10.5826/dpc.1204a174
Introduction:&nbsp;Non-invasive imaging techniques offer the possibility to optimize the first approach to melanoma. RCM has a promising role in predicting the main prognostic events in the dermoepidermal and papillary dermis.
&nbsp;
Objectives:&nbsp;To identify&nbsp;pre-surgical&nbsp;criteria that can predict the main prognostic features of melanoma.
&nbsp;
Methods:&nbsp;A retrospective&nbsp;cohort-study&nbsp;evaluated&nbsp;dermoscopic, confocal and histopathological characteristics of consecutively diagnosed sporadic melanomas.&nbsp;RCM-melanoma&nbsp;patterns&nbsp;classified into&nbsp;1) dendritic-cell, 2) round-cell, 3) dermal nest and 4) combined type.&nbsp;Acral, facial and mucosal locations were excluded.
&nbsp;
Results:&nbsp;92 primary melanomas were included:&nbsp;44 male and 48 female&nbsp;(mean age&nbsp;60.4 years,&nbsp;SD 16.2) with a mean Breslow of 1.43mm (SD 1.6).&nbsp;The most frequent dermoscopic&nbsp;presentation was the multicomponent pattern, the predominant confocal pattern was dendritic-cell type&nbsp;(44.6%).&nbsp;The presence of&nbsp;pigmented network on dermoscopy was related to lower Breslow and mitotic rates (both p=0.002); in contrast to the presence of&nbsp;visible&nbsp;vessels,&nbsp;which was related to higher Breslow and mitotic indexes (both p=0.001). Confocal observation of dermal nests or atypical cells in the papillary dermis was related to a higher mitotic rate (p=0.006 and p=0.03, respectively). Similarly, diffuse inflammatory infiltrates visible in the superficial dermis was associated with higher Breslow (p=0.04) and mitotic index (p=0.04).
&nbsp;
Conclusions:&nbsp;Dermoscopic and RCM&nbsp;in vivo&nbsp;findings&nbsp;on&nbsp;primary melanoma correlate with histopathologic Breslow index, mitotic rate and tumor infiltrating lymphocytes.&nbsp;The architecture and cytology of primary melanoma can be estimated by combining dermoscopy and RCM prior to excision.
text/xml
2160-9381
2174
en
Cristina Carrera
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
prognostic markers
Dermoscopy And Reflectance Confocal Microscopy To Estimate Breslow Index And Mitotic Rate In Primary Melanoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-11-16
2022-10-31
2022-12-01
e2022174
Dermatol Pract Concept
Introduction:&nbsp;Non-invasive imaging techniques offer the possibility to optimize the first approach to melanoma. RCM has a promising role in predicting the main prognostic events in the dermoepidermal and papillary dermis.
&nbsp;
Objectives:&nbsp;To identify&nbsp;pre-surgical&nbsp;criteria that can predict the main prognostic features of melanoma.
&nbsp;
Methods:&nbsp;A retrospective&nbsp;cohort-study&nbsp;evaluated&nbsp;dermoscopic, confocal and histopathological characteristics of consecutively diagnosed sporadic melanomas.&nbsp;RCM-melanoma&nbsp;patterns&nbsp;classified into&nbsp;1) dendritic-cell, 2) round-cell, 3) dermal nest and 4) combined type.&nbsp;Acral, facial and mucosal locations were excluded.
&nbsp;
Results:&nbsp;92 primary melanomas were included:&nbsp;44 male and 48 female&nbsp;(mean age&nbsp;60.4 years,&nbsp;SD 16.2) with a mean Breslow of 1.43mm (SD 1.6).&nbsp;The most frequent dermoscopic&nbsp;presentation was the multicomponent pattern, the predominant confocal pattern was dendritic-cell type&nbsp;(44.6%).&nbsp;The presence of&nbsp;pigmented network on dermoscopy was related to lower Breslow and mitotic rates (both p=0.002); in contrast to the presence of&nbsp;visible&nbsp;vessels,&nbsp;which was related to higher Breslow and mitotic indexes (both p=0.001). Confocal observation of dermal nests or atypical cells in the papillary dermis was related to a higher mitotic rate (p=0.006 and p=0.03, respectively). Similarly, diffuse inflammatory infiltrates visible in the superficial dermis was associated with higher Breslow (p=0.04) and mitotic index (p=0.04).
&nbsp;
Conclusions:&nbsp;Dermoscopic and RCM&nbsp;in vivo&nbsp;findings&nbsp;on&nbsp;primary melanoma correlate with histopathologic Breslow index, mitotic rate and tumor infiltrating lymphocytes.&nbsp;The architecture and cytology of primary melanoma can be estimated by combining dermoscopy and RCM prior to excision.
Cristina Carrera
2022/10/31
10.5826/dpc.1204a174
e2022174
Department of Dermatology Hospital Clínic Barcelona, University of Barcelona. Melanoma Group IDIBAPS Barcelona, Spain.
2160-9381
prognostic markers
en
e2022174
Navarrete-Dechent C, Cordova M, Postow MA, et al. Evaluation of the Response of Unresectable Primary Cutaneous Melanoma to Immunotherapy Visualized With Reflectance Confocal Microscopy. JAMA Dermatology. 2019;155(3):347. doi:10.1001/jamadermatol.2018.3688
Dermoscopy And Reflectance Confocal Microscopy To Estimate Breslow Index And Mitotic Rate In Primary Melanoma
https://dpcj.org/index.php/dpc/article/download/2174/1780
      Dermoscopy and Reflectance Confocal
 Microscopy to Estimate Breslow Index and Mitotic
            Rate in Primary Melanoma
      Zamira Faride Barragán-Estudillo1, Johanna Brito1,2, Marion Chavez-Bourgeois1,
    Beatriz Alejo1, Llucia Alos2, Adriana Patricia García2, Susana Puig1,3, Josep Malvehy1,3,
                                       Cristina Carrera1,3


1 Department of Dermatology Hospital Clínic Barcelona, University of Barcelona. Melanoma Group IDIBAPS Barcelona, Spain.
2 Department of Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
3 Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) Instituto de Salud Carlos III, Barcelona Spain.



Key words: melanoma, confocal microscopy, mitotix rate, Breslow index, prognostic markers
Citation: Barragán-Estudillo ZF, Brito J, Chavez-Bourgeois M, et al. Dermoscopy and Reflectance Confocal Microscopy to Estimate
Breslow Index and Mitotic Rate in Primary Melanoma. Dermatol Pract Concept. 2022;12(4):e2022174. DOI: https://doi.org/10.5826/
dpc.1204a174
Accepted: February 9, 2022; Published: October 2022
Copyright: ©2022 Barragán-Estudillo 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: The research at the Melanoma Unit in Barcelona is partially funded by Spanish Fondo de Investigaciones Sanitarias grants
PI12/00840, PI15/00716, PI15/00956 and PI18/0959; CIBER de Enfermedades Raras of the Instituto de Salud Carlos III, Spain,
co-financed by European Development Regional Fund “A way to achieve Europe” EDRF; AGAUR 2014_SGR_603 of the Catalan
Government, Spain; European Commission under the 6th Framework Programme, Contract No. LSHC-CT-2006-018702 (GenoMEL)
and by the European Commission under the 7th Framework Programme, Diagnoptics; A grant from “Fundació La Marató de TV3,
201331-30”, Catalonia, Spain; a grant from Telemaraton of Spain “Todos somos raros” and a grant from “Asociación Española Contra el
Cáncer (AECC)”.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Cristina Carrera, MD, PhD, Associate Professor, Department of Dermatology, Hospital Clínic Barcelona, University
of Barcelona. Villarroel 170, 08036 Barcelona, Spain. E-mail: ccarrera@clinic.cat




  ABSTRACT             Introduction: Non-invasive imaging techniques offer the possibility to optimize the first approach
                       to melanoma. Reflectance Confocal Microscopy (RCM) has a promising role in predicting the main
                       prognostic events in the dermo-epidermal and papillary dermis.
                       Objectives: To identify pre-surgical criteria that can predict the main prognostic features of m
                                                                                                                      ­ elanoma.
                       Methods: A retrospective cohort-study evaluated dermoscopic, confocal and histopathological char-
                       acteristics of consecutively diagnosed sporadic melanomas. RCM-melanoma patterns classified into 1)
                       dendritic-cell, 2) round-cell, 3) dermal nest and 4) combined type. Acral, facial and mucosal locations
                       were excluded.
                       Results: Ninety-two primary melanomas were included: 44 males and 48 females (mean age 60.4
                       years, standard deviation [SD] 16.2) with a mean Breslow of 1.43 mm (SD 1.6). The most frequent




Original Article | Dermatol Pract Concept. 2022;12(4):e2022174                                                                          1
                      dermoscopic presentation was the multicomponent pattern, the predominant confocal pattern was
                      dendritic-cell type (44.6%). The presence of pigmented network on dermoscopy was related to lower
                      Breslow and mitotic rates (both P = 0.002); in contrast to the presence of visible vessels, which was
                      related to higher Breslow and mitotic indexes (both P = 0.001). Confocal observation of dermal nests
                      or atypical cells in the papillary dermis was related to a higher mitotic rate (P = 0.006 and P = 0.03,
                      respectively). Similarly, diffuse inflammatory infiltrates visible in the superficial dermis was associated
                      with higher Breslow (P = 0.04) and mitotic index (P = 0.04).
                      Conclusions: Dermoscopic and RCM in vivo findings on primary melanoma correlate with histo-
                      pathologic Breslow index, mitotic rate and tumor infiltrating lymphocytes. The architecture and cy-
                      tology of primary melanoma can be estimated by combining dermoscopy and RCM prior to excision.




Introduction                                                       their cytology and architectural morphology: 1) dendritic-cell
                                                                   melanomas, 2) round-cell melanomas, 3) dermal nest mela-
Currently, the 10-year cause-specific survival rate of patients    nomas and 4) combined type (that may represent an evolu-
diagnosed with localized cutaneous melanoma (that is, in           tion of the other three types) [13,14].
the absence of nodal or visceral involvement) varies from
75% to 98% [1]. Promising results from molecular profiling
                                                                   Objectives
of melanoma will shed some light on the prognostic clas-
sification of primary tumors [2]; the revised 8th version of       Beyond the morphological classification of primary tumors,
AJCC, however, considers that the main prognostic mark-            the goal of the present study was to identify pre-surgical der-
ers of cutaneous melanoma are still ulceration and Breslow         moscopic and confocal features of primary tumors that can
depth index of the primary tumor. Mitotic rate is no longer        be correlated with prognostic markers in localized cutaneous
included in the current AJCC; nevertheless, the Melanoma           melanoma.
Expert Panel recognizes mitotic rate as an important prog-
nostic parameter to predict sentinel lymph node status and
                                                                   Methods
outcome in N0 stage [3].
    The prediction given by the prognostic markers prior to        A retrospective cohort study of consecutively pathologi-
removing the tumor could 1) optimize the first approach to         cally proven cutaneous melanomas diagnosed in a referral
the patient: devising an accurate surgery plan and indica-         unit was conducted. Inclusion criteria stipulated available
tions for staging tests, and 2) help to preserve fresh samples     tumors with high quality clinical, dermoscopic and confo-
for further molecular studies in the areas of interest.            cal images prior to excision, and pathological samples to
    Dermatological non-invasive imaging techniques have            re-review. Only sporadic cases of melanoma were included.
opened a new era of in vivo tumor characterization. Dermo-         Mucosal, acral and facial locations were excluded. The in-
scopically, several attempts have been made to predict mi-         clusion period was from February 2011 to February 2015.
totic and Breslow indexes, and even the sentinel lymph node            Stored high-resolution clinical-dermoscopy images were
status, based on the various in vivo morphologic features of       obtained by Canon G11 and Dermlitephoto® (3 GEN, LLC).
primary melanoma [4-6].                                            RCM images obtained by Vivascope 1500 (Lucid Inc.) in-
    Reflectance   confocal   microscopy     (RCM)     provides     cluded a minimum of three mosaics on a horizontal plane
real-time evaluation of skin by generating horizontal opti-        (“VivaBlock” modality) covering a maximum area of 7 mm2,
cal sections from the epidermis to the papillary dermis with       acquired in the spinous-granular layer, the dermal-epidermal
cellular-level resolution. Multiple studies have demonstrated      junction and the upper dermis respectively. Furthermore,
not only the high correlation of dermoscopic and confocal          several confocal sections at 500 x 500 microns with verti-
features with histopathology, but also the impact of RCM           cal montage images (stack images) from stratum corneum to
on melanoma diagnostic accuracy - an ancillary tool to der-        papillary dermis (maximum depth achieved, 250 µm) were
moscopy, especially with challenging and amelanotic tu-            acquired in the areas of interest.
mors [7-11]; and in a recent Chochrane systematic review,              Based on the literature, twenty clinical-dermoscopic
RCM demonstrated may have a potential role in the assess-          criteria, including a quantitative Total Dermoscopy Score
ment of lesions that are difficult to diagnose using visual in-    (TDS) [15], the 7-checkpoint list [16] and 22 confocal fea-
spection and dermoscopy alone [12].                                tures, were established. Confocal characterization of primary
    Additionally, four different RCM melanoma patterns             melanomas according to the Pellacani et al classification and
have been described in order to classify melanomas based on        the confocal Barcelona algorithm, were also assessed [9,13].



2                                                                       Original Article | Dermatol Pract Concept. 2022;12(4):e2022174
In addition, confocal features were evaluated according to        Table 1. Dermoscopic and reflectance confocal
the percentage of the lesion surface that each presented:                          features
25%, 50%, 75% or 100% of the lesion. For the histolog-
                                                                                           Primary Melanomas
ical review, 12 histological routine features were evaluated
                                                                    Dermoscopic Features         (N= 92)
(Breslow, ulceration, radial or vertical growth phase, mitotic
                                                                  Global pattern
index per mm2, and also 4 characteristics described by Vios
                                                                  Reticular                    27 (29.3%)
et al [17]: nesting or scatter growth, pigmentation and cell
                                                                  Multicomponent               51 (55.4%)
shape (summarized in Tables 2 and 3). The Hospital Clínic
                                                                  Unspecific                   12 (13.0%)
Ethics Committee approved the protocol and all procedures
                                                                  Globular                      1 (1.1%)
followed the principles of the Declaration of Helsinki.
                                                                  Homogeneous                   1 (1.1%)

Statistical Analysis                                              Pigmented Network

SPSS Statics for Windows, version 22.0 (IBM Corp. Released        Absent                       20 (21.7%)

2013) was used to assess: descriptive values of all qualitative   Typical                       6 (6.5%)
variables by Pearson’s Chi Square test; quantitative (age, size   Atypical                     66 (71.7%)
of lesions, dermoscopic and confocal scores, and Breslow          Globules
index) and semi-quantitative scales (such as mitosis, regres-     Absent                       27 (29.3%)
sion, nesting, pagetoid extension) by Student t-test. Com-        Typical                       7 (7.6%)
parisons between categorical variables and the correlation        Atypical                     58 (63.0%)
between them were analyzed using Pearson’s chi-square and         Streaks
Fisher exact test when any cell had an expected count of less     Absent                       35 (38.0%)
than 5. For quantitative continuous variables, Student t-test     Typical                      16 (17.4%)
was used for comparison between two groups and ANOVA              Atypical                     41 (44.6%)
where more than two were compared. Person coefficient was
                                                                  Structureless areas
used to study the correlation between variables and Spear-
                                                                  Absent                        70 (76%)
man correlation coefficient if nonparametric applicability
                                                                  Present                       22 (24%)
conditions were not reached. The level of statistical signif-
                                                                  Blue-white veil
icance was set at bilateral 5%. The linear regression model
                                                                  Absent                       61 (66.3%)
was applied to identify independent markers among quanti-
tative variables.                                                 Present                      31 (33.7%)
                                                                  Regression
                                                                  Absent                       49 (53.3%)
Results                                                           Present                      43 (46.7%)
From the 132 patients who were initially included, 40 were        Milky-red areas
excluded due to poor quality of images or the unavailability      Absent                       60 (65.2%)
of histopathologic samples for reevaluation. All 92 patients      Present                      32 (34.8%)
were finally included with demographics and clinical staging      Shiny-white streaks
collected from their medical records.                             Absent                       37 (40.2%)
                                                                  Present                      55 (59.2%)
Clinical-dermoscopic Attributes                                   Rosettes
In total, 92 patients, 44 males (47.8%) and 48 females            Absent                       75 (81.5%)
(52.2%) with a mean age of 60.4 years (range 15-86) were          Present                      17 (18.5%)
studied. Most of the tumors were located on the trunk             Vessels
(57.6%), the remaining on the limbs. The most common              Absent                       48 (52.2%)
overall dermoscopic patterns were multicomponent in
                                                                  Present                      44 (47.8%)
51 (55.4%) and reticular in 27 (29.3%). Dermoscopic
                                                                  Dotted                       25 (27.2%)
­erosions/ulceration was observed in 18 tumors (19.6%).
                                                                  Hairpin                       8 (8.70%)
                                                                  Polymorphic                  27 (29.3%)
Reflectance Confocal Microscopy Attributes
                                                                  Ulceration
Table 1 summarizes the dermoscopic and confocal features
evaluated. According to the melanoma RCM classification [13],                                   Table 1 (Continued)



Original Article | Dermatol Pract Concept. 2022;12(4):e2022174                                                   3
Table 1. Dermoscopic and reflectance confocal       Atypical Basal
            features. (Continued)                   Dendritic cells

                               Primary Melanomas    Absent                                    33 (35.9%)
    Dermoscopic Features            (N = 92)        Present                                   59 (64.1%)
Absent                            74 (80.4%)        Basal atypia
Present                           18 (19.6%)        Absent                                     2 (2.2%)
                                                    Moderate                                  40 (43.5%)
Atypical Blotches
                                                    Marked                                    50 (54.3%)
Absent                            63 (68.5%)
                                                    Nucleated dermal cells
Present                           29 (31.5%)
                                                    Absent                                    56 (60.9%)
Negative network
                                                    Present                                   36 (39.1%)
Absent                            74 (80.4%)        Dermal Nests
Present                           18 (19.6%)        Absent                                    39 (42.4%)
                               Primary Melanomas    Present:                                  53 (57.6%)
    Confocal Characteristics        (N = 92)        Dense                                     54 (58.7%)
Epidermal Cobblestone                               Sparse cell                                1 (1.1%)
Absent                             38 (41.3%)       Cerebriform                                5 (5.4%)
Typical                            21 (22.8%)       Inflammatory cells in
Atypical                           33 (35.9%)       dermis
Epidermal Honeycomb                                 Plump cells                               40 (43.5%)
Absent                              7 (7.6%)        Bright particles                          88 (95.7%)
Typical                            39 (24.4%)       Collagen bundles
Atypical                           46 (50.0%)       Visible                                   59 (64.1%)
Epidermal Disarranged                               Non visible                               33 (35.9%)
Absent                             34 (37.0%)       Dermal vessels
Present                            58 (63.0%)       Absent                                    69 (75.0%)
Large pagetoid round cells                          Present                                   23 (25.0%)
Absent                             14 (15.3%)       Horizontal                                11 (12.0%)
Present                            78 (84.7%)       Coiled                                     2 (2.2%)
Large pagetoid dendritic                            Thin / Thick                        3 (3.3%) / 20 (21.7%)
cells
Absent                             31 (33.7%)
Present                            61 (66.3%)      subtypes fell into 4 groups: the predominant confocal sub-
Atypical pagetoid pleomor-                         type was the so-called dendritic type (41, 44.6%), the round
phic cells                                         cells type (40, 43.5%), followed by the combined (9, 9.8%).
Absent                             84 (91.3%)      One case was considered dermal nest type (1.1%) and one
Present                            8 (10.2%)       case was non-classifiable (1.1%).
Pagetoid star-shaped cells                            The Barcelona algorithm score was equal to or higher
Absent                             90 (97.8%)      than 0 in 84 out of 92 cases (91.3%), which is highly sugges-
Present                             2 (2.2%)       tive of melanoma; the remaining 8 (8.7%) achieved a score
                                                   of -1, which means it could be melanoma [9].
Mainly edged papilla
Absent                             53 (57.6%)
                                                   Histological Characterization
Present                            39 (42.4%)
                                                   The most common histological subtype observed was superfi-
Typical cells at the basal
                                                   cial spreading melanoma (SSMM) in 52 (56.6%) of the cases,
Absent                             77 (83.7%)
                                                   followed by in situ melanomas in 28 lesions (30.4%), lentigo
Present                            15 (16.3%)
                                                   maligna melanoma (LMM) in 6 (6.5%), nodular (NM) in 5
Atypical Basal Round cells
                                                   (5.4%) and one spitzoid melanoma (1.1%). Only 6.5% of
Absent                             20 (21.7%)
                                                   melanomas presented histological ulceration. According to
Present                            72 (78.3%)      tumor infiltrating lymphocytes (TILs), 58 cases (63%) were



4                                                      Original Article | Dermatol Pract Concept. 2022;12(4):e2022174
considered non-brisk, while 28 (30.4%) were considered                 Table 2. Histopathological characterization
brisk; in 6 (6.5%), TILs were absent. The predominant cy-              Histological features     Primary melanomas (n:92)
tology was epithelioid (ovoid) in 49 (53.3%) cases. Growth       Histological Type
pattern was classified into marked scattered or pagetoid in      In situ                                28 (30.4%)
25 (27.2%) cases, moderate in 22 (23.9%) and mild in 38          Superficial spreading                  52 (56.5%)
(41.3%), while nesting pattern was considered marked in 28       Lentigo maligna                         6 (6.5%)
(30.4%), moderate in 11 (12%) and mild in 30 (32.6%). Cy-        Nodular                                 5 (5.4%)
                                                                 Spitzoid                                1 (1.1%)
toplasmic pigmentation was absent in 11 cases (12%), faint
                                                                 Clark Level
in 26 (28.3%), moderate in 35 (38%), high in 13 (14.1%),
                                                                 II                                     10 (10.9%)
and very high in 7 (7.6%).
                                                                 III                                    22 (23.9%)
    Some degree of solar elastosis was present in 70 pa-         IV                                     30 (32.6%)
tients (80.4%). Only 2 patients presented vascular invasion      Mitotic Rate
and 1 neural invasion. Regression was classified as marked       < 1/mm2                                29 (45.3%)
(> 50% of surface) in 20 (21.7%), partial (< 50%) in 27          1-3/mm2                                10 (15.6%)
(29.3%), focal in 20 (21.7%) and absent in 25 (27.2%)            > 4/mm2                                12 (18.7%)
cases. Among the invasive cases (N = 64) the mean Breslow        Pagetoid infiltration grade /
                                                                 Scattered cells
index was 1.43 mm (SD 1.6). The mean mitotic rate was
                                                                 0 none                                  7 (7.6%)
1.25/mm2 (SD 2.0): in 29 invasive cases (45.3%) less than
                                                                 1 mild                                 38 (41.3%)
1 mitosis/mm2, and 10 cases (15.6%) between 1 and 3 mi-          2 moderate                             22 (23.9%)
tosis/mm2. The remaining 12 cases (18.7%) showed a high          3 marked                               25 (27.2%)
mitotic index (4 or more mitosis/mm2). Table 2 summarizes        Nesting grade
the histopathology in detail.                                    0 none                                 23 (25%)
                                                                 1 mild                                 30 (32.6%)
Association of in Vivo Findings with Histological                2 moderate                              11 (12.0)
                                                                 3 marked                               28 (30.4%)
Prognostic Markers (Table 3)
                                                                 Cytoplasmatic Pigmentation
Dermoscopic Correlations
                                                                 Faint                                  26 (28.3%)
As regards the global dermoscopic pattern, a multicompo-         Moderate                               35 (38.0%)
nent pattern was associated with higher nesting growth on        High                                   13 (14.1%)
histology (P = 0.05) while a reticular pattern was protective    Very High                               7 (7.6%)
against nesting on histology (P = 0.001).                        Cytomorphology

    The presence of a pigment network was related to a lower     Round                                  29 (31.5%)
                                                                 Ovoid                                  49 (53.3%)
Breslow index and lower mitotic rate (both P = 0.002), while
                                                                 Elongated                              10 (10.9%)
the presence of blotches, structureless pigmentation, visible
                                                                 Spindled                                4 (4.3%)
vessels and blue white veil were related to a higher Breslow
                                                                 Elastosis
index and mitotic rate (P = 0.05, p < 0.01, P < 0.01 and         Low                                    28 (30.4%)
P < 0.01 respectively).                                          Moderate                               29 (31.5%)
    Multivariate analysis demonstrated that a dermoscopic        Marked                                 17 (18.5%)
pigment network was related to a lower Breslow index and         Ulceration
a lower mitotic rate (both P = 0.002), while the presence of     Present                                 6 (6.5%)

atypical blotches was related to a higher Breslow index and      TIL s Brisk
                                                                 Non-Brisk                              58 (63.0%)
mitotic rate (P = 0.05, P < 0.01).
                                                                 Brisk                                  34 (37.0%)
Confocal Correlations                                            Type of growth
                                                                 Vertical                               62 (67.4%)
The presence of typical epidermal cobblestone and honey-
                                                                 Radial                                 30 (32.6%)
comb patterns was more likely to be associated with in-situ
                                                                 Regression
melanomas (51.7% and 53.6% of in situ cases, P = 0.04),
                                                                 >50%                                   20 (21.7%)
and as expected, the presence of mainly edged papillae           <50%                                   27 (29.3%)
as well (48.7% of in situ versus 20.1% of invasive cases,        Focal                                  20 (21.7%)
P = 0.005).                                                      Vascular Invasion
    The observation of atypical epidermal cobblestone was        Present                                 2 (2.2%)
related to lentigo maligna subtype (LMM), seen in 50% of         Neural Invasion
cases, in contrast to 34.8% of non-LMM cases (P = 0.04).         Present                                 1 (1.1%)




Original Article | Dermatol Pract Concept. 2022;12(4):e2022174                                                              5
                  Table 3. Dermoscopic and confocal features with prognostic value (P < 0.05).
                            Higher                                                                  Lower
      Breslow:                   Mitotic Rate:                                  Breslow:                              Mitotic Rate:
    Dermoscopic Criteria:
    Atypical blotches
    Structureless pigmentation
    Visible vessels
    RCM Criteria:
    Bright particles and plump cells in dermis                  Edged papillae and typical                   Typical cells in basal layer
                                                                epidermisa
                      Dermal nests
                      Atypical nucleated cells in dermis
a
    Existence of typical honeycomb and cobblestone patterns in epidermis, and edged papillae were associated with in situ melanomas.




Figure 1. Dermoscopic and Confocal findings in primary melanoma. (A) Clinical appearance of pigmented asymmetric lesion on the leg.
(B)Dermoscopic presence of asymmetric polychromic lesion, showing negative network (white square), bluewhite veil, atypical vessels (red square),
ulceration and structureless pigmented areas. (C) Reflectance Confocal Microscopy (RCM) imaging (800micronsx800micros) at dermoepidermal
junction (DEJ) and superficial dermis showing cerebriform nests with amorphous pleomorphic cells. Non edged papillae and atypical cells were
visible at DEJ. (D) RCM imaging (1mmx1mm) at superficial dermis demonstrated multiple atypical high caliber vessels (red squares).



Atypical honeycomb was more frequently found in super-                    pagetoid cells were both more frequent in SSMM (60.7%,
ficial spreading melanomas (SSMM) - seen in 65.2% while                   P = 0.01 and 59%, P = 0.05; respectively).
only in 37.5% of non-SSMM cases (P = 0.03). The presence                      Importantly, confocal observation of dermal nests showed
of large atypical pagetoid cells and the dendritic shape of               a mean increase of 1.6 mitosis over the mean mitotic rate


6                                                                              Original Article | Dermatol Pract Concept. 2022;12(4):e2022174
Figure 2. Confocal and histopathological correlation of primary melanoma. (A) Clinical image of superficial spreading ulcerated melanoma
on the thigh of a lady in her 60s. (B) Reflectance confocal microscopy (RCM) single image (0.5 mm x 0.5 mm) at superficial epidermis layer,
multiple dendritic and roundish pagetoid cells (combined type melanoma). (C) RCM mosaic imaging (1.5 mm x 1.5 mm) at suprabasal
epidermal layer; multiple dendritic and roundish atypical cells. (D) RCM mosaic imaging (1.5mm x 1.5 mm) at DEJ and papillary dermis;
atypical dendritic and pleomorphic cells at DEJ isolated and forming junctural nests and junctural thickenings, with non-edged papillae.
(E) Histopathological (H&E) (x40) demonstrated ulcerated superficial spreading melanoma with vertical growth, Breslow 2mm.
    ­ istopathological (H&E) (x100) correlated with nesting tendency and mitotic index of 10/mm2.
(F) H



(P = 0.006) and the presence of bright particles and plump             histological prognostic factors in localized melanoma. The in
cells (that is, diffuse inflammatory infiltrate in the superfi-        vivo predictors of high mitotic rate and tumor thickness are
cial dermis) was associated with a mean increase of 0.6 mm             1) dermoscopically: absence of pigment network and the
in the Breslow index (P = 0.04) and a higher mitotic rate              presence of structureless pigmentation and vessels, and 2)
(P = 0.04). The presence of atypical nucleated cells within            confocal dermal presence of: diffuse inflammatory infiltrate,
dermal papillae was strongly associated with a higher mitotic          atypical nucleated cells and nests (related only to a higher
rate (P = 0.003). On the other hand, the presence of typical           mitotic rate).
basal cells was related to a lower mitotic rate (P = 0.002).               Dermoscopy has previously been demonstrated to pre-
    As regards the confocal patterns, a dendritic confocal             dict histologic features such as regression phenomena or
pattern was significantly associated with brisk tumour infil-          melanoma depth [18-23]. Further, the presence of a brown
trating lymphocytes (TILs) (29.4%, P = 0.021). The dendritic           atypical pigmented network has been associated with mel-
subtype tends to appear in tumors showing more histo-                  anomas showing no mitoses [4]. In accordance with the
logical regression, but the association was not significant,           literature, the present study validates the observation of
(P = 0.38). No other significant associations were found               a dermoscopic pigmented network as related to early mela-
regarding the 4 melanoma confocal subtypes. Histological               nomas (that is, with both lower Breslow index and mitotic
ulceration was not associated with any specific confocal               rate). Additionally, we found that visualization of atypical
pattern: it was observed in 2.4% dendritic confocal patterns           vessels, blotches or structureless pigmentation are related to
(P = 0.16) and in 11% combined confocal patterns (P = 0.47).           higher thickness.
                                                                           In contrast to what we expected, the presence of dermo-

Conclusions                                                            scopic ulceration and blue-white veil were not significantly
                                                                       associated with higher invasiveness or mitotic rate as reported
The present study on 92 primary melanomas allowed                      by Deinlein et al [5]. Interestingly, in our series, there was a
the identification of in vivo features related to the main             ­notable discrepancy between dermoscopic ulceration (present


Original Article | Dermatol Pract Concept. 2022;12(4):e2022174                                                                           7
in almost 20% of cases) and histopathologic ulceration (less     tumors, such as the complementation of RCM with optical
than 7% were ulcerated in the definite report).                  coherence tomography, which has a deeper reach and a dy-
    Interestingly, dermoscopy of primary melanoma has also       namic mode of vascular examination [29,30].
been demonstrated as useful in predicting sentinel lymph            The relevance of this study lies in the identification of in
node biopsy status [6]. There is a dermoscopic algorithm,        vivo predictors of melanoma thickness and high mitotic rate
which can achieve a sensitivity of 96.3% and a specific-         by dermoscopically identifying the absence of pigment net-
ity of 52.1% (P < 0.001) for positive sentinel lymph node        work and the presence of structureless pigmentation and
prediction.                                                      vessels, and on RCM, the presence of nests and diffuse inflam-
    On the other hand, molecular studies support the view        matory infiltrate in the dermis. A more accurate prediction of
that melanoma comprises distinct types of tumors and sug-        prognosis prior to excision of a primary tumor would opti-
gest that specific morphological features may help predict its   mize the first approach to melanoma patients in terms of ac-
clinical behavior. In line with this, and given some dermo-      curate indications for radiologic staging tests and for surgery.
scopic attributes of melanoma, such as features of regression    This preliminary study lays out a new approach to further
and vascularity, were strongly linked to the overall amount      characterization of early junctional phenomena, crucial for
of genomic damage [24].                                          melanoma progression such as the study of TILs and environ-
    In the present study, with the addition of confocal          mental interaction between melanoma cells and host stroma.
pre-surgical characterization, we demonstrated that a higher
mitotic index is expected when dermal nests and atypical nu-
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022174                                                                                 9
