Sergio Yamada1, Mauricio Mendonça do Nascimento1, Sergio Henrique Hirata1
Keywords: DERMOSCOPY, MELANOMA, PHOTOGRAPHY
The early detection of cutaneous melanomas is an impor-
tant factor in the patient''''''''s prognosis. Dermoscopy is an impor-
tant instrument in the indication of excision for thin melano-
mas, however small lesions do not always clearly display high-
risk structures. The correct indication for the excision of small
uncharacteristic melanomas requires a systematic assessment that
includes:
1 – Characterization of high-risk patients: phototype, his-
tory of sun exposure, sunburns, presence of multiple nevi, aty-
pical nevi, family or personal melanoma history, and (possibly)
genetic risk assessment;
2 – Self-examination and body mapping (image-based
monitoring);
3 – Dermoscopy on all lesions, including those that are cli-
nically suspected;
4 – Excision of lesions with unspecific pigment patterns;
5 – Excision of lesions with spitzoid pattern, mainly in
adults;
6 – Excision of lesions with signs of regression;
7 – Excision of lesions where there is an absence of clini-
cal-dermoscopic correlation;
8 – Excision of lesions that present changes during the
short-term follow-up period (3 to 4 months)
1;
9 – In patients with multiple nevi, excision or reassessment
in the short-term of lesions that present a dermoscopic pattern
that is diverse from the patient''''''''s other lesions (ugly duckling
sign);
10 – Excision of pink lesions with an atypical vascular pat-
tern;
2
and
11 – Re-assessment or excision, in the short term, of
lesions with an unusual pattern for benign melanocytic lesions;
12 – In the longer-term follow-up,
3
excision of lesions that
have:
– Focal growth with a change in shape;
– High-risk structures (peripheral points that are irregular-
ly distributed, expansion of pigmented network with atypical
features); and
– Expansion of hypopigmentation area and appearance of
scar depigmentation, combined with a focal inflammatory res-
ponse.
1 – A phototype II patient with a previous personal histo-
ry of melanoma presented an emerging pigmented lesion on the
lateral region of the left arm during the monitored clinical follow-up. The lesion was shown to have a spitzoid pattern in the
dermoscopic exam (Figure 1). The spitzoid pattern in adults
indicates excision of the lesion for anatomical pathological
assessment. The assessment confirmed a micro-invasive melano-
ma for the patient.
2 – A phototype III patient with a previous personal histo-
ry of melanoma presented lesions in the left mammary region,
with a dermoscopic pattern different from those of other lesions
analyzed in the same examination (ugly duckling sign), in addi-
tion to erythema. The lesion was recorded and monitored, and
presented asymmetric growth and minor modifications in the
morphology of its structures (Figure 2). The anatomopathologi-
cal examination confirmed an in situ melanoma.
3 – A phototype II patient with a personal history of mela-
noma presented a darkening lesion in the right lumbar region in
the monitored follow-up. Dermoscopy revealed an atypical net-
work (thickened) and multifocal hyperpigmentation (Figure 3).
The development of the clinical and dermoscopic patterns were
taken into account, and excision was recommended. The anato-
mopathological examination revealed an in situ melanoma.
4 – A female phototype II patient presented a pigmented
lesion on the right thigh. Dermoscopy evidenced irregularly dis-
tributed peripheral points and discreet radial streaming that were also irregularly distributed (Figure 4). Borders were well defined
around the entire periphery of the lesion. The anatomopatholo-
gical examination verified an in situ cutaneous melanoma.
The clinical observations illustrate that the risk of not removing uncharacteristic small melanomas can be minimized with clinical and dermoscopic systematic follow-up.
1 . Kittler H; Guitera P; Riedl E; Avramidis M; Teban L; Fiebiger M; Weger RA;Dawid M; Menzies S: Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging Arch Dermatol 2006;142:1113-1119.
2 . Argenziano G; Zalaudek I; Ferrara G; Johr R; Langford D; Puig S; Soyer HP; Malvehy J: Dermoscopy features of melanoma incognito: indications for biopsy J Am Acad Dermatol 2007;56:508-13.
3 . Kitler H; Pehamberger H; Wolff K; Binder M: Follow-up of melanocytic lesions with digital epiluminescence microscopy: Patterns of modifications observed in early melanoma, atypical nevi, and commom nevi J Am Acad dermatol 2000;43:467-76.