Conflicts of interest

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1 Dermoscopy of acral melanoma Luc THOMAS Service de Dermatologie Université Claude Bernard, Lyon 1 Centre Hospitalier Lyon Sud Lyon, France Conflicts of interest Jean Marie Naeyaert Full-time Employee of the French Ministry for Education and Research, no private practice and no personal financial relationship with pharmaceutical or bio-medical industry PI skin oncology clinical trials (VICAL, ROCHE, GSK, BMS, INTUISKIN, PIXIENCE, NOVARTIS, GENENTECH, GALDERMA, MERCK-SERONO) no personal honorarium. (Public declaration of interest(s) available on HAS website : Author of «Atlas de Dermoscopie» RP Braun et L Thomas Elsevier Masson Paris 2007 (French, Portuguese (Brazil) & Polish) «Précis de dermatologie et IST» JH Saurat, JM Lachapelle, D Lipsker et L Thomas 5eme édition, Elsevier, Masson, Paris 2009 (French & Italian) «Diseases of the nail and their management» R Baran, D de Berker, M Holzberg & L Thomas Willey-Blackwell, London 2012 «Dermatologie chirurgicale» JM Amici, D Egasse, M Beylot Barry et L Thomas Elsevier Masson Paris 2012 Funding(s) Université Claude Bernard Lyon 1 Ligue Contre le cancer du Rhône et de l Ain Fondation APICIL Funds (mainly honoraria of clinical trials) are 100% kept under the responsibility of the Direction de la Recherche des Hospices Civils de Lyon and of Lyon 1 - Claude Bernard University as well as expenses The best quality for a chief is his ability to be rewarded for things that happen just by themselves Scott Adams Ezus 1

2 Alice Phan Stéphane Dalle Nicolas Poulalhon Sébastien Debarbieux Clélia Moulin Mona Amini-Adlé 2

3 Fanny Julia Marie Perrier-Muzet Olivier Béatrix Brigitte Balme Robert Baran All pictures presented during this lecture, except when specifically mentioned, belong to the collection of the department of dermatology of Lyon 1 University. When applicable, credit for borrowed pictures is mentioned on the slides. All patients gave their consent for photographs shown. Reproduction, publication, public use of any image without permission is strictly prohibited. 3

4 Dermoscopy A Dermoscopy reflects the anatomy M Exceptions Face Palms and soles Scars Nail Courtesy of S. Puig and J. Malvehy Mucous membranes Two-steps diagnostic strategy «Special location» pigmented lesions Pigmented skin lesion 1 st step Algorithm Melanocytic Non melanocytic 2 nd step Benign Suspicious Malignant ABCD rule Menzies s 7 points checklist Pattern analysis 4

5 Palms & soles Nails Harald Kittler Palms and soles CLINICAL AND LABORATORY INVESTIGATIONS DOI /j x Acral lentiginous melanoma: a clinicoprognostic study of 126 cases A. Phan, S. Touzet,* S. Dalle, S. Ronger-Savlé, B. Balme and L. Thomas Department of Dermatology, Hôtel Dieu, Claude Bernard University, Lyon cedex 02, France *Technology Assessment Unit, Department of Medical Information, Hôpitaux de Lyon, Claude Bernard University, Lyon cedex 03, France Summary Correspondence Luc Thomas. luc.thomas@chu-lyon.fr Accepted for publication 20 February 2006 Key words achromic melanoma, acral lentiginous melanoma, melanoma, prognosis, skin cancer Conflicts of interest None declared. Background Although the histopathological subtype of melanoma has not been clearly proven to carry independent prognostic significance, acral lentiginous melanoma (ALM) seems to confer a poorer prognosis mainly because disease is often more advanced at the time of diagnosis. Objectives To investigate the distinctive epidemiological and clinical characteristics of ALM, a peculiar histological entity, and to identify prognostic factors. Methods We performed a register-based review of cases from a single large referral centre, the University Hospital Department of Dermatology, Lyons, France. We reviewed patient demographics, the initial presentation of the lesion, and clinical outcome. ALM-specific and disease-free survival were estimated using the Kaplan Meier method and compared using the log-rank test. A Cox model was used to identify prognostic factors. Wallace s line Palms and soles Anatomy of volar skin Eccrine duct opening Crista superficialis (ridge) Sulcus superficialis (furrow) ldelanoma Nevus Crista superficiatis limitans Crista profunda intermedia Courtesy of T. Saida 5

6 Furrows Ridges Furrow Furrow Furrow Ridge Ridge Nevus crista profunda limitans Melanoma canal sudoripare canal sudoripare Palleschi et al, Clin Exp Derm 2006;31: Saïda et al, Clin Derm 2002;20: Two malignant patterns Two malignant patterns Two important rules Parallel ridge pattern Parallel ridge pattern Saida et al, Arch Dermatol 2004;140: Irregular diffuse pigmentation 6

7 A. Phan et al. Br J Dermatol (2010) 162 : Nevus Melanoma Braun RP et al, Arch Dermatol 2008 Dec; 144(12): Irregular diffuse pigmentation Saida et al, Arch Dermatol 2004;140: A. Phan et al. Br J Dermatol (2010) 162 :

8 Melanoma ALM subtype Clark s III, 0.3 mm Two important rules Rule N # 1 : Never be reinsured by the presence of a benign pattern within others patterns Rule N # 2 : Always consider the presence of a malignant pattern, within others, as a warning sign 8

9 SECTION EDITOR: JAMES M. GRICHNIK, MD, PhD; ASSISTANT SECTION EDITORS: ASHFAQ A. MARGHOOB, MD; ALON SCOPE, MD A A B Figure 1. B A B Figure 3. R-P. Braun et al. Dermatology (2013) skinsight Benign Dermoscopic Parallel Ridge Pattern Variants T Alice Phan, MD; Stéphane Dalle, MD; Marie-Cécile Marcilly, MD; Jean-Pierre Bergues, MD; Luc Thomas, MD, PhD; Centre Hospitalier Lyon-Sud, Claude Bernard University, Pierre Bénite, France HE PARALLEL RIDGE PATTERN (PRP) IS A VOlar dermoscopic pattern that is characterized by an accentuated pigmentation on the ridges of the skin markings, while the furrows are hypopigmented or unpigmented. It has been demonstrated to be highly specific for acral melanoma, and its presence must be considered a warning sign of melanoma. However, rare cases of benign acral melanocytic nevus can exhibit the PRP, as in the edge of the compound melanocytic nevus shown in Figure 1A. The acral blue nevus (Figure 1B) usually shows a bluish, quite homogeneous pigmentation involving the ridges. Ethnic pigmentation clinically presents as pigmented macules with a typical PRP on the palms and soles (Figure 2A). The multiplicity, bilateral location, and chronicity of the lesions are suggestive of ethnic-type pigmentation. The presentation is similar in Laugier-Hunziker or Peutz-Jeghers syndrome. Ectasic papillary capillaries of acral angioma present as regular red-blue globules along the ridges (Figure 2B). Repetitive microtrauma can cause extravasation of erythrocytes in the cornified layer, with subsequent misleading globular reddish brown pigmentation on the ridges, as seen in Figure 3A, which shows a posttraumatic purpura due to the friction of the fifth finger caused by regular use of the computer mouse. The PRP was also found in subcorneal hematoma. The lesion appears as well-demarcated roundish macule, with reddish brown pigmentation along the ridges (Figure 3B). Deposit of exogenous pigmentation on the ridges, especially in areas where the stratum corneum is thicker, can also simulate melanoma, as shown in Figure 4,withtheuse of a self-tanning preparation by a woman with localized palmar hyperkeratosis. A. Phan et al. Arch Dermatol (2011) 147 :

10 Robertson et al, Austral J Dermatol 2010;51: Nails

11 Melanonychia striata Ethnic-type pigmentation Melanocytic nevus Melanoma Sub-ungual haemorrhage Laugier Hutziker disease Drug-induced pigmentation Onychomycosis Trauma-induced pigmentation 11

12 Bowen s disease Onychomatricoma Clinical algorithm Clinical algorithm Acquired during childhood Polydactylic Stable Another (good) explanation for pigmentation (drug, ethnic, etc ) No periungual involvement Onset during adulthood Monodactylic Changes over time Peri-ungual involvement (Hutchinson s sign) Polychromia Triangular shaped (adult) Change of the plate Childhood onset Polydactylic / other explanation Rather benign Clinical algorithm Clinical algorithm Hutchinson s sign Change over time Polychromia Plate change Rather Malignant M 0 M 18 Triangular shape Rather Malignant 12

13 Dermoscopy Arch Dermatol 2002, 138, A. Phan et al. Br J Dermatol (2010) 162 : Known from dermoscopy Blood spots Brown color of the background 13

14 Regular pattern of the longitudinal lines Irregular pattern of the longitudinal lines Gray-yellowish color of the background 14

15 Micro-Hutchinson s sign Longitudinal leuco/ xanthonychia Distal subungual hyperkeratosis Linear micro-hemorrhages 15

16 Diagnoses Pigmented melanoma Brown background (95%) Irregular pattern of lines (95%) Micro-Hutchinson s sign (15%) Blood spots (5%) Nail-matrix melanocytic nevus Brown Background (100%) Regular pattern of lines (94%) Irregular lines (6%) 16

17 Subungual hemorrhage Blood spot (100 %) M Absence of any other symptom M Follow-up : clearance of the lesion within 3 to 6 months Nail unit lentigo and lentiginosis Identical in isolated lentigo and in lentiginoses of different types Gray line (93 %) No other change of the nail plate (92 %) Drug-induced nail pigmentation Dermoscopical pattern of a lentigo : Homogeneous gray line (93 %) 17

18 Ethnic-type nail pigmentation Dermoscopical pattern of a lentigo : Homogeneous gray line (87 %) Repetitive trauma-induced nail pigmentation Dermoscopical pattern of a lentigo : Homogeneous gray line (no statistical evaluation available) Trauma-induced changes (no statistical evaluation available) Blood spots, micro-hemorrhages Change of the nail plate surface Pigmented Bowen s / SCC Subungual distal hyperkeratosis (70%) Longitudinal leuco-xanthonychia (60%) Polychromia (45%) Triangular distal onycholysis, convex deformity and yellow spot (40%) Disappearance of the lunula and linear microhemorrahges (35%) Irregular linear telangiectasias (30%) Triangular lunula (20%) 18

19 Onychomatricoma Subungual distal hyperkeratosis (73%) Linear microhemorrahges (67%) Convex deformity of the nail plate, longitudinal superimposition above the lunula and longitudinal leucoxanthonychia (53%) Triangular distal onycholysis (47%) Longitudinal erythronychia, irregular linear telangiectasias (40%) Digital follow-up M 0 M 0 M 0 ALM, Clark s II, 0.18mm M 18 M 0 M 3 In situ ALM 19

20 Onychomycosis First Evaluation M 0 Atypical Subungual hemorrhage Non Atypical persistance Clearance 4 months control Surgical Biopsy modification No modification Annual follow-up M 0 M 6 (after treatment) Intra-operative dermoscopy J Am Acad Dermatol 2005, 53, In vivo Ex vivo Non melanocytic Melanocytic 20

21 Non melanocytic Melanocytic Benign Patterns Lines regular and globules Non melanocytic Lines regular Lines regular and globules Non melanocytic Lines regular Lines regular and globules Benign Patterns Malignant pattern Lines irregular & irregular globules Lines irregular & irregular globules 21

22 Lines irregular & irregular globules Lines irregular & irregular globules Nevus Lines irregular & irregular globules Melanoma Melanoma 22

23 M 7 Squamous cell carcinoma of the nail bed Limitation(s) Ex-vivo reflectance confocal microscopy 23

24 In-vivo reflectance confocal microscopy Ex vivo in vivo ex vivo in vivo ex vivo 24

25 Melanoma Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time Melan A Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time Dermoscopy Nail matrix dermoscopy Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time In-vivo RCM In-vivo RCM 25

26 Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time In-vivo RCM Male patient 48 year old Skin type IIIb Melanonychia striata Monodactylic Present for about 3 years Changing over time M 2 In press Br J Dermatol

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