An Asymptomatic, Small, Pinkish Plaque on the Arm of a Female Elderly Patient

Despina Exadaktylou, Kanella Kalapothakou, Niki Arnogiannaki, Evelina Skafida, Spyridon Stavrianos
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Figure 2.</p><p>Upon clinical examination, the slowly growing, pinkish, indurated plaque with peripheral pigmentation and superficial scaling pointed towards the differential diagnosis of Bowen's disease (BD), basal cell carcinoma (BCC) and amelanotic—hypomelanotic melanoma (AHM). The detailed dermoscopic examination revealed asymmetric shape, scaling, multiple colors, polymorphic vessels that included dotted vessels mainly in the periphery and linear irregular vessels located centrally, scar-like central depigmentation and focal irregular pigmentation on the periphery with atypical pigment network and atypical globules. Figure 2. These findings excluded BCC and narrowed the differential diagnosis between BD and AHM.</p><p>Dermoscopic findings of dotted vessels, scaling and pigmentation are observed both in BD and AHM, and careful analysis of subtle differences is needed to distinguish between them. In our patient, the dermoscopy photo was carefully examined and discussed between two consultant dermatologists. In BD, vessels are described as “glomerular” which are usually larger in size, looped and regularly arranged in clusters while pigmented globules are usually smaller and scattered throughout the lesion [<span>1</span>].</p><p>The combination of dotted and linear irregular vessels, scar-like central depigmentation and atypical pigment network and globules, pointed to the diagnosis of hypomelanotic melanoma which was confirmed by histology.</p><p>The lesion was excised with a 2.0 mm peripheral skin margin. Histological examination as shown in Figure 3, revealed atypical melanocytes infiltrating the papillary dermis as nests and solitary units with a pagetoid pattern. Histology and immunohistochemistry confirmed the diagnosis of stage pT1a/N0/M0 malignant melanoma: Breslow 0.55 mm, one mitosis/mm2, diffuse lymphocytic infiltration, absence of histological ulcerations, melan-A (+) and HMB45 (+). The patient underwent surgical re-excision with 1.0 cm peripheral skin margin and was regularly followed up thereafter.</p><p>Amelanotic and hypomelanomatic melanomas (AHMs) are estimated at 2%–8% of all melanomas but it is postulated that their prevalence could be greater due to misdiagnosis [<span>2</span>].</p><p>In contrast with the absence of clinical criteria, dermoscopic findings are more specific. In scarcity of pigment, dermoscopy is based on the characteristics of the vasculature. As positive indicators of AHM are reported the combined presence of dotted and irregular linear vessels and their atypical distribution in the periphery of the lesion [<span>1-5</span>]. The type of vessels is indicative of tumor progression: dotted vessels are reported to dominate in early AM, while linear vessels appear in increasing number as the tumor progresses [<span>2</span>].</p><p>Upon dermoscopy, in our patient, the presence of both dotted vessels peripherally and linear irregular vessels located centrally was an important clue towards the diagnosis.</p><p>In addition to vascular characteristics, other dermoscopic features of AHM include an asymmetric shape, multiple colors, blue-white veil, multiple blue-gray dots, milky red-pink areas, a scar-like depigmentation, and ulceration [<span>3-5</span>]. In our case, the asymmetric shape, multiple colors and a central scar-like depigmentation were present. 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Histological and immunohistochemical examination revealed malignant ductal breast carcinoma of nonspecific type, 9.0 mm diameter, stage 2, with negative local lymph nodes.</p><p>Epidemiological studies report an elevated risk of developing second primary cancers (SPCs) in patients with a previous cancer diagnosis. Standardized incidence ratio (SIR) ranged from 1.03 to 4.10 for primary breast carcinoma after cutaneous melanoma. The risk is reported as higher within a year of melanoma diagnosis [<span>6</span>].</p><p>The predominant theories for this correlation are the presence of common tumor susceptibility genes such as BRCA2 and CDK2NA, biological factors such as oestrogen exposure and surveillance bias [<span>6</span>].</p><p>In our patient, breast cancer was detected at a routine mammography 6 months after the initial diagnosis of AHM. In Greece, the National Breast Cancer Screening Program provides a free annual Digital Mammography to all women aged 45–74. 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引用次数: 0

Abstract

A 79-year-old female patient presented to our clinic for a six -months history of an asymptomatic lesion on her right arm.

Clinical examination revealed a pinkish, indurated plaque with peripheral foci of grey- brown pigmentation and superficial scaling, measuring 0.8 × 1.0 cm. Figure 1.

Dermoscopic examination revealed asymmetric shape, scaling, polymorphic vessels, central depigmentation and focal pigmentation on the periphery. Figure 2.

Upon clinical examination, the slowly growing, pinkish, indurated plaque with peripheral pigmentation and superficial scaling pointed towards the differential diagnosis of Bowen's disease (BD), basal cell carcinoma (BCC) and amelanotic—hypomelanotic melanoma (AHM). The detailed dermoscopic examination revealed asymmetric shape, scaling, multiple colors, polymorphic vessels that included dotted vessels mainly in the periphery and linear irregular vessels located centrally, scar-like central depigmentation and focal irregular pigmentation on the periphery with atypical pigment network and atypical globules. Figure 2. These findings excluded BCC and narrowed the differential diagnosis between BD and AHM.

Dermoscopic findings of dotted vessels, scaling and pigmentation are observed both in BD and AHM, and careful analysis of subtle differences is needed to distinguish between them. In our patient, the dermoscopy photo was carefully examined and discussed between two consultant dermatologists. In BD, vessels are described as “glomerular” which are usually larger in size, looped and regularly arranged in clusters while pigmented globules are usually smaller and scattered throughout the lesion [1].

The combination of dotted and linear irregular vessels, scar-like central depigmentation and atypical pigment network and globules, pointed to the diagnosis of hypomelanotic melanoma which was confirmed by histology.

The lesion was excised with a 2.0 mm peripheral skin margin. Histological examination as shown in Figure 3, revealed atypical melanocytes infiltrating the papillary dermis as nests and solitary units with a pagetoid pattern. Histology and immunohistochemistry confirmed the diagnosis of stage pT1a/N0/M0 malignant melanoma: Breslow 0.55 mm, one mitosis/mm2, diffuse lymphocytic infiltration, absence of histological ulcerations, melan-A (+) and HMB45 (+). The patient underwent surgical re-excision with 1.0 cm peripheral skin margin and was regularly followed up thereafter.

Amelanotic and hypomelanomatic melanomas (AHMs) are estimated at 2%–8% of all melanomas but it is postulated that their prevalence could be greater due to misdiagnosis [2].

In contrast with the absence of clinical criteria, dermoscopic findings are more specific. In scarcity of pigment, dermoscopy is based on the characteristics of the vasculature. As positive indicators of AHM are reported the combined presence of dotted and irregular linear vessels and their atypical distribution in the periphery of the lesion [1-5]. The type of vessels is indicative of tumor progression: dotted vessels are reported to dominate in early AM, while linear vessels appear in increasing number as the tumor progresses [2].

Upon dermoscopy, in our patient, the presence of both dotted vessels peripherally and linear irregular vessels located centrally was an important clue towards the diagnosis.

In addition to vascular characteristics, other dermoscopic features of AHM include an asymmetric shape, multiple colors, blue-white veil, multiple blue-gray dots, milky red-pink areas, a scar-like depigmentation, and ulceration [3-5]. In our case, the asymmetric shape, multiple colors and a central scar-like depigmentation were present. In addition, we observed foci of atypical pigment network and atypical globules at the periphery, findings that in combination with the above mentioned vessel formations, further supported the diagnosis of HM.

Finally, the prominent scaling in our case has been identified as a common clinical feature of AHM and BD in numerous case reports. In AHM, scaly appearance is thought to be the result of increasing differentiation and proliferation of keratinocytes triggered by neoplastic melanocytes [1, 2].

Six months after her dermatology visit, at a presymptomatic screening the patient was diagnosed with carcinoma of the right breast which was surgically removed. Histological and immunohistochemical examination revealed malignant ductal breast carcinoma of nonspecific type, 9.0 mm diameter, stage 2, with negative local lymph nodes.

Epidemiological studies report an elevated risk of developing second primary cancers (SPCs) in patients with a previous cancer diagnosis. Standardized incidence ratio (SIR) ranged from 1.03 to 4.10 for primary breast carcinoma after cutaneous melanoma. The risk is reported as higher within a year of melanoma diagnosis [6].

The predominant theories for this correlation are the presence of common tumor susceptibility genes such as BRCA2 and CDK2NA, biological factors such as oestrogen exposure and surveillance bias [6].

In our patient, breast cancer was detected at a routine mammography 6 months after the initial diagnosis of AHM. In Greece, the National Breast Cancer Screening Program provides a free annual Digital Mammography to all women aged 45–74. Our patient, although 79 years old continued her annual screening and was even more encouraged to do so after the melanoma diagnosis.

Our elderly patient was not subjected to oestrogens. The possible mechanisms for the SPC she developed in the right breast 6 months after the AHM diagnosis, include surveillance bias and genetic factors.

Dermoscopy should be regarded as routine examination of lesions that persist longer than 1 month. It is cheap, readily available, easy to apply and with the advance of dermoscopic technology, visualization is of better quality. Recognition of suspicious lesions is enhanced with adequate training and is of primary importance.

Patients with a diagnosis of AHM should be screened for SPCs, even at an advanced age.

Despina Exadaktylou: overall responsibility for the integrity of the entire work, from inception to the published article: Conceptualization, design, investigation, data acquisition, analysis and interpretation, writing–original draft, writing–review and editing. Kanella Kalapothakou: data acquisition, critically revising the article for important intellectual content, final approval of the version to be published. Niki Arnogiannaki: data analysis, critically revising the article for important intellectual content, final approval of the version to be published. Evelina Skafida: data interpetation, critically revising the article for important intellectual content, final approval of the version to be published. Spyridon Stavrianos: data acquisition, critically revising the article for important intellectual content, final approval of the version to be published.

The patient in this manuscript has given written informed consent for participation in the study and the use of her deidentified, anonymized, aggregated data and her case details (including photographs) for publication. Ethical Approval: not applicable.

The authors declare no conflicts of interest.

一名79岁女性患者因右臂无症状病变6个月前来就诊。临床检查发现一个粉红色硬化斑块,周围有灰褐色色素沉着和浅表鳞屑,大小为0.8 × 1.0 cm。图1所示。皮肤镜检查显示形状不对称,有鳞屑,血管多形,周围有中央色素沉着和局灶性色素沉着。图2。经临床检查,缓慢生长,粉红色,硬化斑块伴周围色素沉着和浅表脱垢,提示Bowen病(BD),基底细胞癌(BCC)和无色素-低黑色素瘤黑色素瘤(AHM)的鉴别诊断。详细皮肤镜检查显示:形状不对称,有鳞屑,颜色多样,血管形态多样,主要分布在周围的点状血管和位于中心的线状不规则血管,周围有瘢痕样中央色素沉着和局灶性不规则色素沉着,色素网络和非典型小球。图2。这些发现排除了BCC,缩小了BD和AHM之间的鉴别诊断范围。在皮肤镜下,BD和AHM均可观察到点状血管、结垢和色素沉着,需要仔细分析它们之间的细微差异来区分它们。在我们的病人中,皮肤科医生仔细检查并讨论了皮肤镜照片。在BD中,血管被描述为“肾小球”,通常体积较大,呈环状,并有规则地排列成簇,而色素球通常较小,分散在整个病变[1]。点状和线状不规则血管合并,瘢痕样中央色素脱色,不典型的色素网和色素球,提示低黑色素瘤的诊断,经组织学证实。病变切除2.0 mm周围皮肤边缘。组织学检查如图3所示,非典型黑素细胞浸润乳头状真皮层,呈巢状和孤立单位,呈页状。病理及免疫组化证实pT1a/N0/M0期恶性黑色素瘤:Breslow 0.55 mm, 1个有丝分裂/mm2,弥漫性淋巴细胞浸润,无组织学溃疡,melan-A(+)和HMB45(+)。患者再次手术切除周围皮肤缘1.0 cm,术后定期随访。无色素黑色素瘤和低黑色素瘤(AHMs)估计占所有黑色素瘤的2%-8%,但假设由于误诊,其患病率可能更高。与缺乏临床标准相比,皮肤镜检查结果更具体。在色素缺乏的情况下,皮肤镜检查是基于血管系统的特点。据报道,作为AHM的阳性指标,点状和不规则的线状血管同时存在,并且它们在病变周围的不典型分布[1-5]。血管的类型是肿瘤进展的指示:据报道,在AM早期,点状血管占主导地位,而随着肿瘤的进展,线状血管的数量越来越多。在我们的患者的皮肤镜检查中,周围有点状血管和位于中心的线状不规则血管的存在是诊断的重要线索。除血管特征外,AHM的其他皮肤镜特征还包括形状不对称、多种颜色、蓝白面纱、多个蓝灰点、乳白色红粉色区域、疤痕样色素沉着和溃疡[3-5]。在我们的病例中,存在不对称的形状,多种颜色和中央疤痕样色素沉着。此外,我们在周围观察到非典型色素网络和非典型小球的病灶,结合上述血管形成,进一步支持了HM的诊断。最后,在许多病例报告中,我们病例中突出的鳞屑已被确定为AHM和BD的共同临床特征。在AHM中,鳞状外观被认为是由肿瘤黑色素细胞引发的角质形成细胞分化和增殖增加的结果[1,2]。在她皮肤科就诊六个月后,在症状前筛查中,患者被诊断为右乳房癌,并通过手术切除。组织学及免疫组化检查示非特异性型乳腺导管癌,直径9.0 mm, 2期,局部淋巴结阴性。流行病学研究报告,既往癌症诊断的患者发生第二原发癌症(SPCs)的风险升高。皮肤黑色素瘤后原发性乳腺癌的标准化发病率(SIR)范围为1.03 - 4.10。据报道,在黑色素瘤确诊后的一年内,患黑色素瘤的风险更高。 这种相关性的主要理论是存在常见的肿瘤易感基因,如BRCA2和CDK2NA,生物因素,如雌激素暴露和监测偏差[6]。在我们的患者中,乳腺癌是在首次诊断AHM 6个月后通过常规乳房x光检查发现的。在希腊,国家乳腺癌筛查计划为所有45-74岁的女性提供免费的年度数字乳房x光检查。我们的病人,虽然已经79岁了,但她仍然坚持每年一次的筛查,在确诊黑色素瘤后,她更被鼓励这样做。我们的老年患者没有使用雌激素。在AHM诊断6个月后,她在右乳房出现SPC的可能机制包括监测偏差和遗传因素。皮肤镜检查应作为持续1个月以上病变的常规检查。它便宜,容易获得,易于应用,并且随着皮肤镜技术的进步,可视化质量更好。对可疑病变的识别通过适当的训练得到加强,这是最重要的。诊断为AHM的患者应进行SPCs筛查,即使是高龄患者。Despina Exadaktylou:全面负责整个工作的完整性,从开始到发表文章:概念化,设计,调查,数据采集,分析和解释,写作-原稿,写作-审查和编辑。Kanella Kalapothakou:数据采集,对文章重要知识内容进行批判性修改,最终审定发布版本。Niki Arnogiannaki:数据分析,对文章的重要知识内容进行批判性修改,最终审定出版版本。Evelina Skafida:数据解读,对文章的重要知识内容进行批判性修改,最终审定出版版本。Spyridon Stavrianos:数据采集,对文章的重要知识内容进行批判性修改,最终批准发表的版本。本文中的患者已书面同意参与研究,并同意使用其去身份、匿名、汇总的数据和病例细节(包括照片)进行发表。伦理批准:不适用。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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