Risk stratification. A practical approach to using epiluminescence microscopy/dermoscopy in melanoma screening.

Risk stratification of pigmented lesions during melanoma screening is a method of classifying lesions into groups based on their relative risk of being melanoma. Risk stratification accepts the fact that clinical examination with and without ELM is not perfect but uses potential ELM clues to early melanoma to increase the sensitivity of screening. Risk stratification permits the use of all available a priori clinical information and the physician's judgement in making a final management decision for each lesion and for each patient. Risk stratification using ELM is based on two primary concepts: (1) a pigment network suggests a lesion is melanocytic and (2) melanoma causes the network to develop heterogeneous (i.e., irregular) and eccentric (i.e., not centered) pigmentation. In applying ELM risk stratification to melanoma screening the physician follows these four steps: 1. Inspect each lesion carefully for a pigment network. 2. If a pigment network is seen, group lesions by their relative degrees of heterogeneity and eccentricity of the pigment network. 3. If a network is not seen, look for typical patterns of benign lesions and melanoma mimickers. 4. Use the resulting clinical risk class to guide management using all available clinical information combined with clinical judgment.

Clinicopathological correlation of pigmented skin lesions using dermoscopy.

Dermoscopy (dermatoscopy, epiluminescence microscopy) is an additional measure for making the diagnosis of pigmented skin lesions more accurate. It enables the clinician to visualize features not discernible by the naked eye. By applying enhanced digital dermoscopy and a standardized gross pathology protocol to pigmented skin lesions, a precise clinicopathological correlation of relevant dermoscopic features can be made. Histological specimens of four pigmented skin lesions (melanoma in situ, Clark's nevus, Reed's nevus, seborrheic keratosis) were processed using a standardized gross pathology protocol and viewed along with the clinical photographs and digital dermoscopic images that were magnified and enhanced to better visualize the corresponding dermoscopic structures. Furthermore, measurements of dermoscopic structures using digital equipment were correlated with histometric findings. Our understanding of dermoscopic features, especially the broadened pigment network - a specific dermoscopic criterion for melanoma - was refined by this detailed case-by-case correlation. In addition, some not yet fully characterized dermoscopic features, such as black lamella, radial streaks, and exophytic papillary structures, were described in detail dermoscopically and histopathologically. Moreover, measurements of these dermoscopic features and the underlying histological structures were found to be similar. Linking dermoscopy more closely with cutaneous pathology may help refine the definitions and diagnostic criteria of pigmented skin lesions for dermatologists as well as dermatopathologists.

Malignant mesothelioma metastatic to the skin, presenting as inflammatory carcinoma.

We report a 50-year-old man with a history of malignant pleural mesothelioma diagnosed 1 year previously and treated with pneumonectomy and radiotherapy who presented with an erythematous eruption on the left chest wall. A skin biopsy showed a proliferation of malignant epithelioid cells lining irregular clefts in the dermis. Some groups of cells were observed filling vascular lumina. Immunohistochemically, the tumor cells expressed cytokeratins (with antibodies AE1/AE3, MNF 116, and CAM 5.2), and epithelial membrane antigen (EMA), and were negative with Ulex europaeus (UE) and for carcinoembryonic antigen (CEA), CD34, CD15 (with LeuM1 antibody), and factor VIII-related antigen (FVIIIra). The histologic features and immunohistochemical profile were comparable to those observed in the primary pleural mesothelioma. This is the first reported case in which malignant mesothelioma metastatic to the skin presented as "inflammatory carcinoma." Although a very uncommon presentation, mesothelioma should be considered in the differential diagnosis of erythematous eruptions on the chest.

Atypical melanocytic lesions in epidermolysis bullosa.

We report a 6-year-old female with recessive dystrophic epidermolysis bullosa (RDEB) who presented with a very large acquired melanocytic lesion. The lesion demonstrated many features both clinically and histologically that made the distinction from malignant melanoma difficult. The pathogenesis of this lesion and other unusual melanocytic lesions seen in the setting of acute and chronic blistering disorders seems related to repeated episodes of disruption of the dermal-epidermal junction.

Clinical diagnosis of pigmented lesions using digital epiluminescence microscopy. Grading protocol and atlas.

BACKGROUND AND DESIGN: Epiluminescence microscopy (ELM) is a clinical technique that permits in vivo visual inspection of pigmented anatomic structures of the epidermis, dermoepidermal junction, and papillary dermis. A protocol is proposed for systematic visual inspection of pigmented lesions. Seventy pigmented lesions were imaged with a digital ELM camera system. Images were visually inspected for eight "global" ELM features, 23 "local" ELM features, and 18 network features. An atlas of the most clinically significant ELM features is presented with pilot estimates of their sensitivity and specificity for detecting melanoma. RESULTS: Preliminary data suggest that ELM features that may be most specific for melanoma include multicomponent pattern, nodular pattern, pseudopods, radial streaming, blue-gray areas, whitish veil (milky way), and sharp network margins. Epiluminescence microscopic features that may be most sensitive for melanoma include pigment dots, peripheral erythema, peripheral dark network patches, marked mean network irregularity, network line thickness variability, radial streaming, blue-gray areas, and whitish veil (milky way). Epiluminescence microscopic features that may be most sensitive for severe melanocyte atypia include pigment dots, peripheral erythema, hypopigmented network patches, peripheral dark network patches, marked mean network irregularity, and focal absence of network. In addition, features that may have a very high specificity for benign lesions include saccular pattern (suggests hemangioma), globular pattern (suggests a compound or dermal nevus), and multiple comedolike openings (suggests seborrheic keratosis). CONCLUSIONS: Features most sensitive for severe atypia and melanoma could form the basis for a screening test for considering biopsy. Features most specific for melanoma then could be applied to further triage management of pigmented lesions that meet initial screening criteria. In addition, features with very high specificity for benign lesions may help develop ELM criteria to avoid unnecessary surgery.