tools for the diagnosis of the melanomas on€¦ · \爀屲hay melanomas que se desarrollan en...

Tools for the diagnosis of the melanomas on

the foot

Alicia Gavillero Martín Prof. Universidad Católica de Valencia. Podóloga.Eduardo Nagore EnguídanosProf. Universidad Católica de Valencia. Dermatólogo.

Introduction

• Health problem: increasing incidence and mortality.

• Melanoma on the foot:– Etiophatogenia is unknown– Misdiagnosis rate is high– The prognostic is worst

PresenterPresentation NotesMelanoma is a malignant tumor which arise from melanocytic cells.Health problem: increasing incidence and mortality

Genetic Factors

AmbientalFactors

Skin characteristics

Highly penetrant genesLow penetrant genes

RUV (+UVA)

Nevi, skin type, hair color....

? ?

?

PresenterPresentation NotesThe transformation of melanocytes in tumoral cells is due to the consecuence between the interaction of ambiental factors (the most relevant one is the sun exposure) , skin characteristics (such as light-skinned or tendency to develop nevi), and genetic factors (the constitutive presence of genes responsibles of these skin characteristics or tendency to develop melanoma themselves. The combination of these factores, and the different importance of each one, is the key to determine the somatic mutations of the melanoma. These mutations are relevant because they are in driver genes… genes which regulate the main processes of the cell such as survival, proliferation or cell growing.The main mutation genes in melanomagenesis are BRAF, NRAS and KIT. What happens in the foot? This models doesn’t work because the rol of the sun exposure is limited, there is no defined skin characteristics with risk and we don’t still know underlaying genes.

------------

La heterogeneidad (M,F,C,H) es el concepto de moda en cáncer y, el MA, siguiendo con la moda, es una de los tumores especialmente heterogéneo. Esa heterogeneidad molecular que acabamos de ver se corresponde con una heterogeneidad fenotípica, clínica o histológica. Es por eso que es difícil encontrar patrones que permitan desarrollar protocolos de screening para la población general y hace especialmente interesante el estudio del comportamiento biológico de este grupo de tumores y la patogenia. Además, la etiopatogenia del melanoma acral es aún desconocida, a diferencia de lo bien caracterizados que están los otros tipos de melanomas. La exposición solar no tiene un papel relevante, así como los fenotipos típicos de riesgo, por lo que no se conoce qué peso tienen los factores genéticos

PresenterPresentation NotesAnd there are other external factors due to the fact that we walk and we wear shoes, such as:Pressure, trauma with the shoes, isquemia (less blood supply), in this case, combined with pressure, and friction as well.

And we don’t still know how this contribute to the mutations of the driver genes, throtught inflamation, but we know that the clinical aspect and the biological behavior is highly heterogeneous.-------

En relación a su etiopatogenia, es indudable que el pie tiene una serie de influencias que otras localizaciones no tienen derivadas del hecho de que vamos calzados y caminamos, que no está claro de qué manera pueden contribuir solas o en combianción a su desarrollo o progresión.

Hay melanomas que se desarrollan en áreas con un claro traumatismo, como este melanoma en la región subungueal de un dedo hiperextendido que choca contra continuamente con el zapato. Otros melanomas se desarrollan en áreas de presión, como este melanoma de la zona de apoyo metatarsal. Otros se pueden relaciona más con zonas de fricción, especialmente por calcetines y zapatos, aunque este melanoma también podría estar sometido a presión, si la persona llevara zapatos de puntera estrecha. Otro factor a tener en cuenta es la posibilidad de la influencia de la isquemia, como en este paciente diabético con neuropatía y arteriopatía, que desarrolla un melanoma en un área de isquemia y traumatismo por tener un dedo muy largo.

Que salgan las fotosRepresentar: presión, roce/fricción, traumatismo y alguna que combine varios factores.

Introduction




PresenterPresentation NotesThey are very different.------Por otra parte, la heterogeneidad es un concepto de moda en cáncer y, siguiendo con la moda, el MA presenta gran heterogeneidad desde el punto de vista epidemiológico, clínico, histológico y molecular.

Aquí se muestra, por ejemplo, lo heterogénea que es la presentación clínica de melanomas tanto lentiginosos como no lentiginosos. Se puede comprobar lo distinto que son.

Por ello es difícil encontrar patrones que permitan desarrollar protocolos de cribado para la población general y hace especialmente interesante el estudio del comportamiento biológico de este grupo de tumores y su etiopatogenia.

La heterogeneidad (M,F,C,H) es el concepto de moda en cáncer y, el MA, siguiendo con la moda, es una de los tumores especialmente heterogéneo. Esa heterogeneidad molecular que acabamos de ver se corresponde con una heterogeneidad fenotípica, clínica o histológica. Es por eso que es difícil encontrar patrones que permitan desarrollar protocolos de screening para la población general y hace especialmente interesante el estudio del comportamiento biológico de este grupo de tumores y la patogenia. Además, la etiopatogenia del melanoma acral es aún desconocida, a diferencia de lo bien caracterizados que están los otros tipos de melanomas. La exposición solar no tiene un papel relevante, así como los fenotipos típicos de riesgo, por lo que no se conoce qué peso tienen los factores genéticos

---Mas melanomas en el pie que muestran la gran heterogeneidad de este grupo y lo diferentes que pueden llegar a ser unos de otros.

Introduction




Soudry E, Gutman H, Feinmesser M, Gutman R, Schachter J. “Gloves-and-Socks” Melanoma: Does Histology Make a Difference?. Dermatologic Surgery .2008, Oct; 34(10): 1372-1378.

PresenterPresentation NotesAnd we alreday know the behavior is work.On the other hand, one of the most important points is the tumor thickness, it is higher in acral melanomas in the foot in comparison to melanomas in other locations.

Correlation of Breslow tumor thickness with prognosis Tumor tickness

(mm) Ulceration Survival

(5years) Survival

(10 years) =< 1.0 No 96% 88% =< 1.0 Sí 91% 83% 1.1-2.0 No 89% 80% 1.1-2.0 Sí 78% 64% 2.1-4.0 No 79% 64% 2.1-4.0 Sí 63% 50% >4 No 67% 54% >4 Sí 45% 32%

Balch DM, Soong S, Gershenwald JE, Thompson JF, Reintgen DS, Cascinelli N, et al. Pronostic Factors analysis of 17600 melanoma patients: validation of the American Joint committee on Cancer Melanoma Satging System. Journal od Clinical oncology, 2001, Aug; 19(16): 36223634.

PresenterPresentation NotesThe survival is worst. Most of melanomas on the foot have between 2.1 and 4.0 at diagnosis and this mean around 50-64% of survival, which is poor.

So it is very important we learn how to recognize this lesions the sooner the better. Early recognition is the key to improving survival rates.

Correlation of Breslow tumor thickness with prognosis

Tumor tickness

(mm)

Ulceration

Survival

(5years)

Survival

(10 years)

=< 1.0

No

96%

88%

=< 1.0

Sí

91%

83%

1.1-2.0

No

89%

80%

1.1-2.0

Sí

78%

64%

2.1-4.0

No

79%

64%

2.1-4.0

Sí

63%

50%

>4

No

67%

54%

>4

Sí

45%

32%

ABCDE

Czeschik JC, Hillen U, Schadendorf D. Diagnostik des malignen Melanoms. Onkologie. 2010;16:1121-30.

PresenterPresentation NotesEarly recognition is the key to improving survival rates.

We have always used the ABCDE rule for the diagnosis of pigmented lesions. As you know, melanoma are asymetric, with irregular borders, different colors, wide diameter, and finally can develop a change.

Source: Dr. V. García-Patos

Asymmetry

Borders

Color

Diameter

Evolution

PresenterPresentation Notes

Bristow: Early recognition is the key to improving survival rates[29]. As cutaneous melanoma is a visible disease, both the patient and practitioner play a major role in recognising suspicious lesions. Initially, the time taken to reach a diagnosis depends on the patient's ability to recognise and seek professional advice. Secondly, diagnosis depends on the professional's capacity to recognise the lesion. Data were available for 19 patients showing that the time from first noticing a lesion to diagnosis ranged from 1 – 36 months, which shows similarities to other studies of patients with ALM[26]. In a series of 590 patients they examined the reasons for delay in melanoma diagnosis and discovered that male gender, increasing age and a low educational level were all risk factors for a later presentation to physicians. In a second paper[31] examining physician delays, acral locations and lack of lesion pigmentation were factors more likely to lead to a delay in diagnosis by a physician, particularly lesions in acral locations without pigmentation. One third of the lesions, in the presented cohort, were seen prior to diagnosis by a chiropodist or podiatrist. Unfortunately, typical features of melanoma as exhibited by the "ABCDE" rule may not be present in a proportion of ALM and so misdiagnosis remains a significant risk. Therefore it is important to remain vigilant and where there is clinical suspicion, patients should be referred for a prompt dermatological opinion. In suggesting ways to heighten awareness, the typical patient profile should be borne in mind as well as continuing the patient health education message. In addition,dermoscopy has been demonstrated as a useful, noninvasive technique to increase sensitivity in acral lesions[39]improving early recognition.

¿Is this a melanoma?


Asymmetry

Borders

Color

Diameter

Evolution

PresenterPresentation NotesBut this is a melanoma and does it follow the ABCDE?No. Why?Because is symetric, regular, same color, small and no change

¿Do they follow the ABCDE?

PresenterPresentation NotesDo they follow the ABCDE?NoWhy?Nodular melanomas don’t follow ABCDENeither do subngueal melanoma or amelanotic melanomas

Typical features of melanoma as exhibited by the "ABCDE" rule may not be present in a proportion of ALM and so misdiagnosis remains a significant risk.

7 points of Glasgow

Mayor criteria Minor criteriaChange in the size 2 Diameter: more than 7 mm 1

Change in the shape 2 Inflamation 1

Change in the color 2 Bledding 1

Changes in the sensibility 1

≥ 3 points suggest acral melanoma

PresenterPresentation Notes7 puntos de Glasgow. Los autores encontraron que todos los signos y síntomas incluidos en este sistema se correlacionaban con el espesor tumoral. Se asociaban a tumores de mayor espesor el cambio de tamaño, la presencia de inflamación, la presencia de una superficie exudativa o sangrante y la sobreelevación. Por el contrario, la presencia de una pigmentación o de una forma irregulares, la presencia de molestias en la lesión (ej: prurito) o la observación de un diámetro mayor de 6 mm, se asociaron a lesiones de menor espesor. Para los autores, los resultados fueron especialmente relevantes por cuanto observaron, además, que en los tumores de mayor espesor se encontraban con menor frecuencia los signos y síntomas que forman parte de los criterios mayores de este sistema (un cambio de tamaño o la aparición de una lesión nueva, un cambio de forma o un cambio de color), lo que paradójicamente puede conducir a un retraso en el diagnóstico si no se tienen en cuenta los criterios menores (un diámetro menor o igual de 7 mm, presencia de inflamación, sangrado, o formación de costra y alteraciones sensitivas).

Poner aquí fácil de diagnosticar con Glasgow .Poner una foto poco valorada por ABCDE y muy valorada por Glasgow

¿Is this a melanoma?


Change size: 2 points

Change shape: 2 points

Change color

Diameter

Inflamation

Bledding

Changes in sensibility

PresenterPresentation NotesBut this is a melanoma and does it follow the ABCDE?No. Why?Because is symetric, regular, same color, small and no change

Ungueal ABCDEF

PresenterPresentation NotesEntre 1 y 3% de los melanomas son ungueales, con una supervivencia del 15% a los cinco años.El 25% son amelanóticos (1 de cada cuatro) frente al 7% de los MM!!!!!!!!!!

El melanoma subungueal se suele presentar como una banda pigmentada que va aumentando en tamaño y cambiando de color. La lesión se extiende a lo largo del pliegue ungueal proximal o lateral, lo que se conoce con el signo de Hutchinson. Por estos motivos, toda melanoniquia mayor de 6mm o que presente cualquier cambio deberá ser biopsiada.

Albresky. Melanoma of the feet: misdiagnosed and misunderstood . ABCDELos melanomas subungueals pueden visualizar signos de Hutchinson. Cuando está presente, este signo es una prueba presunta para el diagnóstico de melanoma subungueal. Hay, sin embargo, tres excepciones a considerar en la evaluación de pacientes con pigmentación periungueal que presumiblemente pueden presentar melanoma subungueal. La presencia del signo de Hutchinson puede ser ilusoria. Desórdenes benignos como hematoma subungueal y nevos melanocíticos produce pigmento limitado exclusivamente a la matriz ungueal y al lecho. Porque los pliegues de la uña y la cutícula son relativamente trasparentes, coloración marrón-negra puede aparecer para elevarse en los tejidos periungueales cuando, de hecho, la pigmentación es limitada al lecho ungueal y a la matriz. El color oscuro atraviesa la cutícula trasparente y el pliegue ungueal, simulando el signo de Hutchinson. Este no infrecuente simulación representa el pseudo signo de Hutchinson. Cuando el signo de Hutchinson implica al eponiquio, puede ayudar en el diagnóstico de un melanoma, aunque puede estar presente en numerosas condiciones benignas.La dermatoscopia puede ayudar en el diagnóstico.Habla de porqué existe factor traumático en el pie: dedo largo, no recorrido mov 1ª art MTF, etc y dice que solo 8.7% de los pacientes recordaron un trauma previo con lo que deducen que si el trauma fuera un factor importante, tendría que haber sido más alto el porcentaje. Pero está en controversia.

Age

Band

Change

Digit

Extension

Family or personal history

PresenterPresentation NotesAbajo a la izquierda de todo: melanoniquia mayor de 4mm, es un melanoma del articulo grabado como melanomas de las uñasArriba izquierda: ALM signo de Hutchinson. Figure 7. Subungual melanoma in situ of the great toe – a broad and multicoloured pigmented band is seen (longitudinal melanonychia)Arriba en medio y lateral: (a) Melanoma in situ in a 91-year-old man, showing broad irregular melanonychia accompanied by a prominent Hutchinson’s sign. (b) Melanoma in situ in a 33-year-oldwoman. Although the lines of this melanonychia are not so irregular, micro-Hutchinson’s sign is clearly apparent.

Abajo izquierda: Vicente García Patos, asegurar, melanoniquia benignaAbajo derecha: García Patos, hematoma subungueal

Signo de Hurchinson es muy sensible, es en la fase de crecimiento radial más que vertical, es la progresión de la pigmentación más allá del borde libre de la uña o de la cutícula. Es un signo preocupante. Nos permite actuar. Signos tardíos en la uña: ulceración, sangrado, onicodistrofiaEl 25% son amelanóticos (1 de cada cuatro) frente al 7% de los MM!!!!!!!!!!

Age

Band

Change

Digit

Extension


PresenterPresentation NotesSignos tardíos en la uña: ulceración, sangrado, onicodistrofiaEl 25% son amelanóticos (1 de cada cuatro) frente al 7% de los MM!!!!!!!!!!

Abajo a la izquierda: melanoma en estadío avanzadoDebemos tener en cuenta que el MLA también puede cursar con distrofia ungueal, ulceración y hemorragia6. Además, no debemos olvidar el MM subungueal amelanótico, asi, Banfield et al. en su estudio retrospectivo de 105 melanomas subungueales encontraron que un 23% de sus MLA eran amelanóticos14. A nivel subungueal, los diagnósticos diferenciales más importantes son las hemorragias de origen traumático y las onicomicosis6. Recordar que un antecedente traumático no excluye el diagnóstico de MM, puesto que se ha encontrado este antecedente hasta en un 46-60% de los MM subungueales6.

André J, Moulonguet I, Goettmann-Bonvallot S. In situ amelanotic melanoma of the nail unit mimicking lichen planus: report of 3 cases. Arch Dermatol. 2010 Apr;146(4):418-21.

Age

Band

Change

Digit

Extension



Debemos tener en cuenta que el MLA también puede cursar con distrofia ungueal, ulceración y hemorragia6. Además, no debemos olvidar el MM subungueal amelanótico, asi, Banfield et al. en su estudio retrospectivo de 105 melanomas subungueales encontraron que un 23% de sus MLA eran amelanóticos14. A nivel subungueal, los diagnósticos diferenciales más importantes son las hemorragias de origen traumático y las onicomicosis6. Recordar que un antecedente traumático no excluye el diagnóstico de MM, puesto que se ha encontrado este antecedente hasta en un 46-60% de los MM subungueales6.

Arriba izquierda: The first case was diagnosed as psoriasis because of a medical history of scalp psoriasis and the presence of onycholysis with splinter hemorrhages. However, the clinical aspect with longitudinal ridges and nail plate atrophy was more lichenoid than psoriasi form. Figure 1. Right thumb of a 51-year-old woman. Superficial longitudinal striations with thinning affecting the distal two-thirds of the median nail plate. Slight distal onycholysis, rare splinter hemorrhages, and a thin crevice across the distal nail ridge were also present.

Arriba derecha y abajo izquierda: In both other cases, the clinical diagnosis was monodactylic, isolated lichen planus. Indeed, longitudinal ridging and splitting, nail plate thinning, and focal redness of the lunula are classic signs of nail lichen planus

Abajo izquierda: (ya arriba también) Foto arriba izquierda (parece liquen plano): A 60-year-old woman presented with lateral longitudinal splitting of her right thumbnail, which had disturbed her for several months. There was a red spot in the lunula, with no associated pain. Magnetic resonance imaging did not reveal any pathologic process and especially no glomus tumor. Six months later (Figure4), there was complete longitudinal nail splitting, isolating a lateral spicule. The whole nail plate was flattened, with thin longitudinal ridges. Two splinter hemorrhages were also noted. A lateral longitudinal biopsy was performed. Histopathologically, many atypical melanocytes with hyperchromatic nuclei were present as solitary units along the basal layer of the nail bed epithelium. The melanocytes were tightly packed without pagetoid spread and without any nests. No inflammatory infiltrate was observed. In situ ALM was diagnosed. Total excision of the nail apparatus was performed followed by secondary intention healing. Histologic examination of the specimen revealed a proliferation of atypical melanocytes both in single units and in nests in the nail matrix and nail bed epithelium. There was no dermal invasion. The diagnosis of in situ ALM was confirmed. One year later, the patient was free of disease.

Signo de Hurchinson es muy sensible, es en la fase de crecimiento radial más que vertical, es la progresión de la pigmentación más allá del borde libre de la uña o de la cutícula. Es un signo preocupante. Nos permite actuar.

Signos tardíos en la uña: ulceración, sangrado, onicodistrofiaEl 25% son amelanóticos (1 de cada cuatro) frente al 7% de los MM!!!!!!!!!!

Amelanotic NAM represents 20% to 30% of ungual melanoma cases compared with less than 7% of the other cutaneous melanomas.1 It usually presents as a chronic paronychia,a torpid granulomatous ulceration, a wart like keratotic tumor, or a pyogenic granuloma.4,5 It is usually located in the periungual folds or in the nail bed. Clinical misdiagnosis, which is particularly frequent in amelanotic melanoma,3 is responsible for a delay in diagnosis as well as a poor prognosis. In situ NAM usually starts in the nail matrix and presents as a slowly widening longitudinal melanonychia with possible extension to the periungual skin (Hutchinson sign).6-10 It may also start as multiple longitudinal melanonychia on a single nail. From a histologic point of view, it corresponds to ALM. Histologic diagnosis may be difficult in early cases, especially when small incisional biopsies are involved. To the best of our knowledge, only 1 case of in situ amelanotic NAM has been reported.11 The clinical aspect was a longitudinal erythronychia with mild distal onycholysis. This aspect is different from that observed in our cases. Our3 cases were seen by dermatologists who are skilled in nail diseases. However, the clinical diagnosis of melanoma was missed. The first case was diagnosed as psoriasis because of a medical history of scalp psoriasis and the presence of onycholysis with splinter hemorrhages. However, the clinical aspect with longitudinal ridges and nail plate atrophy was more lichenoid than psoriasi form.In both other cases, the clinical diagnosis was monodactylic, isolated lichen planus. Indeed, longitudinal ridging and splitting, nail plate thinning, and focal redness of the lunula are classic signs of nail lichen planus.12 Confronted with the atypical monodactylic presentation that did not affect thewholenail plate, biopsies were performed in all 3 cases to assess the diagnosis and to exclude another process. Partial biopsies were performed because a melanoma was not expected. A total excision of the lesion would otherwise have been performed, thus allowing an accurate histologic diagnosis.Superficial ridging is sometimes observed in junctional nevus and in in situ melanoma. It is probably the result of a dysfunction of the proximal nail matrix that is related to a florid melanocytic hyperplasia. Nail brittleness is more frequent and manifests as distal splitting or onychoschizia, also reflecting nail matrix dysfunction. The severe median nail plate atrophy observed in cases 1 and 2 could be related to the severe nail bed involvement. Whether the nail bed may contribute up to 20% of the nail plate formation is debatable.13 It has been suggested that the matrix involved by the in situ melanoma produces a brittle nail. When the nail plate grows further, the dysfunction of the nail bed then creates the atrophy because its contribution to the nail plate is impaired. In our cases, the histologic diagnosis was obvious in all biopsy specimens. This obvious diagnosis contrasts with the known difficult diagnosis in early nail melanoma presenting as longitudinal melanonychia. The lesions of our patients were amelanotic and might have remained unnoticed for a long time. This long evolution would also explain the severe histologic involvement of the nail matrix and nail bed by the in situ melanoma. In conclusion, we diagnosed 3 amelanotic ALMs at an early, in situ stage. In contrast, most invasive cases of amelanotic NAM are nodular melanoma, which explains a completely different clinical presentation. Monodactylic longitudinal splitting, lichenoid nail changes with nail plate atrophy, and longitudinal ridges should be added to the more conventional signs of incipient nail melanoma. To the best of our knowledge, these clinical features have not been reported to date. Chronic unexplained monodactylic nail dystrophy, especially in adults, should always be histologically investigated. Monodactylic nail lichen planus should be confirmed histologically before treatment.

Age

Band

Change

Digit

Extension


1 out of 4 nail melanomas are amelanotic


Debemos tener en cuenta que el MLA también puede cursar con distrofia ungueal, ulceración y hemorragia6. Además, no debemos olvidar el MM subungueal amelanótico, asi, Banfield et al. en su estudio retrospectivo de 105 melanomas subungueales encontraron que un 23% de sus MLA eran amelanóticos14. A nivel subungueal, los diagnósticos diferenciales más importantes son las hemorragias de origen traumático y las onicomicosis6. Recordar que un antecedente traumático no excluye el diagnóstico de MM, puesto que se ha encontrado este antecedente hasta en un 46-60% de los MM subungueales6.

Arriba izquierda: The first case was diagnosed as psoriasis because of a medical history of scalp psoriasis and the presence of onycholysis with splinter hemorrhages. However, the clinical aspect with longitudinal ridges and nail plate atrophy was more lichenoid than psoriasi form. Figure 1. Right thumb of a 51-year-old woman. Superficial longitudinal striations with thinning affecting the distal two-thirds of the median nail plate. Slight distal onycholysis, rare splinter hemorrhages, and a thin crevice across the distal nail ridge were also present.

Arriba derecha y abajo izquierda: In both other cases, the clinical diagnosis was monodactylic, isolated lichen planus. Indeed, longitudinal ridging and splitting, nail plate thinning, and focal redness of the lunula are classic signs of nail lichen planus

Abajo izquierda: (ya arriba también) Foto arriba izquierda (parece liquen plano): A 60-year-old woman presented with lateral longitudinal splitting of her right thumbnail, which had disturbed her for several months. There was a red spot in the lunula, with no associated pain. Magnetic resonance imaging did not reveal any pathologic process and especially no glomus tumor. Six months later (Figure4), there was complete longitudinal nail splitting, isolating a lateral spicule. The whole nail plate was flattened, with thin longitudinal ridges. Two splinter hemorrhages were also noted. A lateral longitudinal biopsy was performed. Histopathologically, many atypical melanocytes with hyperchromatic nuclei were present as solitary units along the basal layer of the nail bed epithelium. The melanocytes were tightly packed without pagetoid spread and without any nests. No inflammatory infiltrate was observed. In situ ALM was diagnosed. Total excision of the nail apparatus was performed followed by secondary intention healing. Histologic examination of the specimen revealed a proliferation of atypical melanocytes both in single units and in nests in the nail matrix and nail bed epithelium. There was no dermal invasion. The diagnosis of in situ ALM was confirmed. One year later, the patient was free of disease.

Signo de Hurchinson es muy sensible, es en la fase de crecimiento radial más que vertical, es la progresión de la pigmentación más allá del borde libre de la uña o de la cutícula. Es un signo preocupante. Nos permite actuar.

Signos tardíos en la uña: ulceración, sangrado, onicodistrofiaEl 25% son amelanóticos (1 de cada cuatro) frente al 7% de los MM!!!!!!!!!!

Amelanotic NAM represents 20% to 30% of ungual melanoma cases compared with less than 7% of the other cutaneous melanomas.1 It usually presents as a chronic paronychia,a torpid granulomatous ulceration, a wart like keratotic tumor, or a pyogenic granuloma.4,5 It is usually located in the periungual folds or in the nail bed. Clinical misdiagnosis, which is particularly frequent in amelanotic melanoma,3 is responsible for a delay in diagnosis as well as a poor prognosis. In situ NAM usually starts in the nail matrix and presents as a slowly widening longitudinal melanonychia with possible extension to the periungual skin (Hutchinson sign).6-10 It may also start as multiple longitudinal melanonychia on a single nail. From a histologic point of view, it corresponds to ALM. Histologic diagnosis may be difficult in early cases, especially when small incisional biopsies are involved. To the best of our knowledge, only 1 case of in situ amelanotic NAM has been reported.11 The clinical aspect was a longitudinal erythronychia with mild distal onycholysis. This aspect is different from that observed in our cases. Our3 cases were seen by dermatologists who are skilled in nail diseases. However, the clinical diagnosis of melanoma was missed. The first case was diagnosed as psoriasis because of a medical history of scalp psoriasis and the presence of onycholysis with splinter hemorrhages. However, the clinical aspect with longitudinal ridges and nail plate atrophy was more lichenoid than psoriasi form.In both other cases, the clinical diagnosis was monodactylic, isolated lichen planus. Indeed, longitudinal ridging and splitting, nail plate thinning, and focal redness of the lunula are classic signs of nail lichen planus.12 Confronted with the atypical monodactylic presentation that did not affect thewholenail plate, biopsies were performed in all 3 cases to assess the diagnosis and to exclude another process. Partial biopsies were performed because a melanoma was not expected. A total excision of the lesion would otherwise have been performed, thus allowing an accurate histologic diagnosis.Superficial ridging is sometimes observed in junctional nevus and in in situ melanoma. It is probably the result of a dysfunction of the proximal nail matrix that is related to a florid melanocytic hyperplasia. Nail brittleness is more frequent and manifests as distal splitting or onychoschizia, also reflecting nail matrix dysfunction. The severe median nail plate atrophy observed in cases 1 and 2 could be related to the severe nail bed involvement. Whether the nail bed may contribute up to 20% of the nail plate formation is debatable.13 It has been suggested that the matrix involved by the in situ melanoma produces a brittle nail. When the nail plate grows further, the dysfunction of the nail bed then creates the atrophy because its contribution to the nail plate is impaired. In our cases, the histologic diagnosis was obvious in all biopsy specimens. This obvious diagnosis contrasts with the known difficult diagnosis in early nail melanoma presenting as longitudinal melanonychia. The lesions of our patients were amelanotic and might have remained unnoticed for a long time. This long evolution would also explain the severe histologic involvement of the nail matrix and nail bed by the in situ melanoma. In conclusion, we diagnosed 3 amelanotic ALMs at an early, in situ stage. In contrast, most invasive cases of amelanotic NAM are nodular melanoma, which explains a completely different clinical presentation. Monodactylic longitudinal splitting, lichenoid nail changes with nail plate atrophy, and longitudinal ridges should be added to the more conventional signs of incipient nail melanoma. To the best of our knowledge, these clinical features have not been reported to date. Chronic unexplained monodactylic nail dystrophy, especially in adults, should always be histologically investigated. Monodactylic nail lichen planus should be confirmed histologically before treatment.

Diferencial diagnosis

PresenterPresentation NotesArriba izquierda: Acral lentiginous melanoma involving the medial great toe treated as a diabetic neuropathic ulceration for more than 1 year. A 61-year-old white man was monitored for 1 year with a chronic non-healing ulceration of the medial aspect of his left great toe. His medical history was positive for uncontrolled diabetes mellitus complicated by peripheral neuropathy, vascular impairment, and heart disease. The patient had a significant smoking history and occasional alcohol usage. Treatment before his referral to us included periodic wound débridement, antibiotics, and daily dressing changes. The patient also related a 30-year history of a pigmented lesion of the medial aspect of his hallux that was irregular in pigmentation and in an area near the ulceration (Figure 6).

La foto de la izquierda es del articulo que relaciona ulc diab con lesiones verrugosas y pone SI PONER


PresenterPresentation NotesArriba derecha: A patient presented with a long-standing lesion that was initially described as a darkened patch on his plantar right foot (Figure 2). A diagnosis of tinea pedis was made, and the area was treated with topical antifungal cream. After 6 months of treatment by an outside physician, the lesion continued to persist and spread. Topical treatment was discontinued, and the patient was referred to our module because of extensive involvement of the lateral arch of his right foot with a pigmented area. A biopsy revealed ALM, Clark level V, with clinical and histologic multiple inguinal lymph node involvement.


PresenterPresentation NotesAbajo izquierda: Dalmau et al. Mujer de 58 años de edad que presenta una lesión hiperqueratósica plantar en el pie izquiedro, de varios meses de evolución. Consultó un podólogo que realizó curetaje por sospecha de verruga plantar. La paciente se remitió posteriormente al dermatólogo por presentar una respuesta pobre al tratamiento y por presentar hemorragia durante el curetaje. Un mes después del curetaje, habiendo valorado la lesión como verruga plantar, el dermatólogo administró crioterapia. Cuatro semanas más tarde, el dermatólogo observó hiperqueratosis y una mácula marrón alderedor del sitio del tratamiento y prescribió tratamiento queratolítico con…. ..y ácido salicílico durante varias semanas. La lesión no mejoró y finalmente se realizó una biopsia, que reveló AM in situ.

Verruga plantar a la izquierda del ar´ticulo guardado como plantar wart


PresenterPresentation Notes-Arriba izquierda y derecha: Vicente García PatosFoto melanoma talon del ar´ticulo: Acral lentiginous melanoma: conventional histology vs three dimensional histology


PresenterPresentation NotesA la izquierda es foto de una ulcera diabetica del articulo diab ulc toe pictureLas dos de arriba son nuestrasLa de la derecha es un melanoma de un artículo y no recuerdo cual


PresenterPresentation NotesA la derecha: Melanoma acral simulando un granuloma piogénico Mujer de 55 an õs que consulto ´ por una lesio ń en el tercer dedo de su mano derecha, que habı á aparecido 7 meses antes, de r apidocrecimiento. Habı á recibido tratamiento con amoxicilina/ acido clavul anico y electrocoagulacio ń en 2 ocasiones con la sospecha de granuloma pio ´ geno. La exploracio ń(fig. 1) mostro ´ un no ´dulo ulcerado de color rojo intenso, de 1,81 cm de taman õ. La biopsia incisional fue compatible con melanoma. Se practico ´ amputacio ń del dedo y linfadenectomı á axilar, y se encontro ´ met astasis en 4 ganglios. El estudio de la pieza quir ´ urgica confirmo ´ el diagno ´ stico de melanoma lentiginoso acral de 5,25mm de microinvasio ń y nivel V de Clark. Los valores analı ´ticos ası ´ como la TAC toracoabdominal fueron normales. Tras 18 meses no se han detectado met astasis a distancia.


PresenterPresentation NotesBuscar de qué artíuclo es y asegurar que es melanoma


PresenterPresentation NotesAbajo en medio: García Patos melanoma amelanótico


PresenterPresentation NotesAbajo Izquierda: Nevus congénito. Ella tenía una lesión pigmentada en el pie derecho desde el nacimiento. El examen clínico reveló una placa azulada, de diámetro de 40 x 20 mm, con bordes regulares y bien definidos. La dermatoscipi mos´tró un patron azul homogéneo similara a un nevus azul y a metástasis de melanoma. Se realizó la excisión y el diagnóstico patológico fue de nevus congénito melanocítico intradérmico, debido a la presencia de melanocitos, sin atipia, infiltrado al extremidad de la piel. Congenital melanocytic nevi are present in 1 percent of newborns. They may be small, medium, or giant (>20cm) and the development of malignancy appears to be associated the lesion size (with a risk of between 5% and 40% for patients with giant nevus) [1]. Acral congenital nevi are less common than in other locations.

A la derecha melanoma desde nevo congénito, del artículo grabado con el nombre melanoma desde nevo congénito

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Slide Number 1IntroductionIntroductionSlide Number 4Slide Number 5IntroductionSlide Number 7IntroductionSlide Number 9Slide Number 10ABCDE Slide Number 12¿Is this a melanoma?¿Do they follow the ABCDE?Slide Number 15¿Is this a melanoma?Ungueal ABCDEFSlide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Diferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisDiferencial diagnosisSlide Number 32Slide Number 33

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