6/17/2018. Breaking Bad (Part 1) Dermoscopy of Brown(ish) Things. Bad?

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1 Breaking Bad (Part 1) Dermoscopy of Brown(ish) Things Jennie T. Clarke, MD ssociate Professor of Dermatology University of Utah School of Medicine Bad? 1

2 Brown(ish) Things Bad Melanoma Pigmented basal cell carcinoma t Bad Nevi Blue nevus cral nevus Solar lentigo Seborrheic keratosis Dermatofibroma Two Step Method 1. Is it a melanocytic neoplasm? 1. Pigment Network or streaks ggregated globules Homogenous 2. Is it a benign or malignant melanocytic neoplasm? 1. Pattern and Features 1. Is it a Melanocytic Tumor? Pigment Network, lines or streaks ggregated globules Homogenous 2

3 Network Grid-like/honeycomb intersecting pigmented lines and hypopigmented holes - lines = melanin along the epidermal rete ridges - holes = tips of the dermal papillae Lines & Streaks Lines (Branched streaks) irregular/broken network Streaks (pseudopods or thin linear projections) seen at periphery of pigmented lesion ggregated Globules Globules = round to oval structures that may be brown, black, blue-gray 3

4 Homogenous DermNet New Zealand Homogenous blue pigment = blue nevus Homogenous light brown pigment = solar lentigo Step 2. Is it a Benign or Malignant Melanocytic Neoplasm? Benign Nevus Patterns Marghoob, et al. The Beauty and the Beast Sign in Dermoscopy. Derm Surg. v

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7 Nevus evolution Peripheral globules & Reticular Patchy reticular Central reticular network What bout cral Skin? Pigment in parallel lines Parallel furrow pattern = benign Parallel ridge pattern = malignant Ridges are risky and furrows are fine Basicdermatoscopy.blogspot.com Look at the edge of the lesion to find the ridge/furrow pattern 7

8 Step 2. Fit a Benign Nevus Pattern? Step 1: Melanocytic? pigment network, globules, homogeneous? Observe Step 3. re there Melanoma Features? Melanoma Biopsy/Excise Concerning: Biopsy/Excise or Short-term monitoring re There Melanoma Features? 1. typical Pigment Network - color variegation, differing line widths, differing hole sizes, branched streaks, abrupt cutoff at periphery 2. Focal Streaks pseudopods, radial streaming 3. Negative Network - serpiginous interconnecting hypopigmented lines surrounding irregularly shaped pigmented structures, usually distributed asymmetrically and found focally 4. Chrysalis - short white streaks that often oriented at right angles - can only be seen with polarized light (Can also occur in lichenoid keratoses, DF, BCC) 5. typical Dots & Globules - vary in size and color; dots tend to be located toward the periphery of the lesion and not overlying network lines 6. Off-center Blotch - often has a heterogeneous appearance with multiple shades of color 7. Peripheral Structureless rea 8. typical Vasculature - comma vessels are characteristic of dermal nevi; any other vessel morphology should raise suspicion for melanoma, particularly if more than one vessel type is present 9. Regression Signs - blue-white veil over a flat portion of a lesion, regression structures also include peppering/ granularity and scar-like depigmentation 10. Blue-white veil - irregular blue-white veil consists of a prominent blue-white color that has different shades, and thus appearing heterogeneous Marghoob, shfaq. n tlas of Dermoscopy, 2nd Edition re There Melanoma Features? 1. typical pigment network 2. Focal Streaks Pseudopods, Radial Streaming 3. Negative Network 4. Chrysalis 5. typical Dots & Globules 6. Off-center Blotch 7. Peripheral Structureless rea 8. typical Vasculature 9. Regression Signs 10. Blue-white veil 8

9 re There Melanoma Features? 1. typical Pigment Network 2. Focal Streaks Pseudopods, Radial Streaming 3. Negative Network 4. Chrysalis 5. typical Dots & Globules 6. Off-center Blotch 7. Peripheral Structureless rea 8. typical Vasculature 9. Regression Signs -- Peppering, Scar-like white areas 10. Blue-white veil Step 2. Fit a Benign Nevus Pattern? Does it Fit? Step 1: Melanocytic? pigment network, globules, homogeneous? Step 2. Structures seen in DF, BCC, SK, ngioma, SCC? Observe Step 3. re there Melanoma Features? Melanoma Biopsy/Excise Concerning: Excise or Short-term monitoring Step 1. Is it a Melanocytic Neoplasm? 9

10 Copyright restrictions may apply. Marghoob,.. et al. rch Dermatol 2010;146: Melanocytic Mimickers: Dermatofibromas Structureless white area (scar-like) centrally, may contain vessels Fine reticular network or structureless periphery Melanocytic Mimickers: Pigmented Basal Cell Carcinomas Branched (arborizing) vessels Blue globules Gray dots Radial lines 10

11 Melanocytic Mimickers: Pigmented Basal Cell Carcinoma Melanocytic Mimickers: Seborrheic Keratoses Keratin cysts/orange & white globules Thick curved lines (fat fingers/sulci and gyri) Fingerprint-like lines Sharply demarcated border bsence of wobble sign Melanocytic Mimickers: Seborrheic Keratoses Fingerprint-like lines Gyri & Sulci DermNet New Zealand 11

12 Melanocytic Mimickers: ngiomas Red/purple globules bsence of vessels Step 2. Fit a Benign Nevus Pattern? Step 1: Melanocytic? pigment network, globules, homogeneous? Step 2. Structures seen in DF, BCC, SK, ngioma, SCC? Observe Step 3. re there Melanoma Features? Melanoma Biopsy/Excise Concerning: Excise or Short-term monitoring 12

13 1. Is this a melanocytic neoplasm?, there s a pigment network 2. Is this a benign or malignant melanocytic neoplasm? Diagnosis: melanoma in situ, chrysalis, regression signs, structureless area at periphery. This is malignant! Hmmm, it doesn t fit a benign pattern re there melanoma features? Question 1 25 year-old man who just got his hair cut and the barber noted: Is there a pigment network/lines/streaks, aggregated globules, or homogeneous color?. B. 13

14 Is there a pigment network/lines/streaks, globules, or homogeneous color?. * B. Does it fit a benign pattern?. B. Does it fit a benign pattern?. * B. 14

15 Question 2 55 year old man with an enlarging growth on his forehead Is there a pigment network/lines/streaks, aggregated globules, homogeneous?. B. * What dermatoscopic structures do you see?. Chrysalis structures B. rborizing vessels C. Blue gray ovoid nests D. Both B and C E. ll of the above 15

16 What dermatoscopic structures do you see?. Chrysalis structures B. rborizing vessels C. Blue gray ovoid nests D. Both B and C* E. ll of the above Question 3 Dermoscopy of Brown(ish) Things Question 3 16

17 Question 4 63 year old man comes to see you about a non-healing sore. Is there a pigment network, aggregated globules, homogeneous?. B. Question 4 63 year old man comes to see you about a non-healing sore. Is there a pigment network/lines/streaks, aggregated globules, homogeneous?. B. Question 4 63 year old man comes to see you about a non-healing sore. Is there a pigment network/lines/streaks, aggregated globules, homogeneous?.* B. 17

18 Does it fit a known pattern?. B. * Does it fit a known pattern?. B. What dermatoscopic structures do you see?. Focal streaks pseudopods, radial streaming B. typical dots & globules C. Off-center Blotch D. typical vascular pattern E. ll of the above 18

19 What dermatoscopic structures do you see?. typical dots & globules B. Focal streaks pseudopods, radial streaming C. Off-center Blotch D. typical vascular pattern E. ll of the above* Diagnosis: Melanoma Step 2. Fit a Benign Nevus Pattern? Does it Fit? Step 1: Melanocytic? pigment network, globules, homogeneous? Step 2. Structures seen in DF, BCC, SK, ngioma, SCC? Observe Step 3. re there Melanoma Features? Melanoma Biopsy/Excise Concerning: Excise or Short-term monitoring References Marghoob,, Malvehy J, Braun R, eds. n tlas of Dermoscopy, 2nd Edition. 2013; CRC Press, Boca Raton, FL Marghoob, Korzenko J, Chancchien L, Scope, Braun RP, Rabinovitz H. The beauty and the beast sign in dermoscopy. Dermatol Surg. 2007;33: BasicDermatoscopy.blogspot.com Dermnetznz.org Dermoscopy CME. images were changed; 19

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