Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773

Volume 3 Number 4

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Diagnostic Imaging

Detection of small melanomas

Detecção de melanomas pequenos

Sergio Yamada1, Mauricio Mendonça do Nascimento1, Sergio Henrique Hirata1

Received on: 25 October 2011
Approved on: 15 November 2011

The clinical cases in this study were retrospectively selected from the database of the Dermoscopy Group of the UNIFESP’s Dermatology Department and private practices.

Financial support: None
Conflicts of interest: None



Four clinical cases of small melanomas detected by dermoscopy associated with clinical data and total body photographs with systematic monitoring are described. In small melanomas, dermatoscopic findings alone are not always sufficient to correctly indicate the excisional biopsies used in anatomical-pathological examinations.


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.

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