10.5826/dpc.1201a35
Introduction: Whether extrafacial lentigo maligna (EFLM) differs clinically and/or dermoscopically according to location has not been analyzed in depth.
Objectives: To evaluate clinical and dermoscopic characteristics regarding different localization in a series of EFLM.
Methods: We conducted a retrospective analysis of clinical and dermoscopic characteristics of 69 histologically proven EFLM retrieved from the database of two private institutions.
Results: Of the 69 EFLM included in the study, 25 (36.2%) were located in posterior trunk (PT), 16 (23.2%) in anterior trunk (AT), 15 (21%) in upper extremities (UE), and 13 (18.8%) in lower extremities (LE). Mean diameter among localization were as follows: 14.3 mm in PT, 11.8 mm in AT, 14 mm in UE, and 10 mm in LE (p 0.44). The most frequent dermoscopic criteria were angulated lines and tan structureless areas (70%), followed by atypical pigment network (60%), both with similar distribution among groups. Angulated lines pattern was the most frequent global pattern, observed in 55% of cases. Tan structureless/granularity pattern and patchy peripheral pigmented islands pattern were seen in 15.6% and 11.6% cases, respectively. No statistically significant differences were observed in the distribution of global dermoscopic pattern in the different localizations.
Conclusions: From the clinical point of view, EFLM did not differ in terms of patient’s age and diameter regarding localization. Upon dermoscopy, we found no significant differences in the overall dermoscopic pattern in the different localizations.
text/xml
2160-9381
1940
en
Horacio Cabo
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Extrafacial Lentigo Maligna: A Clinical And Dermoscopic Analysis According to Localization
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-08-05
2022-02-02
2022-02-09
e2022035
Dermatol Pract Concept
Introduction: Whether extrafacial lentigo maligna (EFLM) differs clinically and/or dermoscopically according to location has not been analyzed in depth.
Objectives: To evaluate clinical and dermoscopic characteristics regarding different localization in a series of EFLM.
Methods: We conducted a retrospective analysis of clinical and dermoscopic characteristics of 69 histologically proven EFLM retrieved from the database of two private institutions.
Results: Of the 69 EFLM included in the study, 25 (36.2%) were located in posterior trunk (PT), 16 (23.2%) in anterior trunk (AT), 15 (21%) in upper extremities (UE), and 13 (18.8%) in lower extremities (LE). Mean diameter among localization were as follows: 14.3 mm in PT, 11.8 mm in AT, 14 mm in UE, and 10 mm in LE (p 0.44). The most frequent dermoscopic criteria were angulated lines and tan structureless areas (70%), followed by atypical pigment network (60%), both with similar distribution among groups. Angulated lines pattern was the most frequent global pattern, observed in 55% of cases. Tan structureless/granularity pattern and patchy peripheral pigmented islands pattern were seen in 15.6% and 11.6% cases, respectively. No statistically significant differences were observed in the distribution of global dermoscopic pattern in the different localizations.
Conclusions: From the clinical point of view, EFLM did not differ in terms of patient’s age and diameter regarding localization. Upon dermoscopy, we found no significant differences in the overall dermoscopic pattern in the different localizations.
Horacio Cabo
2022/02/02
10.5826/dpc.1201a35
e2022035
Dermatology Department, Universidad de Buenos Aires, Argentina
2160-9381
dermoscopy
en
e2022035
Stolz W, Schiffner R, Burgdorf WH. Dermatoscopy for facial pigmented skin lesions. Clin Dermatol. 2002;20(3):276-278. DOI: 10.1016/s0738-081x(02)00221-3. PMID: 12074867.
Extrafacial Lentigo Maligna: A Clinical And Dermoscopic Analysis According to Localization
https://dpcj.org/index.php/dpc/article/download/1940/1464
                    Dermatology Practical & Conceptual


       Extrafacial Lentigo Maligna: A Clinical And
     Dermoscopic Analysis According to Localization
                             Gabriel Salerni1, Emilia Cohen-Sabban2, Horacio Cabo3


1 Dermatology Department, Hospital Provincial del Centenario de Rosario, Universidad Nacional de Rosario, Diagnóstico Médico Oroño,
  Rosario, Argentina
2 Dermatology Service, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Argentina
3 Dermatology Department, Universidad de Buenos Aires, Argentina



Key words: skin cancer, melanoma, lentigo maligna, dermoscopy
Citation: Salerni G, Cohen-Sabban E, Cabo H. Extrafacial lentigo maligna: a clinical and dermoscopic analysis according to localization.
Dermatol Pract Concept. 2022;12(1):e2022035. DOI: https://doi.org/10.5826/dpc.1201a35
Accepted: August 30, 2021; Published: January 2022
Copyright: ©2022 Salerni et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding author: Gabriel Salerni, MD, Dermatology Department, Hospital Provincial del Centenario de Rosario - Universidad
Nacional de Rosario - Diagnóstico Médico Oroño, Rosario, Argentina. Email: gabrielsalerni@hotmail.com




  ABSTRACT             Introduction: Whether extrafacial lentigo maligna (EFLM) differs clinically and/or dermoscopically
                       according to location has not been analyzed in depth.
                       Objectives: To evaluate clinical and dermoscopic characteristics regarding different localization in a
                       series of EFLM.
                       Methods: We conducted a retrospective analysis of clinical and dermoscopic characteristics of 69 his-
                       tologically proven EFLM retrieved from the database of two private institutions.
                       Results: Of the 69 EFLM included in the study, 25 (36.2%) were located in posterior trunk (PT), 16
                       (23.2%) in anterior trunk (AT), 15 (21%) in upper extremities (UE), and 13 (18.8%) in lower extrem-
                       ities (LE). Mean diameter among localization were as follows: 14.3 mm in PT, 11.8 mm in AT, 14 mm
                       in UE, and 10 mm in LE (p 0.44). The most frequent dermoscopic criteria were angulated lines and
                       tan structureless areas (70%), followed by atypical pigment network (60%), both with similar distri-
                       bution among groups. Angulated lines pattern was the most frequent global pattern, observed in 55%
                       of cases. Tan structureless/granularity pattern and patchy peripheral pigmented islands pattern were
                       seen in 15.6% and 11.6% cases, respectively. No statistically significant differences were observed in
                       the distribution of global dermoscopic pattern in the different localizations.
                       Conclusions: From the clinical point of view, EFLM did not differ in terms of patient’s age and di-
                       ameter regarding localization. Upon dermoscopy, we found no significant differences in the overall
                       dermoscopic pattern in the different localizations.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022035                                                                             1
Introduction                                                         Results
Lentigo maligna (LM) is a variant of in situ melanoma that           Of the 69 EFLM included in the study, 25 (36.2%) were
develops mainly in chronic sun exposure areas in middle-aged         located in posterior trunk (PT), 16 (23.2%) in anterior trunk
and elderly patients. If left untreated, it can evolve to its        (AT), 15 (21%) in upper extremities (UE), and 13 (18.8%) in
invasive form, LM melanoma [1]. Hence, early recognition             lower extremities (LE).
and proper management is crucial to reduce morbidity and
mortality associated to melanoma.                                    Population
    Dermoscopy has shown to increase the sensitivity and             The study population consisted of 24 females (34.8%) and 45
specificity in the clinical diagnosis of melanoma by allowing        males (65.2%), with a mean age of 68.5 years (range 38-86).
the visualization of diagnostic criteria not visible to naked eye.   No statistically significant differences were observed in age
Moreover, its routine use for the evaluation of melanocytic and      according to localization (Figure 1). Distribution according
non-melanocytic skin lesions is recommended in most of the           to gender was homogeneous among the 4 groups.
clinical guidelines worldwide [2,3]. Dermoscopic criteria such as
granularity, angulated lines, or vessels as well as overall dermo-
                                                                     Clinical Evaluation
scopic patterns have been described to improve recognition of
                                                                     Mean diameter among localization were as follows: 14.3 mm
lentigo maligna in nonfacial chronically sun-damaged skin [4].
                                                                     (5-24 mm) in PT, 11.8 mm (6-23 mm) in AT, 14 mm (2-30 mm)
                                                                     in UE, and 10 mm (range 4-24 mm) in LE (Figure 2). No
Objectives                                                           statistically significant differences were observed regarding
                                                                     diameter and localization (P = 0.44). EFLM in individuals
We sought to evaluate clinical and dermoscopic characteris-
                                                                     older than 70 years showed a significantly greater diameter
tics regarding different localization in a series of extrafacial
                                                                     than in those younger than 70 years (P = 0.002).
lentigo maligna (EFLM) confirmed by histopathology.
                                                                           In clinical examination (Table 1), 60 out of the 69 EFLM
                                                                     included (87%) were considered striking from the clinical point
Methods                                                              of view. Concerning localization, all lesions located in UE were
                                                                     considered clinically striking, 92% of the lesions in PT, 80% in
We conducted a retrospective analysis of clinical and der-           AT, and 70% in LE, respectively. Light brown and dark brown
moscopic characteristics of 69 histologically proven EFLM            were the most frequent colors, observed in about the 90% of
diagnosed between 2016 and 2020 in two private clinics. The          the cases. White, blue-grey and pink were the less frequent
study included primary LM with clinical and dermoscopic              colors observed clinically. Lesions located in AT ­displayed only
pictures of acceptable quality to allow reliable evaluation.
Dermoscopic images were captured with polarized light using
hand-held dermatoscope (Dermlite II pro Hybrid, 3Gen LLC)
attached to a digital camera and digital dermoscopy devices
                                                                           90
(FotoFinder Systems GmbH).
                                                                           80
    The study was conducted according to the Declaration
of Helsinki; patient’s written consent was obtained for all
                                                                           70
invasive procedures.
                                                                     AGE




    Epidemiological data such as age and gender of the
                                                                           60
patients and clinical data the localization and diameter of
the lesions were incorporated along with the clinical and
                                                                           50
dermoscopic images in a PowerPoint presentation (Microsoft
Corp). This collection was presented to 2 dermatologists with
                                                                           40
experience in dermoscopy (G.S. and H.C.) who performed
both clinical and dermoscopic evaluation. Dermoscopic
images were assessed for the presence or absence of criteria                           LE          UE           AT           PT
for melanoma previously described in nonfacial skin [4-6].                                         LOCALIZATION

Statistical Analysis                                                 Figure 1. Age distribution is similar among localization categories
                                                                     (Kruskal-Wallis test, P = 0.343).
The χ2 test was used to compare qualitative variables, and
the t test was used to compare means. Differences were set as        LE = lower extremities; UE = upper extremities; AT = anterior
statistically significant at P ≤ 0.05.                               trunk; PT = posterior trunk



2                                                                          Original Article | Dermatol Pract Concept. 2022;12(1):e2022035
                                                                          similar observation among groups. Hyperpigmented follicular
                 30                                                       pigmentation was observed in almost one third of the cases,
                                                                          being less frequent in PT. Aggregated dots were seen in less
                                                                          than 20% of the EFLM, being more frequent in AT. Blue-
                                                                          white veil and negative pigment network were observed in
DIAMETER IN MM




                 20                                                       6% of the cases; none of the EFLM displayed circle within
                                                                          circle criteria. Only 1 lesion located in TP showed radial
                                                                          projections.
                                                                             Almost half of the EFLM showed regression structures:
                 10                                                       36.2% granularity and 23.2% scar-like areas; regression
                                                                          structures were less frequent in LE.
                                                                             Dotted and polymorphous vessels were the most frequent
                                                                          vascular pattern observed (15.9% and 11.6%, respectively).
                                                                          Serpentine vessels and milky-red areas were observed in 7%
                      LE       UE         AT           PT
                                                                          of all EFLM, with similar distribution among different local-
                               LOCALIZATION                               izations, but milky-red areas criterion was not observed in
Figure 2. Diameter distribution is similar among localization cate-       LE. None of the melanomas included showed red globules.
gories (Kruskal-Wallis test, P = 0.44).                                      Near half of the EFLM displayed dermoscopic criteria for
                                                                          seborrheic keratosis, being more frequent in PT and UE, but
LE=lower extremities; UE=upper extremities; AT=anterior
                                                                          no statistically significant differences were observed regarding
trunk; PT=posterior trunk
                                                                          localization.
                                                                             The 6 colors were observed in all localizations upon
3 colors: light brown, dark brown and blue-grey, while in the             dermoscopy. Light brown was observed in all cases, and
other localizations at least 5 colors were observed.                      dark brown in 66 out of 69 lesions. Blue-grey color was
                                                                          present in more than half of the lesions, with similar distri-
Dermoscopic Evaluation                                                    bution regarding localization. Pink, white, and black colors
The dermoscopy evaluation findings are shown in Table 2.                  were seen in near 40% of all EFLM. Pink and white colors
The most frequent dermoscopic criteria were angulated lines               were more frequent in PT and UE. Black color was more
and tan structureless areas, observed in more than three                  frequent in LE.
quarters of all the EFLM analyzed, with quite similar distri-                Global dermoscopic pattern analysis is shown in Table 3.
bution among the different localizations. Atypical pigment                Angulated lines pattern was the most frequent pattern,
network was observed in 60% of all the EFLM, also with                    observed in 55% of cases. Tan structureless/granularity pat-



                                               Table 1. Clinical Characteristics.
                                        Lower               Upper                                   Posterior
                                      extremities         extremities          Anterior trunk        trunk                 Total
                                          n (%)                  n (%)              n (%)             n (%)                n (%)
     Cases                              13 (18.8)           15 (21.7)             16 (23.2)         25 (36.2)            69 (100)
     Colors
     Light brown                        11 (84.6)           14 (93.3)             15 (93.7)          23 (92)             63 (91.3)
     Dark brown                         12 (92.3)           13 (86.6)             13 (81.2)          24 (96)             62 (89.9)
     Pink                                3 (23)                  3 (20)              0 (0)             2 (8)             8 (11.6)
     Blue-gray                           1 (7.7)             2 (13.3)              2 (12.5)            0 (0)              5 (7.2)
     White                                0 (0)              1 (6.6)                 0 (0)             2 (8)              3 (4.3)
     Black                              5 (38.4)             5 (33.3)                0 (0)            7 (28)             17 (24.6)
     Borders
     Ill defined                        6 (46.1)                 6 (40)             8 (50)           20 (80)             41 (59.4)
     Well defined, irregular            5 (38.4)                 9 (60)            7 (43.5)           5 (20)             26 (37.7)
     Well defined, regular              2 (15.4)                 0 (0)               0 (0)             0 (0)              2 (2.9)
     Striking lesion                    9 (69.2)            15 (100)              13 (81.2)          23 (92)              60 (87)



Original Article | Dermatol Pract Concept. 2022;12(1):e2022035                                                                          3
                                      Table 2. Dermoscopic Characteristics.
                                          Lower             Upper          Anterior            Posterior           Total
                                     extremities n (%) extremities n (%) trunk n (%)          trunk n (%)          n (%)
Cases                                    13 (18.8)         15 (21.7)          16 (23.2)        25 (36.2)         69 (100)
Angulated lines                          13 (100)          11 (73.3)           12 (75)           17 (68)         53 (76.8)
Aggregated dots                          2 (15.4)           1 (6.6)            5 (31.2)          4 (16)          12 (17.4)
Atypical pigment network                 8 (61.5)          8 (53.3)           10 (62.5)          15 (60)         41 (59.4)
Asymmetric perifollicular                5 (38.4)          7 (46.6)            7 (43.5)           2 (8)          21 (30.4)
hyperpigmentation
Peripheral tan structureless areas       10 (76.9)          12 (80)           14 (87.5)          18 (72)         54 (78.3)
Negative network                           0 (0)           2 (13.3)              0 (0)            2 (8)           4 (5.8)
Circle within circle                       0 (0)             0 (0)               0 (0)            0 (0)            0 (0)
Blue-white veil                           1 (7.7)           1 (6.6)            1 (6.2)            1 (4)           4 (5.8)
Streaks
    Pseudopods                             0 (0)             0 (0)               0 (0)            0 (0)            0 (0)
    Radial projections                     0 (0)             0 (0)               0 (0)            1 (4)           1 (1.4)
Vascular structures
    Dotted vessels                        3 (23)           5 (33.3)              0 (0)           3 (12)          11 (15.9)
    Serpentine vessels                    1 (7.7)           3 (20)             1 (6.2)            1 (4)           6 (8.7)
    Polymorphous vessels                 2 (15.4)           3 (20)             1 (6.2)            2 (8)           8 (11.6)
    Milky-red areas                        0 (0)           2 (13.3)            1 (6.2)            2 (8)           5 (7.2)
    Red globules                           0 (0)             0 (0)               0 (0)            0 (0)            0 (0)
    White shiny structures
    Shiny white lines                    2 (15.4)          2 (13.3)            1 (6.2)            2 (8)           7 (10.1)
    White shiny areas                      0 (0)             0 (0)               0 (0)            0 (0)            0 (0)
    Rosettes                               0 (0)             0 (0)               0 (0)            0 (0)            0 (0)
Regression structures
    Absence                              11 (84.6)         8 (53.3)             8 (50)           10 (40)         37 (53.6)
    Granularity or peppering             2 (15.4)          5 (33.3)         7 (43.5)             11 (44)         25 (36.2)
    Scar-like areas                        0 (0)           4 (26.6)            3 (18.7)          9 (36)          16 (23.2)
Prominent skin markings
Criteria for seborrheic keratosis        4 (30.7)          8 (53.3)            6 (37.5)          15 (60)         33 (47.8)
Colors
    Light brown                          13 (100)          15 (100)           16 (100)          25 (100)         69 (100)
    Dark brown                           13 (100)          15 (100)           16 (100)           24 (96)         66 (98.6)
    Pink                                  3 (23)           8 (53.3)            5 (31.2)          14 (56)         30 (43.5)
    Blue-gray                            7 (53.8)           9 (60)             9 (56.2)          12 (48)         37 (53.6)
    White                                 3 (23)           7 (46.6)            5 (31.2)          12 (48)         27 (39.1)
    Black                                6 (46.1)           6 (40)             5 (31.2)          8 (32)          25 (36.2)



                                          Table 3. Dermoscopic Patterns
                                          Lower             Upper          Anterior   Posterior              Total n
                                     extremities n (%) extremities n (%) trunk n (%) trunk n (%)               (%)          P
Cases per localization                   13 (18.8)        15 (21.7)           16 (23.2)       25 (36.2)     69 (100)
Global dermoscopic pattern
    Patchy peripheral pigmented            0 (0)           2 (13.3)           3 (18.7)         3 (12)       8 (11.6)    0.62
    islands
    Angulated lines                      8 (61.5)          7 (46.7)           7 (43.7)         16 (64)      38 (55.1) 0.64
    Tan structureless and                2 (15.4)           1 (6.7)            4 (25)          4 (16)       11 (15.9) 0.59
    granularity
    None                                 3 (23.1)          5 (33.3)           2 (12.5)          2 (8)       12 (17.4) 0.19



4                                                                Original Article | Dermatol Pract Concept. 2022;12(1):e2022035
Figure 3. Global dermoscopic pattern. (A-C) Angulated lines, (D-F) granularity (middle row), (G-I) and patchy peripheral pigmented
islands.


                  Table 4. Number of Colors in the Clinical and Dermoscopic Examination
         Number of colors in clinical examination n (%)            Number of colors in dermoscopic examination n (%)
   1              7 (10)                                                 0 (0)
   2            42 (60.9)                     64 (92.7)                 9 (13)                           32 (46.3)
   3            15 (21.7)                                              23 (33.3)
   4              2 (2.9)                                              21 (30.4)
   5              3 (4.3)                      5 (7.3)                 12 (17.4)                         37 (53.6)
   6               0 (0)                                                4 (5.8)

P < 0.001

tern and patchy peripheral pigmented islands pattern were          percentage of melanomas displaying at least 4 colors raised
seen in the 15.6% and 11.6% of cases, respectively (Figure 3).     from 7.3% to 53.6% (P < 0.001)
Twelve of 69 lesions (17.3%) showed none of these global
patterns. No statistically significant differences were observed
                                                                   Conclusions
in the distribution of global dermoscopic pattern in the dif-
ferent localizations.                                              LM is a distinct form of melanoma in situ, which is char-
                                                                   acterized by an increased number of histologically atypical
Colors Upon Clinical versus. Dermoscopic                           melanocytes situated along the dermo-epidermal junction.
Evaluation                                                         It mainly develops in middle-age and elderly individuals on
Table 4 shows number of colors observed upon clinical and          chronically sun exposed areas. Although LM can precede by
dermoscopic examination. With the use of dermoscopy, the           many years the dermal invasion, rapid progression has been



Original Article | Dermatol Pract Concept. 2022;12(1):e2022035                                                                   5
described [7,8]. Therefore, early diagnosis and appropriate       the overall dermoscopic pattern distribution according to
treatment are essential to improve prognosis. Whether EFLM        localization.
differs clinically and/or dermoscopically according to location      Our study does not lack of limitations due to its retro-
has not been analyzed in depth.                                   spective design, the lack of control groups and the fact that
    The clinical diagnosis of EFLM can be challenging since       evaluators were not blinded to the diagnoses. Additionally,
it can simulate other conditions especially solar lentigo or      selection and verification bias may lead to an overestima-
pigmented actinic keratosis. In our study, 90% of the EFLM        tion of specificity of dermoscopic criteria in the diagnosis
were striking from the clinical point of view; the lesions        of EFLM.
were clinically polychromatic (at least 3 colors) and with a         We believe that this study provides useful and valuable
similar diameter regardless of location. Lesions tend to have     information to learn more about the dermoscopic aspects of
a greater diameter in upper extremities and posterior trunk,      EFLM and to improve early detection, especially by providing
but differences were not statistically significant.               relevant information for the identification of the most preva-
    Dermoscopy has become a key diagnostic tool to                lent dermoscopic criteria in different locations.
enhance both sensitivity and specificity in the clinical diag-       In this study we evaluated clinical and dermoscopic aspect
nosis of melanoma [2,3]. The dermoscopic criteria of LM           in a series of 69 EFLM according to localization. From the
and its invasive form, LM melanoma, were first described          clinical point of view, EFLM did not differ in terms of patient
in facial location. Furthermore, a progression model for          age and diameter regarding localization. Upon dermoscopy,
facial LM has been well established and has been widely           angulated lines were more frequent in LE, aggregated dots
accepted [9]. More recently, dermoscopic features of LM           were more frequent in AT, regression structures were more
in extrafacial location were described [4-6]. In 2013, Keir       prevalent in PT, asymmetric perifollicular hyperpigmenta-
reported that the global criterion of lentigo-like pigment        tion was much less frequent in PT, vascular structures were
pattern lacking a lentigo-like border, combined with the          more frequent in UE, white shiny lines were more frequently
criteria of asymmetrically pigmented follicular openings          observed in extremities than in the trunk. We found no sig-
and large polygons detected the great majority of mel-            nificant differences in the overall dermoscopic pattern in the
anoma in his series of 20 cases (18 in situ) [5]. Jaimes          different localizations.
et al described and analyzed the clinical and dermoscopic
characteristics of both in situ and invasive melanomas on
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Original Article | Dermatol Pract Concept. 2022;12(1):e2022035                                                                       7
