10.5826/dpc.1204a137
text/xml
2160-9381
1843
en
Marina Agozzino
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
diagnostic accuracy
Benefits and Pitfalls of Using In Vivo Reflectance Confocal Microscopy in Lentigo Maligna Diagnostics. Case Reports
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-10-31
2021-09-13
2022-10-31
2022-11-29
e2022137
Dermatol Pract Concept
Marina Agozzino
2022/10/31
10.5826/dpc.1204a137
e2022137
Dermatology and Venereology Department, Maggiore hospital, University of Trieste, Trieste, Italy
2160-9381
diagnostic accuracy
en
e2022137
Benefits and Pitfalls of Using In Vivo Reflectance Confocal Microscopy in Lentigo Maligna Diagnostics. Case Reports
https://dpcj.org/index.php/dpc/article/download/1843/1826
                   Benefits and Pitfalls of Using in Vivo Reflectance
                      Confocal Microscopy in Lentigo Maligna
                              Diagnostics: Case Reports
                         Ieva Povilaite1, Giuseppe Argenziano2, Graziella Babino2, Claudio Conforti4,
                  Elvira Moscarella2, Francesca Pagliuca3, Andrea Ronchi3, Iris Zalaudek4, Marina Agozzino4


             1 Department of Skin and Venereal diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
             2 Dermatology Unit, University of Campania, Naples, Italy
             3 Department of Advanced Biomedical Sciences, Pathology Section, University of Naples Federico II, Naples, Italy
             4 Dermatology and Venereology Department, Maggiore hospital, University of Trieste, Trieste, Italy



             Key words: lentigo maligna, in vivo reflectance confocal microscopy, pigmented facial lesion, diagnostic accuracy
             Citation: Povilaite I, Argenziano G, Babino G, et al. Benefits and pitfalls of using in vivo reflectance confocal microscopy in lentigo maligna
             diagnostics: case reports. Dermatol Pract Concept. 2022;12(4):e2022137. DOI: https://doi.org/10.5826/dpc.1204a137
             Accepted: January 13, 2022; Published: October 2022
             Copyright: ©2022 Povilaite 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: Ieva Povilaite, MD, Department of Skin and Venereal diseases, Eiveniu st.2, Kaunas, Lithuania; LT-50161.
             Email: ievapovilaite@gmail.com




             Introduction                                                             routine examination using a dermatoscope a macule on the
                                                                                      tip of the nose was noted (Figure 1A). Dermoscopically a
             The differential diagnosis between lentigo maligna (LM) and              structureless brownish color pigmentation and irregular
             pigmented facial lesions (PFL) might be challenging clinically           grayish ­
                                                                                              pigmentation around some follicles were present
             and dermoscopically, especially in its early phases, because             (Figure 1B). Due to the doubtful appearance in dermoscopy
             early melanoma may exhibit only subtle malignancy clues                  RCM ­examination was performed revealing the presence of
             and may have overlapping features with PFL [1,2]. There-                 several atypical melanocytes located mainly around hair fol-
             fore, new diagnostic tools such as Reflectance confocal                  licles (Figure 1C). Based on confocal features, a total surgi-
             ­microscopy (RCM) to improve early detection of LM in its                cal excision was performed and a final diagnosis of LM was
             initial growth phases are crucial. Herein reported two cases             confirmed ­(Figure 1D). The patient refused the re-excision,
             of LM and two different approaches of using RCM.                         and adjuvant therapy with Imiquimod 5% cream once daily
                                                                                      for 6 weeks was started. After 2 years of follow up, no mela-
                                                                                      noma recurrence signs were noted.
             Case Presentation
                                                                                           A 61-year-old woman presented at our clinic for evalu-
             A 47-year-old man presented at our department for la-                    ation of a pigmented macule on the left cheek (Figure 2A).
             ser treatment of some facial brownish macules. During                    The patient had no previous history of melanoma. Both



             Research Letter | Dermatol Pract Concept. 2022;12(4):e2022137                                                                                1




DPC_1843.indd 1                                                                                                                                                14/10/22 5:29 PM
                  Figure 1. (A) Clinical appearance of a small brownish macule measuring 5 mm in diameter on the distal part of the nose (red arrow).
                  (B) Dermoscopy showing light grey color around few hair follicles (red arrow). (C) RCM mosaic at level of the epidermis, showing
                  infiltration of atypical melanocytes around adnexal structures (red square); pagetoid/dendritic melanocytes located mainly around hair
                  follicles (red arrows). (D) Histopathology: a lentiginous intraepidermal melanocytic proliferation in the context a skin with severe actinic
                  damage. A junctional nest is shown on the left (red arrow) (H&E, ×200).



             clinically and dermoscopically (Figure 2B) the lesion looked                 us reveal characteristics suggestive of the melanocytic nature
             suspicious. Under RCM examination atypical dendritic                         of the lesion.
             cells were visible at the level of the epidermis, they were                      In the second case the lesion both clinically and dermo-
             not located around follicles nor infiltrating them. Mela-                    scopically looked suspicious, however RCM findings were
             nocytic nests forming cords were visible at the level of the                 subtle. Indeed, on RCM, the lesion had regular epidermal
             dermal-epidermal junction, with no obvious melanoma fea-                     architecture, which is noteworthy and in the early radial
             tures (Figure 2C). However, due to the suspicious dermo-                     growth phase of melanoma, follicles were well defined with-
             scopic aspect, the lesion was excised and a final diagnosis of               out folliculotropism and widespread dendrites. In this case
             LM was confirmed by histology (Figure 2D). The patient is                    the confidence level of the dermatologist in making diagnosis
             recurrence free after 2 years follow up.                                     of LM was higher with the dermatoscope. Therefore, this
                                                                                          second case supported that clinical and dermoscopic criteria
                                                                                          are extremely important for LM diagnosis.
             Conclusions                                                                      In conclusion, LM diagnosis still remains challenging. A
             In the first case presented, the lesion did not show any spe-                combined clinical/dermoscopic/confocal approach should be
             cific features for melanoma. On dermoscopy the only sub-                     used for the management of PFL in order to provide a more
             tle suspicious clue was the presence of greyish color around                 conclusive pre-histological diagnosis leading clinicians to a
             some follicles. This clue shows high sensitivity to malignancy               correct management.
             (85, 1%), but quite low specificity (39, 7%) [1]. RCM helped




             2                                                                                Research Letter | Dermatol Pract Concept. 2022;12(4):e2022137




DPC_1843.indd 2                                                                                                                                                  14/10/22 5:29 PM
                  Figure 2. (A) Pigmented macule located on the left cheek (5 × 7 mm) with irregular borders and variegated color (red arrow).
                  (B) ­Dermoscopy showing an asymmetric pigmented macule with atypical infiltration of interspaces and adnexal structures (red stars).
                  (C) RCM mosaic (1.5 × 2.5 mm) at the level of the DEJ showing junctional nesting (red arrows) without colonization of atypical cells
                  around hair follicles. (D) Histopathology: the sublesional dermis shows marked solar elastosis and increased melanophages (black arrow:
                  melanocytic nest; red arrows: melanophages; black stars: solar elastosis) (H&E, ×200).




             Research Letter | Dermatol Pract Concept. 2022;12(4):e2022137                                                                                  3




DPC_1843.indd 3                                                                                                                                                 14/10/22 5:29 PM
