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Atlas of Diagnostically Challenging Melanocytic Neoplasms Caterina Longo Giuseppe Argenziano Aimilios Lallas Elvira Moscarella Simonetta Piana 123 Atlas of Diagnostically Challenging Melanocytic Neoplasms Caterina Longo • Giuseppe Argenziano Aimilios Lallas • Elvira Moscarella Simonetta Piana Atlas of Diagnostically Challenging Melanocytic Neoplasms Caterina Longo Giuseppe Argenziano Dermatology and Skin Cancer Unit Dermatology Unit Arcispedale Santa Maria Nuova-IRCCS University of Campania Department of Dermatology Naples University of Modena and Reggio Emilia Italy Reggio Emilia Italy Elvira Moscarella Dermatology and Skin Cancer Unit Aimilios Lallas Arcispedale Santa Maria Nuova-IRCCS First Department of Dermatology Reggio Emilia Aristotle University Italy Thessaloniki Greece Simonetta Piana Pathology Unit Arcispedale Santa Maria Nuova-IRCCS Reggio Emilia Italy ISBN 978-3-319-48651-2 ISBN 978-3-319-48653-6 (eBook) https://doi.org/10.1007/978-3-319-48653-6 Library of Congress Control Number: 2017955686 © Springer International Publishing AG 2018 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. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface I must definitely applaud the original idea of Caterina Longo of producing this atlas, which is a superb collection of cases outlining the diagnostic chal- lenges we are facing every day with melanocytic tumors. For clinicians man- aging patients with melanoma, it is clear-cut that differentiating melanoma from benign melanocytic lesions can be very difficult at times. In the last 20 years, the practice changed dramatically because of the introduction of new tools for the preoperative diagnosis. Especially the introduction of dermos- copy and confocal microscopy allowed clinicians to improve their ability to recognize the many faces of melanocytic tumors with a quasi-histopathologic accuracy. However, there is a group of lesions that still are difficult to diag- nose because of their equivocal clinical and/or histopathologic features. In these cases, only a careful clinic-pathologic correlation is the method to rich more closely the final diagnosis and, thus, the correct patient management. What I learned in the last 20 years is that nobody has 100% diagnostic accu- racy, neither the clinician nor the pathologist. In difficult cases only an open- minded discussion among clinicians and pathologists is able to make the difference. Only by integrating all the possible information, the history, the clinical data, and the histopathologic features might we reach a more reason- able management of our patients. The aim of this book is indeed to illustrate this method, the clinic-pathologic correlation of difficult cases! Naples, Italy Giuseppe Argenziano, M.D., Ph.D. v Contents 1 Flat Solitary Pigmented Lesions in the Elderly . . . . . . . . . . . . . . 1 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2 Melanocytic Atypical Lesions in Patients with Multiple Nevi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3 Lesions on the Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 4 Recurrent Nevi and Nevi with Sclerosing Features and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 5 Spitzoid Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 vii viii Contents Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Case 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Case 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Case 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Case 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Case 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 6 Lesions with Regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 7 Acral Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 8 Melanoma Incognito . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 1 Flat Solitary Pigmented Lesions in the Elderly The sentence “we are born and we will die with- scopic follow-up suggest that these melanomas out nevi” summarizes one of the key components belong to a group of slow-growing tumors, which of the diagnosis of atypical lesions in the elderly. may grow in situ for several years. Their histo- Epidemiologic data demonstrate that the nevus logic diagnosis can be very difficult as they are count and prevailing nevus patterns are strongly cytologically bland and show scant epidermotro- influenced by age. Notably, nevus count increases pism and very little atypia. In the early phases, from childhood to midlife and decreases thereaf- only a numerical increase of the melanocytes, ter. In light of these findings, if evolving nevi in scattered along the basal epidermis, can be noted. adolescence are an expected finding and there- The alternation of single cells and irregular nests, fore do not require further interventions, a mela- with skip areas, usually within a sun-d amaged nocytic skin lesion showing signs of growth in skin, is an important histological clue for a diag- the elderly should raise the index for malignancy. nosis of early in situ melanoma. Furthermore, any flat acquired melanocytic What is a common finding in this age group is lesion in this age should be considered with cau- the presence of several benign non-melanocytic tion since the majority of lesions in the elderly skin lesions such as seborrheic keratosis, angio- are persistent intradermal nevi (congenital type). mas, or solar lentigos. Thus, the clues to identify Firstly termed as atypical lentiginous junctional flat melanomas are the following: solitary flat melanocytic proliferations, indeed they are pigmented lesions, large size, with network and regarded nowadays as melanomas. regression on dermoscopy. Conversely, the pres- Clinically, these atypical lentiginous junc- ence of rough surface, comedo-like openings, tional melanocytic proliferations of the elderly fingerprinting, and red lacunae should be are commonly located on the upper back, shoul- regarded as benign clues. However, the recogni- ders, or extremities. They are solitary, often tion of incipient melanomas should always be large (>8 mm), ill-defined macules with differ- based on clinical data, patient’s phenotype, and ent shades of black, brown, and gray. history. Dermoscopically, these lesions are typified by a This section depicts the clinical and dermo- more or less atypical pigmented network, diffuse scopic features of common and problematic structureless brown pigmentation, and areas of melanocytic tumors in the elderly while trying to regression. Studies employing digital dermo- provide clues and rules for the correct diagnosis. © Springer International Publishing AG 2018 1 C. Longo et al., Atlas of Diagnostically Challenging Melanocytic Neoplasms, https://doi.org/10.1007/978-3-319-48653-6_1 2 1 Flat Solitary Pigmented Lesions in the Elderly Case 1 First histopathologic diagnosis: Junctional nevus Patient: Female, 62 years old Second histopathologic diagnosis after clini- Anatomic site of the lesion: Right leg copathologic consultation: Junctional nevus ver- History of the lesion: Acquired lesion, present sus early melanoma in situ. The latter hypothesis since a few years seemed the most likely. Management: Although the dermoscopic Key message: Slow-growing melanomas can aspect revealed the presence of few criteria for show very bland cytological features. The corre- melanoma diagnosis, the lesion was excised to lation among clinical data (in this case, patient’s rule out melanoma diagnosis since it was a larger age), dermoscopic characteristics, and histologi- and darker lesion in the context of the patient’s cal features is mandatory. other nevi. Fig. 1.1 Flat pigmented lesion in the context of a patient with multiple small-sized moles Case 1 3 Fig. 1.2 Flat pigmented macule and darker compared to the surrounding lesions with irregular borders Fig. 1.3 Dermoscopically the lesion was typified by the presence of atypical pigmented network, with the presence of wider skin markings

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