent, Pablo Uribe, Xavier Bosch-­Amate, Cristina Carrera, Bohdan Lytvynenko, and Aimilios Lallas 24 Palpable Non-pigmented Lesions on the Upper Limb��������������������������������������������� 115 André Oliveira, Marija Buljan, Rosario Peralta, and Horacio Cabo 25 Nodular Non-pigmented Lesions on the Upper Limb��������������������������������������������� 119 Emilia N. Cohen Sabban and Horacio Cabo 26 Flat Pigmented Lesions on the Lower Limb������������������������������������������������������������� 121 Francesco Lacarrubba, Anna Elisa Verzì, Giuseppe Micali, Gabriel Salerni, Sergio Hirata, Pille Konno, and Aimilios Lallas 27 Palpable Pigmented Lesions on the Lower Limb����������������������������������������������������� 129 Juan Sebastián Andreani Figueroa, Dimitrios Sgouros, Polytimi Sidiropoulou, Ruzica Jurakic Toncic, Vincenzo Piccolo, Pablo Uribe, Sergio González, Cristián Navarrete-Dechent, Raimonds Karls, Pille Konno, and Aimilios Lallas 28 Nodular Pigmented Lesions on the Lower Limb����������������������������������������������������� 141 Bengu Nisa Akay, Pille Konno, and Aimilios Lallas 29 Flat Non-pigmented Lesions on the Lower Limb ��������������������������������������������������� 145 Cristian Navarrete-Dechent, Michael A. Marchetti, and Horacio Cabo 30 Palpable Non-pigmented Lesions on the Lower Limb ������������������������������������������� 149 Marija Buljan, Cristian Navarrete-Dechent, Ashfaq A. Marghoob, Juan Sebastián Andreani Figueroa, and Horacio Cabo 31 Nodular Non-pigmented Lesions on the Lower Limb��������������������������������������������� 155 Zsuzsanna Lengyel, Mónica Ramos Álvarez, Zoe Apalla, and Aimilios Lallas

Contents

Contents

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32 Acral Lesions��������������������������������������������������������������������������������������������������������������� 161 Yaei Togawa, Sofía Nicoletti Russi, Vincenzo Piccolo, and Aimilios Lallas 33 Nail Lesions����������������������������������������������������������������������������������������������������������������� 167 Yaei Togawa, Rodrigo Schwartz, and Aimilios Lallas 34 Lesions in Genital Areas��������������������������������������������������������������������������������������������� 171 Alejandra Larre Borges, Danica Tiodorovic, and Aimilios Lallas 35 Hair and Scalp Disorders������������������������������������������������������������������������������������������� 177 Gisela D’Atri, Luis Enrique Sánchez Dueñas, and Horacio Cabo Index������������������������������������������������������������������������������������������������������������������������������������� 187

Contributors

Bengu Nisa Akay, MD  Department of Skin and Venereal Diseases, Ankara University Faculty of Medicine, Ankara University, Ankara, Turkey Zoe  Apalla, MD State Dermatology Department, Hippokratio General Hospital of Thessaloniki, Thessaloniki, Greece Montserrat Arceu, MD  Department of Dermatology, University of Chile, Santiago, Chile Renato Marchiori Bakos, MD, PhD  Department of Dermatology, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil Flávia Vasques Bittencourt, MD  Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil Alejandra  Larre  Borges, MD Department of Dermatology, University of the Republic, Montevideo, Uruguay Xavier  Bosch-Amate, MD Department of Dermatology, Hospital Clínic de Barcelona, Barcelona, Spain Marija  Buljan, MD Department of Dermatology and Venereology, Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia Horacio Cabo, MD  Dermatology Section, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina Cristina Carrera, MD, PhD  Dermatology Department, University of Barcelona Melanoma Unit, Hospital Clínic de Barcelona, Barcelona, Spain Emilia  N.  Cohen  Sabban, MD Dermatology Section, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina Head of Dermatology Section, School of Medicine, Universidad of Buenos Aires, Buenos Aires, Argentina Gisela D’Atri, MD  Director Grupo MCI, Buenos Aires, Argentina Pedro  Diego  Zaballos, MD Dermatology Department, Hospital Sany Pau i Santa Tecla, Tarragona, Spain Division Dermatology Department Organization, Hospital Sany Pau i Santa Tecla, Tarragona, Spain Enzo Errichetti, MD  Department of Dermatology and Venereology, Institute of Dermatology, University Hospital “Santa Maria della Misericordia”, Udine, Italy Juan Sebastián Andreani Figueroa, MD  Hospital del Salvador, Santiago, Chile Sergio González, MD  Department of Pathology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile

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Contributors

Virginia  Mariana  González, MD Dermato-oncology and Dermoscopy Section, Hospital Aleman, Buenos Aires, Argentina Sergio Hirata, MD  Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil Andzelka Ilieva, MD  Zan Mitrev Clinic, Skopje, North Macedonia Ruzica  Jurakic Toncic, MD Department of Dermatovenereology, School of Medicine University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia Grazyna  Kaminska-Winciorek, MD, PhD Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie Institute Oncology Center, Gliwice, Poland Raimonds Karls, MD  Dermatology Clinic, Latvian University, Riga, Latvia Pille Konno, MD  Department of Dermatovenereology, East-Tallinn Central Hospital, Tartu University, Tartu, Estonia Francesco Lacarrubba, MD  Dermatology Clinic, University of Catania, Catania, Italy Aimilios Lallas, MD, MSc, PhD  First Department of Dermatology, Aristotle University of Thessaloniki, Thessaloniki, Greece Elizabeth  Lazaridou, MD Department of Dermatology-Venereology, Aristotle University Medical School, Thessaloniki, Greece Zsuzsanna  Lengyel, MD, PhD  Department of Oncodermatology, University of Pécs, Pécs, Hungary

Dermatology, Venereology,

and

Bohdan Lytvynenko, MD  Department of Dermatology, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine Michael A. Marchetti, MD  Dermatology Service, Department of Medicine, Memoral Sloan Kettering Cancer Center, New York, NY, USA Ashfaq A. Marghoob, MD  Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA María Belén Marín, MD  Department of Dermatology, Medical Research Institute A. Lanari, University of Buenos Aires, Buenos Aires, Argentina Guisella Martínez, MD  Department of Dermatology, University of Chile, Santiago, Chile Giuseppe Micali, MD  Dermatology Clinic, University of Catania, Catania, Italy Cristian  Navarrete-Dechent, MD Department of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile André  Oliveira, MD Department of Dermatology, Hospital de Santa Maria, Centro Académico de Medicina, University of Lisbon, Lisbon, Portugal Rosario  Peralta, MD  Department of Dermatology, Medical Research Institute A.  Lanari, University of Buenos Aires, Buenos Aires, Argentina Vincenzo Piccolo, MD  Dermatology Unit, University of Campania, Naples, Italy Mónica Ramos Álvarez, MD  Dermika Centro Dermatológico Láser, Guadalajara, México Sonia Rodriguez Saa, MD  Department of Dermatology, School of Medicine, Universidad Nacional de Cuyo, Mendoza, Argentina Sofía Nicoletti Russi, MD  Department of Dermatology, School of Medicine, Universidad of the Republic, Montevideo, Uruguay

Contributors

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Ahmed Sadek, MD  Cairo Hospital for Dermatology and Venereology, Al-Haud Al-Marsoud, Cairo, Egypt Gabriel Salerni, MD  Department of Dermatology, School of Medicine, National University of Rosario, Rosario, Argentina Luis  Enrique  Sánchez Dueñas, MD Centro de Restauración Capilar-Dermika Centro Dermatológico Láser, Guadalajara, México Rodrigo  Schwartz, MD Department of Dermatology, School of Medicine, University of Chile, Santiago, Chile Dimitrios  Sgouros, MD Dermatologist-Venereologist, 1st Department of Dermato-­ Venereology, “Andreas Syggros” Hospital, University of Athens, Athens, Greece Polytimi  Sidiropoulou, MD 1st Department of Dermatology-Venereology, Faculty of Medicine, Cutaneous Lymphoma Clinic, “A. Sygros” Hospital for Skin and Venereal Diseases, National and Kapodistrian University of Athens, Athens, Greece Danica  Tiodorovic, MD Clinic of Dermatovernerology, Clinical Center of Nis, Medical Faculty University of Nis, Nis, Serbia Verce Todorovska, MD  Dermatology Clinic, Skopje, North Macedonia Yaei Togawa, MD, PhD  Department of Dermatology, Chiba University School of Medicine, Chiba, Japan Pablo  Uribe, MD, PhD Dermatology Department, Melanoma and Skin Cancer Unit, Pontificia Universidad Católica de Chile, Santiago, Chile Lídice Dufrechou Varela, MD  Department of Dermatology, School of Medicine, University of the Republic, Montevideo, Uruguay Anna Elisa Verzì, MD  Dermatology Clinic, University of Catania, Catania, Italy

1

Ten Basic Rules: How Not to Miss a Melanoma Aimilios Lallas and Horacio Cabo

With the addition of dermatoscopy, most melanomas and other malignant tumors are easy to recognise, but some melanomas are still missed or diagnosed late. In our experience, this problem is not so much related to an inability to recognise themin daily practice, but to misconceptions and to problems related to practical issues. To minimize the risk of missing melanoma, we propose ten simple rules that originate from errors that many clinicians (including us) have made and learned from: • Look at the skin, not at parts of the skin. • Put your dermatoscope on everything. • Clinical differential diagnosis comes first; dermatoscopy follows. • Stay with the lesion. • Trust what you see, not what they tell you. • When morphology is not enough, follow-up is not the solution. • Nodules are difficult to interpret but easy to manage. • Compare the moles of each individual. • Before deciding to monitor, think what you expect to see with time. • Interpret histopathologic reports critically.

1.1

 ook at the Skin, Not at Parts L of the Skin

In the everyday clinical practice, patients seek dermatologic consultations for a variety of reasons. Some ask for a total body mole check, but most come with a specific request. For example, they might be worried about a par-

ticular mole, or they might come for a general dermatologic problem. Undoubtedly, addressing the patient’s request is an important task in every single medical visit, but as clinicians, we should realize that a dermatologic consultation is the best opportunity for each individual to receive a total body skin check for melanoma detection. Even if the patient did not come for this reason and even if he or she never thought about it, offering a total body skin check is one of our supreme tasks. It has been speculated that approximately half of melanomas diagnosed today are detected by the patients themselves; the melanoma is the reason prompting the patient to seek the consultation. The other half, though, are detected by clinicians in patients seeking consultations for different reasons. A few years ago, a study showed that, by not performing a total body skin check Melanoma:, we might miss 1 melanoma in every 200 consultations. Figure 1.1 shows a characteristic example.

1.2

Put Your Dermatoscope on Everything

The most important benefit of dermatoscopy is the potential it has to uncover the natural asymmetry of melanoma before it becomes macroscopically visible. Melanomas that are clinically inconspicuous because they are still in an early evolution phase might dermatoscopically display criteria that allow their recognition. Therefore, dermatoscopy should be applied on all lesions, even those that look banal macroscopically. In fact, this is the category of melanomas for which dermatoscopy is a game-changer. More advanced melanomas that fulfill the ABCD criteria can be recognized even without dermatoscopy. But small and clinically symmetric melanomas, like the one shown in Fig. 1.2, will be overlooked if we do not apply dermatoscopy on them.

A. Lallas (*) First Department of Dermatology, Aristotle University of Thessaloniki, Thessaloniki, Greece H. Cabo University of Buenos Aires, Buenos Aires, Argentina © Springer Nature Switzerland AG 2020 H. Cabo, A. Lallas (eds.), Atlas of Dermatoscopy Cases, https://doi.org/10.1007/978-3-030-43672-8_1

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A. Lallas and H. Cabo

1.3

Fig. 1.1  A 70-year-old patient seeking consultation for a burning sensation on his face. The patient was completely unaware of a small melanoma developing on his back. The melanoma was discovered because he accepted the offer of a total body skin check

Fig. 1.2  A tiny melanoma measuring 3  mm in diameter. The melanoma was clinically completely inconspicuous; it was discovered only because dermatoscopy was applied on all the moles of this patient. If dermatoscopy had been applied only on clinically preselected moles, this melanoma probably would not have been examined

 linical Differential Diagnosis Comes C First; Dermatoscopy Follows

In the daily routine, the diagnostic procedure inevitably follows a series of sequential steps. The first information that becomes available is usually the age, sex, and skin type of each patient. This information already begins to form the puzzle of diagnosis, because some diagnoses become much more likely than others. Subsequently, we are confronted with the macroscopic aspect of the tumor (or the eruption), which is often highly informative. At this point, the diagnosis might already be established. If not, then a list of possible diagnoses is created, based on all the previous information (age, sex, skin type, macroscopic aspect). Dermatoscopic examination comes next, and the dermatoscopic findings should always be interpreted within the context of the previously established differential diagnosis, aiming to narrow it to only one diagnosis. If the differential diagnosis includes A, B, and C, then the question to be answered is whether the dermatoscopic findings are more compatible with A, with B, or with C.  This approach helps to correctly classify tumors that do not display clear-cut criteria, like the melanoma shown in Fig. 1.3.

Fig. 1.3  A flat, pigmented lesion developing on the tip of the nose of a 70-year-old woman. The clinical differential diagnosis includes early melanoma, pigmented actinic keratosis (PAK), and solar lentigo/seborrheic keratosis. Dermatoscopy is not highly suggestive of any diagnosis, as the features seen are not specific. The lesion is mainly structureless, with a few dark brown globules that theoretically could be seen in a nevus, but nevus is not included in the clinical differential diagnosis. Of the three tumors included in the differential diagnosis, dermatoscopy is more compatible with melanoma than with PAK or solar lentigo. This was an early Lentigo Maligna

1  Ten Basic Rules: How Not to Miss a Melanoma

1.4

Stay with the Lesion

The interpretation of dermatoscopic findings is usually very fast because it is based mainly on pattern recognition. Especially with accumulated experience, looking at the dermatoscopic aspect of a lesion for very few seconds is usually enough to automatically classify it in one of the “known” categories, without the need to analyze the local features that might be present. This is the so-called blink interpretation, which allows us to examine hundreds of lesions every day in multiple patients. For a small proportion of lesions, however, the “blink” interpretation might not work; we cannot confidently classify the tumor in one of the familiar diagnoses. In such cases, a careful analysis of the global pattern and the local features of the lesion might reveal useful information and solve the diagnostic dilemma. This analysis requires some time and a good knowledge of the dermatoscopic morphology of skin tumors. It may be performed either by pattern analysis or by using one of the semiquantitative dermatoscopic algorithms. A characteristic example is shown in Fig. 1.4.

Fig. 1.4  A heavily pigmented verrucous lesion on the back of a 75-year-old man. The clinical differential diagnosis included heavily pigmented seborrheic keratosis and melanoma. The application of dermatoscopy does not lead to an immediate diagnosis, but an analytic observation of the local features reveals the presence of brown globules at the lower part. The detection of this feature solves the diagnostic dilemma, because brown globules correspond to melanocytic nests, excluding the diagnosis of seborrheic keratosis. This was a 1.7  mm– thick melanoma

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1.5

 rust What You See, Not What They T Tell You

Although the history described by the patient is considered an integral part of any medical clinical examination, in the realm of skin tumors it often might be misleading. The patient’s perception of the evolution of a lesion is highly subjective and also may be inaccurate. Some patients tend to maximize the timeframe; others minimize it. Given that many melanomas are slow-growing, a patient may perceive that it has been on the skin for a very long period, and this information sometimes may lead a clinician to overlook a melanoma that would have been recognized otherwise. A characteristic example is shown in Fig. 1.5. Therefore, when the history is based only on description and not on objective methods such as photographs, it should not affect the morphologic assessment.

Fig. 1.5  A flat, pigmented lesion on the forearm of a 75-year-old woman. Dermatoscopy reveals a marked asymmetry, irregular black dots, and regression structures. The patient insisted that the lesion had been there for many years and had been examined repeatedly by doctors. It is possible that this information led the previous clinicians to overlook this slow-growing melanoma, which was finally excised and histopathologically diagnosed as melanoma in situ

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1.6

A. Lallas and H. Cabo

 hen Morphology Is Not Enough, W Follow-up Is Not the Solution

When examining patients, our aim as clinicians is to establish a confident diagnosis, but what we really have to do is to take multiple management decisions. Many times per day, we have to decide if a lesion should be excised, monitored, or ignored without any further action. Obviously, we decide to excise or biopsy lesions that we consider to be clinically and/or dermatoscopically suspicious. In contrast, when we are able to confidently classify the lesion as benign (angioma, seborrhea, keratosis, nevus, etc.), we usually propose no further action. But there is a subgroup of lesions that do not fit either of these two scenarios—lesions that lack evident criteria for a specific diagnosis, resulting in diagnostic uncertainty. Our inability to classify the lesion with confidence as suspicious or not is followed by uncertainty about a management recommendation. A recommendation to monitor the lesion is often considered as a solution (Fig. 1.6). Theoretically, re-examining the lesion at a later time offers additional information that is not available at baseline, revealing the evolution dynamic. Because malignant tumors usually follow a much more dynamic evolution than benign ones, this approach could be helpful

in solving the diagnostic dilemma and is generally reasonable, but monitoring of tumors has multiple limitations and is associated with significant risk. First, re-examining the lesion depends on the decision of the patient to return for a new visit, so some follow-­up visits never occur. Second, the evaluation of tumors is not black-and-white. Benign tumors that grow do exist, especially in children, and some melanomas are very slow-­growing. Third, if the tumor is finally found to be malignant, the diagnostic delay might have a negative impact on the prognosis. This risk is particularly relevant for ambiguous nodular tumors, which should never be monitored in any scenario. Finally, excising a lesion is usually a very easy task, which is free of the previous limitations, so clinicians should not consider follow-up as a solution to diagnostic uncertainty. Follow-up represents a specific strategy, which has value in managing patients with multiple atypical moles and patients at very high risk of developing melanoma, such as those with a personal melanoma history or genetic predisposition.

1.7

 odules Are Difficult to Interpret N but Easy to Manage

Histopathologic alterations at the level of the dermal-­ epidermal junction usually result in evident dermatoscopic structure. In contrast, histopathologic alterations occurring in the dermis are much less visible with the dermatoscope. Therefore, nodular lesions often appear “structureless” from a dermatoscopic point of view. This situation is particularly relevant for nodular melanoma, which represents the most biologically aggressive melanoma subtype but unfortunately is very often dermatoscopically featureless. Other aggressive malignant tumors such as Merkel cell carcinoma or poorly differentiated squamous cell carcinoma also are relatively featureless dermatoscopically. To manage this significant limitation of dermatoscopy, we should constantly and carefully apply a simple rule: Any nodular lesion that cannot be classified with confidence as a specific benign tumor should be excised as soon as possible (Fig. 1.7). Any other strategy is associated with a significant risk of misdiagnosing aggressive malignant tumors.

1.8 Fig. 1.6  A non-pigmented nodule on the abdomen of a 36-year-old woman. Clinically, the nodule is quite symmetric and could be a non-­ pigmented dermal nevus. Dermatoscopy does not exclude the hypothesis of dermal nevus, but also does not confirm it. The observed vascular pattern includes dotted and linear vessels with few ramifications. Follow-up might be considered as a management idea in order to solve the diagnostic dilemma, but it should not be used, because the lesion is nodular. The lesion was excised and was histopathologically diagnosed as a BAP1-deficient tumor

Compare the Moles of Each Individual

The morphology of any benign or malignant tumor developing on the skin depends on several intrinsic and extrinsic factors. Concerning nevi in particular, it has been suggested that most nevi developing on each individual share similar morphologic characteristics (signature nevus pattern). According to our experience, this is also true for other frequent benign tumors that develop as multiple lesions on a single individ-

1  Ten Basic Rules: How Not to Miss a Melanoma

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ual, such as angiomas and seborrheic keratoses. A similar observation has also been reported for patients developing multiple basal cell carcinomas. The concept of “signature” morphology should be always taken into consideration in clinical practice. Lesions should not be assessed as if they are solitary; instead, each lesion should be evaluated in the context in which it develops. The co-existence of morphologically similar lesions might represent a key sign and guide to the accurate assessment. A lesion deviating from the “signature” pattern of the individual should be interpreted with much more caution (Fig. 1.8).

1.9

Fig. 1.7  A non-pigmented nodule developing on the temporal area of an 80-year-old man. Clinically, the nodule is symmetric. The dermatoscopic findings are highly unspecific, so it is virtually impossible to establish a confident clinical diagnosis, but the management decision— biopsy of this doubtful nodule—should be straightforward. The histopathologic diagnosis was squamous cell carcinoma, and the tumor was managed accordingly

 efore Deciding to Monitor, Think B What You Expect to See With Time

As mentioned above, monitoring is a management strategy with specific indications and contraindications. To increase its efficacy, clinicians should carefully think about why they choose to monitor a lesion, what evolution is expected, and how they will interpret the possible changes. For instance, the detection of growth between two sequential visits is interpreted according the age of the patient. In a child, this finding is absolutely normal, whereas it is highly suspicious in an elderly individual. Therefore, monitoring a nevus in a child seems meaningless; it is expected to change. Similarly, although monitoring Spitz nevi is considered to be a reasonable approach in children, clinicians should keep in mind that Spitz nevi are highly dynamic and often change rapidly and asymmetrically, and this change usually does not have a biologic significance. Therefore, at the moment that we decide to monitor a Spitz nevus, we should think about what we will do if we detect asymmetric growth in the upcoming visit. The same concept applies every time we decide to use follow-up. For example, when deciding to perform mole mapping in a high-risk individual, we should think about how we will react if we detect a growing lesion without melanoma-­specific criteria. If the answer is that we will not assess it as suspicious, then this lesion does not need to be monitored. The correct lesion to be monitored is the one for which, at baseline, we decide that any possible morphologic change will be considered suspicious.

1.10 I nterpret Histopathologic Reports Critically

Fig. 1.8  Multiple flat, pigmented lesions on a 40-year-old man. The moles display mild dermatoscopic atypia, but the ninth lesion (lower right) deviates from the signature pattern of the remaining lesions. Therefore, this lesion should be managed with caution

Although histopathology is considered to be the gold diagnostic standard for melanocytic lesions, it is not free of limitations related to technical issues and interpretation subjectivity. Clinicians should remember that histopathologic examination is a subjective interpretation; morphologic overlap between malignant and benign skin tumors

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does exist and is not always easy to address. This difficulty is illustrated by the very low interobserver agreement among pathologists in the differential diagnosis between atypical nevi and early melanoma. Other characteristic histopathologically gray zones exist in the field of spitzoid tumors or in the field of regressive lesions. In modern med-

A. Lallas and H. Cabo

icine, the gold standard of diagnosis is the integration of clinical, dermatoscopic, histopathologic, and molecular (if available) information, interpreted always in the context of a given patient. In any case, lesions lacking a satisfactory clinicopathologic correlation must be managed with caution.

2

Flat Pigmented Lesions on the Scalp Horacio Cabo and Emilia N. Cohen Sabban

2.1 • • • • • • • • • • •

Case No. 1

Sex: Female Age: 76 years Surface (flat/palpable/nodular): Flat Maximum diameter: 13 mm Duration of the lesion: Unknown History of morphologic changes: Unknown Personal history of skin cancer (if yes, please specify): No Family history of skin cancer (if yes, please specify): No Skin phototype: III Total nevus count: (100): 10 Other clinical findings (optional): No

Fig. 2.2  Dermatoscopic image

Fig. 2.3  Dermatoscopic image: Leaf-like structures (red arrows) and spoke-wheel areas (yellow arrows) Fig. 2.1  Clinical image: flat, pigmented lesion on the scalp

Diagnosis: Pigmented superficial basal cell carcinoma H. Cabo (*) Dermatology Section, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina E. N. Cohen Sabban Dermatology Section, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina Head of Dermatology Section, School of Medicine, Universidad of Buenos Aires, Buenos Aires, Argentina

Key Message Dermatoscopic criteria of basal cell carcinoma can be divided into vascular pattern, blue-gray pigmentation structures, and non-vascular and non-pigmented structures. • Vascular pattern: Arborizing vessels and short and thin vessels

© Springer Nature Switzerland AG 2020 H. Cabo, A. Lallas (eds.), Atlas of Dermatoscopy Cases, https://doi.org/10.1007/978-3-030-43672-8_2

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• Blue-gray pigmented structures can acquire different forms of presentation. –– Blue-gray ovoid nests –– Blue-gray globules –– Multiple blue-gray dots –– Leaf-like structures –– Spoke-wheel areas or radiating areas and concentric structures

H. Cabo and E. N. Cohen Sabban

• Non-vascular and non-pigmented structures –– Ulceration and multiple small erosions –– White shiny lines Notice in this case the presence of leaf-like structures and spoke-wheel areas (Fig. 2.3).

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Palpable Pigmented Lesions on the Scalp Flávia Vasques Bittencourt, Andzelka Ilieva, and Aimilios Lallas

3.1 • • • • • • • • • • • •

Case No. 1

Author: Flávia Vasques Bittencourt Sex: Male Age: 78 years Surface (flat/palpable/nodular): Palpable Maximum diameter: 0.6 mm Duration of the lesion: Several years History of morphologic changes: No changes Personal history of skin cancer (if yes, please specify): No Family history of skin cancer (if yes, please specify): No Skin phototype: III Total nevus count: (100):