10.5826/dpc.1202a70
text/xml
2160-9381
1875
en
Olivier Gaide
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Birth of a Melanoma
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-07-09
2022-05-02
2022-05-24
e2022070
Dermatol Pract Concept
Olivier Gaide
2022/05/02
10.5826/dpc.1202a70
e2022070
Department of Dermatology and Venereology, Lausanne University Hospital (CHUV), Lausanne, Switzerland 
2160-9381
dermoscopy
en
e2022070
Birth of a Melanoma
https://dpcj.org/index.php/dpc/article/download/1875/1570
                    Dermatology Practical & Conceptual


                                          Birth of a Melanoma
                    Sofia Bogiatzi1, Alessandra Pagnoni1, Daniel Hohl1, Olivier Gaide1


1 Department of Dermatology and Venereology, Lausanne University Hospital (CHUV), Lausanne, Switzerland



Key words: dermoscopy, melanoma, total body photography, dermatopathology
Citation: Bogiatzi S, Pagnoni A, Hohl D, Gaide O. Birth of a melanoma. Dermatol Pract Concept. 2022;12(2):e2022070.
DOI: https://doi.org/10.5826/dpc.1202a70
Accepted: September 2, 2021; Published: April 2022
Copyright: ©2022 Bogiatzi 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: Sofia Bogiatzi, MD-PhD, Department of Dermatology and Venereology, Lausanne University Hospital (CHUV),
Avenue Beaumont 29 Lausanne, CH-1011 VD, Switzerland. E-mail: sofia.bogiatzi@chuv.ch




Introduction                                                            non-uniform streaks of uneven width and borders. There
                                                                        was expansion in an asymmetrical starburst pattern with
Early melanoma diagnosis is a major prognostic factor for               melanocytic projections of variable sizes and bulging ends
improved patient survival. Since its introduction in the der-           with no connection to the lesion, predominating in one
matological practice, total body photography has proven                 extremity of the lesion, and corresponding to pseudopods
to be a powerful tool for uncovering new or changing pig-               (Figure 1C). The lesion was excised and the histopatholog-
mented lesions that are either too small or unremarkable                ical analysis revealed an asymmetrical junctional melano-
during a routine clinical skin exam in high-risk individuals            cytic proliferation with nests of various sizes composed of
[1]. Thanks to this technique, the number of reported mela-             large epithelioid melanocytes with cytologic atypia; pleo-
nomas measuring less than 2 mm in diameter, defined as mi-              morphic nuclei, dusky and heavily pigmented cytoplasm,
cro-melanomas, is increasing. Consequently, the relevance of            and mitotic figures. There was focal lentiginous prolifera-
the 6 mm size criterion of the classic ABCDE rule is currently          tion in connection with a peripheral nest, compatible with
under question [2].                                                     the horizontal expansion seen in the dermoscopic image of
                                                                        irregular streaks, as well as isolated melanocytes in a pag-
                                                                        etoid scatter (Figure 2). Two dermatopathologists reviewed
Case presentation
                                                                        the specimen. Given the lentiginous spread extending over 3
A 29-year-old man with a personal history of melanoma                   papilla in the periphery of the lesion, and the pagetoid as-
consulted our clinic for his annual skin exam and to-                   cension, which was limited over the nests in the center of the
tal-body-photography. The comparative photography re-                   lesion, the diagnosis of melanoma in situ, acral lentiginous
vealed a new, tiny, pigmented lesion on his right lateral trunk,        subtype, was retained. A re-excision of the scar with 5 mm
measuring 1.0 mm x 1.5 mm, and appearing darker than the                lateral margins and up to the muscle fascia was performed.
rest of his naevi (Figure 1, A and B). The digital dermos-              We are currently following the patient alternating clinical
copy exam revealed an atypical melanocytic lesion, charac-              exam and total body photography every 6 months accord-
terized by asymmetry, and irregular network composed of                 ing to the Swiss Melanoma guidelines.



Research Letter | Dermatol Pract Concept. 2022;12(2):e2022070                                                                       1
Figure 1. Total Body Photography exam: a new lesion is identified during time-lapse comparison of photos. (A) Total-body-photography at visit
1. (B) Total-body-photography at visit 2, one year later revealing the presence of a new melanocytic lesion. Inset: high power of the new lesion
showing a darker pigmentation than the rest of the nevi. (C) Digital dermoscopy of the new lesion showing an atypical melanocytic network with
irregular streaks and pseudopods in an asymmetrical starburst pattern dominating one extremity of the lesion.




Figure 2. Histopathology correlate revealing features of melanoma in situ. (A-D) 10x magnification sections in different levels of the lesion
depicting the asymmetrical melanocytic growth with junctional nests of various sizes, distributed unevenly. (E) 40x magnification of the
B section showing the lentiginous spread in contact with a peripheral nest, corresponding to the pseudopods seen in dermoscopy. The me-
lanocytes exhibit large nuclei compared to the neighboring keratinocytes with abundant cytoplasm, and heavy pigmentation in some of
the cells. No pagetoid scatter was observed in the periphery of the lesion, compatible with an acral lentiginous subtype melanoma. (F) 40x
magnification of a central nest with a mitotic figure (red asterisk). (G) 40x magnification of the D section showing interconnected nests in the
center of the lesion with scattered melanocytes in the suprabasal layers of the epidermis (green asterisks), compatible with pagetoid ascension.



Conclusions                                                               the excised lesions constitute a great opportunity to study
                                                                          these very early events of malignant melanocytic expansion.
Although rare, acral lentiginous melanomas have been re-
ported in non-acral sites and their dermoscopic features are
similar to the ones observed in our patient. This case illus-
                                                                          References
trates the success of time-lapse total body photography in                 1. Drugge ED, Volpicelli ER, Sarac RM, Strang SR, Elston DM, Drugge
the identification of melanomas, akin to witnessing the birth                 RJ. Micromelanomas identified with time-lapse total body photog-
of a star, but also the fine correlation of dermoscopy and                    raphy and dermoscopy. J Am Acad Dermatol. 2018;78(1):182-183.
                                                                              DOI: 10.1016/j.jaad.2017.07.049. PMID: 29241777.
pathology. Furthermore, the systematic documentation of
                                                                           2. Hornung A, Steeb T, Wessely A et al. The Value of Total Body Photog-
micro-melanomas with digital dermoscopy combined with
                                                                              raphy for the Early Detection of Melanoma: A Systematic Review.
digital pathology and the molecular and genetic profiling of                  Int J Environ Res Public Health. 2021;18(4):1726. DOI: 10.3390/
                                                                              ijerph18041726. PMID: 33578996. PMCID: PMC7916771.


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