SCC of the Nail

Squamous cell carcinoma of the nail apparatus: clinicopathological study of 35 cases
Authors: Dalle, S.1; Depape, L.2; Phan, A.1; Balme, B.; Ronger-Savle, S.1; Thomas, L.1

Source: British Journal of Dermatology, Volume 156, Number 5, May 2007, pp. 871-874(4)

Abstract:

Summary Background 

Subungual squamous cell carcinoma (SCC) is rare. Its diagnosis is often missed or delayed because the clinical presentation is often atypical and can mimic other conditions such as verruca vulgaris, onychomycosis, trauma-induced nail dystrophy or exostosis. Objectives 

To define the different clinical presentations and the main pathological features and to evaluate the most appropriate surgical management of subungual SCC. Methods 

A retrospective review of all the cases of subungual SCC seen in our institution over a 5-year period.
Results 
Thirty-five cases were selected. The spectrum of the clinical features encountered was extremely large including leuconychia, subungual hyperkeratosis, trachonychia, subungual tumoral syndrome, longitudinal erythronychia and melanonychia. Most cases (31 of 35) were invasive. Relapse rate after surgical treatment was low after wide surgical excision (5%) of the nail apparatus or amputation of the digit. However, limited surgical excision led to more frequent relapses (56%). Conclusions 

Nail apparatus SCC is often misdiagnosed. Most cases are invasive at the time of diagnosis. Wide surgical excision bears a lower risk of relapse. Micrographic surgery should be considered for a better control in cases treated with limited surgical excision.

Imiquimod and Atypical Nevi

This article tries to draw some conclusions about the treatment of atypical nevi with Imiquimod but there were only three cases. In essence it says do not do it and urges caution about its use in treating lentigo maligna. (IMCC)
Treatment of Atypical Nevi With Imiquimod 5% CreamNajwa Somani, MD, FRCPC; Magdalena Martinka, MD, FRCPC; Richard I. Crawford, MD, FRCPC; Jan P. Dutz, MD, FRCPC; Jason K. Rivers, MD, FRCPC


Arch Dermatol. 2007;143:379-385.

ABSTRACT

Background 5% Imiquimod cream is a topical immune response modifier that has been used off-label to treat malignant melanocytic proliferations such as lentigo maligna. To our knowledge, imiquimod has not been previously used to treat atypical nevi (AN).

Observations Three patients each with 1 selected clinically AN were treated with imiquimod 5 nights per week for 12 weeks. The lesions were subsequently excised and sent for routine histologic and immunohistochemical analysis. None of the lesions cleared. Two were consistent with atypical compound nevus on excisional biopsy and demonstrated inflammation, while the third showed congenital features and demonstrated minimal inflammation. The AN were initially interpreted as displaying more severe histologic atypia on excisional biopsy than was present at baseline. Immunohistochemical studies revealed that the AN but not the congenital-like nevus exhibited increased staining for CD4+ and CD8+ cells and for a surrogate marker of interferon expression.

Conclusions Twelve weeks of imiquimod treatment failed to cause lesional resolution. A differential inflammatory response was observed between the AN and the congenital-like nevus. The character of the inflammatory infiltrate was similar to that observed with halo nevi. Uncertainties remain concerning imiquimod use for chemoprevention of AN, and the posttreatment histologic features may be misinterpreted as severe melanocytic atypia or melanoma.

Melanoma of the Foot and Ankle

This article from Hugh Greenaway from San Diego looks at a series of melanomas on the foot and ankle. You can access the article in a Wordfile here.

Melanoma of the Foot and Ankle: A Case Series of an Underrecognized Entity
Melanoma is the most common malignancy of the foot and is more likely to be misdiagnosed on the foot than in any other location. Clinical mimics include verruca, onychomycosis, subungual hematoma, or ischemic digits.

Report of Cases

Recently at our institution, we treated 8 melanomas of the foot or ankle over a 6-month period. After obtaining institutional review board approval, we gathered the clinical data of patients with melanoma presenting to our clinic between July 1, 2003, and December 31, 2003, from our cutaneous surgery unit database at Scripps Clinic, La Jolla, Calif. Of the 69 melanomas treated in our unit during this 6-month interval, 8 melanomas (12%) were located on the foot and ankle, in contrast to our 21-year incidence of 4% (January 1985–December 2005, unpublished data). Clinical and pathologic characteristics of these 8 patients were reviewed and compared (Table).

Early markers of Mycosis Fungoides

This article explains some of the latest research confirming digitate dermatosis is a T cell lymphoma of the skin.(IMCC)

CD13 and TCR Clone: Markers of Early Mycosis Fungoides
Issue: Volume 87, Issue 2, March 2007

Pages: 155-159

DOI: 10.2340/00015555-0197

Abstract:
Making a differential diagnosis between early mycosis fungoides (MF) and parapsoriasis is often difficult at the clinical and histological level. The aim of this study was to explore markers that could help in this process. A total of 88 patients were included in 2 categories: large plaque parapsoriasis and digitiform parapsoriasis. A histological examination was performed for each patient, and expression of the antigen My7 (CD13), which is lacking in cutaneous T-lymphomas (CTCL) (but not in inflammatory lesions) and rearrangement of the T-cell receptor gene were analysed. A histological aspect of epidermo­tropic CTCL was observed in 23.5% of cases of large plaque parapsoriasis and 15% of cases of digitiform para­psoriasis. A disappearance of My7 antigen was noted in the 2 forms of parapsoriasis, more frequently when there was CTCL histology. A cutaneous clone was observed in 10.3% of cases of large plaque parapsoriasis, but not of digitiform parapsoriasis. For 3 patients, a cutaneous clone and a disappearance of My7 were associated with a non-specific histology. Considering these histological, immunological and molecular biological data, it appears that My7 antigen combined with T-cell clone may help the dermatologist to confirm the diagnosis of early MF. Moreover, further studies will determine whether CD13 is an early prognostic marker of evolution of a para­psoriasis to MF. Finally, these results demonstrate that digitiform parapsoriasis can be an early stage of MF.

Authors:
Claire Bernier, Jean Michel Nguyen, Gaëlle Quéreux, Jean Jaques Renault, Brigine Bureau and Brigitte Dreno

Poopyfield Bleeding Sign

Has anyone confidently seen this sign? (IMCC)
Poppyfield Bleeding: a New Dermatoscopic Sign and its Histopathological Background
Henrik F. Lorentzen, Kaare Weismann, Kristian Rossen and Henrik Klem Thomsen

Dermatoscopy increases the accuracy of diagnosis of melanoma. An atypical vascular pattern may be an indicator of cutaneous malignant melanoma (CMM). During dermatoscopy of certain CMMs numerous ruby droplets of blood appear when the dermatoscope is pressed firmly against the lesion. The aim of this paper was to examine the histopathological background for this observation. CMMs from 8 patients showing the poppyfield sign, i.e. squirts of ruby blood droplets, were paired with 8 CMMs of equal Breslow thickness not showing this sign. The 16 CMMs were placed in an unsystematic sequence and presented to two dermato-pathologists who assessed the lesions independently for confirmation of Breslow thickness, Clark level, ulceration and presence of dilat­ed tumour vessels. There was no disagreement between the pathologists' assessments. Age of the patients and Breslow thickness of the cutaneous malignant melanoma were similar in the two groups. All 8 poppyfield CMMs had dilated tumour vessels compared with 25% (2/8) of the non-poppyfield CMMs (p< 0.007). Histological ulceration was observed in all poppyfield CMMs and none of the non-poppyfield CMMs (p< 0.001). The poppyfield bleeding sign is a dermatoscopic clue to dilated tumour vessels. It may be a dermatoscopic reflection of increased vascular density described in primary CMMs compared with adjacent skin and may also reflect the presence of primitive vessels in CMMs displaying increased fragility.

Dermatoscopy of Pigmmented Actinic Keratoses

Dermatoscopy of pigmented actinic keratosis – A striking similarity to lentigo maligna
Lumír Pock, MD, Lubomír Drlík, MD, and Jana Hercogová, MDFrom the Department of Dermatology, Šumperk, Prague, Department Dermatology and Venerology, Charles University, Prague, Czech Republic
Correspondence Lumír Pock, MD Dermatohistopathologic Laboratory Mazurská 484 181 00 Prague 8 Czech Republic E-mail: lumir.pock@volny.cz
Abstract

Background Pigmented actinic keratosis (PAK) resembles lentigo maligna (LM) clinically and histopathologically in some cases.

Objectives To describe the dermatoscopical characteristics of this uncommon variant of actinic keratosis and evaluate whether these characteristics show common features with LM.

Observations We had the opportunity to examine a 78-year-old woman who presented with a PAK lesion on her face dermatoscopically and histopathologically. The pigmented pseudo-network had black and gray dust in some areas, which were the main dermatoscopical features. The pigmented pseudo-network was formed by an unhomogenous brown background interrupted by regularly distributed hair follicules. The hyperpigmentation was based not only on an increased presence of melanin within the keratinocytes in the basal and spinous layers of epidermis, but also an intensive apoptosis of keratinocytes connected to numerous melanophages.

Conclusions The dermatoscopical picture of PAK in this patient was practically indistinguishable from the early stage of LM. The authors considered that the pigmented atypical melanocytes’ role in LM presenting as black dots in the dermatoscopical picture was displayed by the individually pigmented keratinocytes in PAK. The groups of melanophages presenting as gray dust were present in PAK similarly to their presentation in LM. The character of the pigmented pseudo-network is the same in the both afflictions. There is a need to examine other cases of PAK in order to decide whether our case represents a general pattern of the dermatoscopical picture.

See an example at the Skincancerclinic blog on Friday 13th April.
The purse-string suture revisited: a useful technique for the closure of cutaneous surgical wounds
Philip R. Cohen, MD, Paul T. Martinelli, MD, Keith E. Schulze, MD, and Bruce R. Nelson, MDFrom the Dermatologic Surgery Center of Houston, Houston, Texas and Department of Dermatology, University of Texas-Houston Medical School, Houston, Texas
Correspondence Philip R. Cohen, MD 805 Anderson Street Bellaire, TX 77401-2806 E-mail: mitehead@aol.com
Reprints request to: Bruce R. Nelson, MD Dermatologic Surgery Center of Houston, PA 6655 Travis, Suite 840 Houston, TX 77030 bnelson@dermsurgeryhouston.com

Abstract

The purse-string suture provides complete or partial closure of round postoperative skin defects. It is a rapid and simple procedure to perform. Tension placed on the suture uniformly advances the skin from the entire periphery of the wound, resulting in a significant reduction of the defect size and enhancement of hemostasis at the wound edge. The history, modifications of the technique, advantages, and potential complications of the purse-string suture are reviewed. It is not only useful following the removal of nonmelanoma skin cancer but also after the local excision of melanoma. In addition, this technique is especially suitable for the repair of round surgical wounds for patients who are unable to modify their active lifestyles during the week following surgery, individuals concurrently being treated with anticoagulants, antiplatelet agents or both, and people with extensive postoperative defects that would otherwise require either a skin graft or a large cutaneous flap. Typically, the site of the surgical wound following partial or complete closure with the purse-string suture demonstrates excellent long-term cosmetic and functional results.

Polarised or non polarised dermatoscopes

This is an important paper for all of us who use a dermatoscope and record images. Polarised dermatoscopes such as the Dermlite Pro (non contact) will not highlight milia in seb ks or the blue colour of deeper melanin or more importantly the blue grey veil. The nonpolarised dermatoscopes such as the Heine Delta 20 will highlight these features better. The new Dermlite fluid is equivalent to the Heine Delta 20. Those of you who were at Ash Marghoob's lecture and quiz when he presented the same lesions photographed with different dermatoscopes will appreciate how it made some of us unwittingly change our diagnosis of the same lesion presented at different stages of the quiz! Worrying!
Differences between polarized light dermoscopy and immersion contact dermoscopy for the evaluation of skin lesions.

Author(s): Benvenuto-Andrade C; Dusza S; Agero A; Scope A; Rajadhyaksha M; Halpern A; Marghoob A;

OBJECTIVE: To evaluate dermoscopic features and patterns of skin lesions by using conventional and polarized light dermoscopy (PD). DESIGN: Observational study.
SETTING: Dermatology clinic at Memorial Sloan-Kettering Cancer
Center.
PATIENTS: Ninety patients with skin lesions.
INTERVENTIONS: Skin lesions were imaged via conventional nonpolarized light contact dermoscopy (NPD), polarized light contact dermoscopy (PCD), and polarized light noncontact
dermoscopy (PNCD).
MAIN OUTCOME MEASURES: The images from the 3 modalities
were evaluated by 3 dermoscopists for colors, structures, and patterns. Level of agreement between modalities was assessed by percentage agreement and the kappa statistic. Qualitative differences between modalities were also assessed.
RESULTS: Ninety lesions comprising 55 melanocytic and 35
nonmelanocytic lesions were reviewed. There was excellent agreement for overall dermoscopic patterns between modalities, with kappa values ranging from 0.88 to 1.00. There was moderate to excellent agreement for most dermoscopic colors, with the exception of blue-white veil and pink (red) color. Most dermoscopic structures had fair to perfect agreement, with
the exception of milialike cysts. Qualitative assessment suggested that melanin appeared darker and blue nevi had more shades of blue on PD compared with NPD images; vessels and red areas were better visualized with PD, suggesting that PD may be helpful in identifying malignancies; milialike cysts and comedolike openings were better visualized with NPD, suggesting that NPD is more helpful for identification of seborrheic keratosis; peppering,
lighter colors, and blue-white areas were more evident under NPD, facilitating recognition of regression areas; and shiny-white streaks, possibly representing fibrosis, were seen more clearly under PD.
CONCLUSIONS: The capabilities of NPD, PCD, and PNCD are not equivalent, but complementary. Further studies are needed to evaluate the effect of these differences on clinical diagnosis.

Archives
of dermatology.; 2007 Mar 1;143(3)

Histological evolution of lentiginous melanoma

I doubt that this variant exists. These are all melanoma in situ. It appears that some lesions can remain in this phase for many years but the nature of the lesion is the same. They do point out that significant solar elastosis was not associated with these lesions. I am sure Weedon and Kossard would report these are lentiginous dysplastic nevus of the elderly but these cases were a bit young for that designation!
Histological evolution of lentiginous melanoma: a report of five new cases
Authors: Davis, Tracy1; Zembowicz, Artur

Source: Journal of Cutaneous Pathology, Volume 34, Number 4, April 2007, pp. 296-300(5)

Abstract:

Background: 

The term lentiginous melanoma was recently used for atypical melanocytic proliferations sharing some histological features with lentigo maligna and associated with a protracted in situ stage before invasion. Lentiginous melanoma was characterized by predominantly single-cell lentiginous growth pattern with focal junctional nests and pagetoid spread, preservation of the dermoepidermal junction, limited cytological atypia, and lack of significant solar elastosis. We report five similar cases. Methods: 

Histological review of routine sections with clinicopathological correlation.
Results: 
Three patients were male and two were female. The age at presentation ranged from 24 to 66 years. All lesions arose on the truck or proximal extremities. All five cases fulfilled histological criteria proposed for lentiginous melanoma. None of the lesions showed significant solar elastosis. One lesion was followed clinically and histologically for 16 years without intervening treatment. It had three local recurrences before culminating in invasive melanoma.
Conclusions: 
Our observations support recent efforts to distinguish lentiginous melanoma as a distinct clinicopathological entity. Lentiginous melanoma can remain in situ for a long time before invasion and may be considered an analogue of lentigo maligna occurring on non-severely sun-damaged skin. Familiarity with the histological features of this variant is important for its early recognition and treatment.

This is an interesting observation of multiple dysplastic nevi and in situ melanomas erupting after chemotherapy immunosupression. Worth looking out for. May be more likely in younger individuals Eruptive Post-Chemotherapy In Situ Melanomas and Dysplastic Nevi
Authors: Reutter, Jason C.1; Long, Erin M.2; Morrell, Dean S.2; Thomas, Nancy E.2; Groben, Pamela A.1

Source: Pediatric Dermatology, Volume 24, Number 2, March/April 2007, pp. 135-137(3)

Publisher: Blackwell Publishing 

A 22-year-old white man without a personal or family history of atypical nevi had received chemotherapy for pre-B-cell acute lymphocytic leukemia at age 17 that includedl-asparaginase, prednisone, methotrexate, mercaptopurine, daunorubicin, and cytoxan. Two to three months after completing maintenance chemotherapy, the patient reports he developed many moles, which remained stable for approximately 2 years.

Upon examination, two dark, atypical appearing plaques with irregular borders and numerous pink papules of varying shapes and sizes were noted on his chest, back, and abdomen. Histology of specimens of both types of lesions revealed three moderately atypical compound dysplastic melanocytic nevi and three in situ melanomas. The lesions with only features of dysplastic nevi exhibited dermal fibrosis, cytologic atypia, junctional shoulders, lentiginous spread, and focal pigmentation. The lesions with in situ melanomas in addition demonstrated pagetoid spread, extension down adnexal structures, and more severe cytologic atypia.

Malignant melanoma has been associated with chronic immunosuppression, and benign nevi have been reported to erupt after chemotherapy. We report an occurrence of multiple eruptive dysplastic nevi and in situ melanomas appearing shortly after completion of chemotherapy.
Document Type: Research article

DOI: 10.1111/j.1525-1470.2007.00359.x

Affiliations: 1: Pathology 2: Dermatology, University of North Carolina, Chapel Hill, North Carolina

This is a good article abstract which outlines the dermatoscopic features of nail pigmentation.
Dermoscopy provides useful information for the management of melanonychia striata
Luc Thomas & Stéphane DalleService de Dermatologie, Université Lyon France and Hôtel Dieu de Lyon, Lyon Cedex France
Address correspondence and reprint requests to: Luc Thomas, MD, PhD, Service de Dermatologie, Hôtel Dieu 69288 Lyon Cedex 02 France, or email: luc.thomas@chu-lyon.fr.
KEYWORDS: dermoscopy, melanoma, melanonychia striata, nail disease, nevus, skin cancerAbstract
ABSTRACT: The diagnosis of melanonychia striata is often difficult, and a biopsy of the nail matrix is required in doubtful cases. However, dermoscopic examination of the nail plate offers interesting information in order to better select the cases in which pathologic examination is indicated. In the case of brown longitudinal pigmentation with parallel regular lines, the diagnosis of nail apparatus melanocytic nevus could be made. On the other hand, the presence of a brown pigmentation overlaid by longitudinal lines irregular in their thickness, spacing, color, or parallelism is highly in favor of a melanoma. Gray homogeneous lines are observed in case of lentigo, lentiginoses, ethnic or drug-induced pigmentations, and in post-traumatic pigmentations. Blood spots are characterized by their round-shaped proximal edge and their filamentous distal edge and are highly suggestive of subungual hemorrhages. Dermoscopic examination of the free edge of the nail plate gives information on the lesion location; pigmentation of the dorsum of the nail plate is in favor of a proximal nail matrix lesion, whereas pigmentation the lower part of the nail edge is in favor of a lesion of the distal matrix.