Atypical Spitz tumours: an epidemiological, clinical and dermoscopic multicentre study with 16 years of follow-up.

BACKGROUND: Atypical Spitz tumours (ASTs) are regarded as an intermediate category distinguished from prototypical Spitz naevus by presenting one or more atypical features and often by an uncertain malignant potential. Clinical and dermoscopic features may play a relevant role in the diagnostic approach. AIM: To evaluate the clinical and dermoscopic features of ASTs, and their evolution over time. METHODS: This was a descriptive, multicentre study of the clinical and dermoscopic characteristics of ASTs. Data on clinical and dermoscopic characteristics, histopathology, local extension, therapy and follow-up, lymph node staging, complete lymph node dissection, and outcome were collected from the databases of four Italian Dermatology Units for the period 2004-2021. RESULTS: The study population consisted of 99 patients (62 female, 37 male) with a histologically confirmed diagnosis of AST, including age at presentation ranged from 2 to 70 years (mean 28.1 years, median 24 years). Of the 99 patients, 29 (29.3%) underwent sentinel lymph node biopsy, which showed evidence of micrometastases in three cases (10.3%); all three patients underwent complete lymph node dissection with no evidence of further metastasis. Considering the whole study population, the clinical outcome was excellent, as all of the patients have no evidence of recurrence or distant metastasis. The follow-up period ranged from 6 to 216 months (mean 81.6 months, median 78 months). In addition, we collected data on the clinical and dermoscopic features of 26 lesions. The most frequent dermoscopic pattern observed was the multicomponent pattern (34.6%), followed by homogeneous (26.9%) and nonspecific (23.2%). In 66.7% of amelanotic ASTs, we observed glomerular (coiled) vessels uniformly distributed within the entire lesion, without asymmetry. CONCLUSION: The results of our study with a long follow-up show no recurrence or distant metastases, confirming the good clinical outcome, even in the case of sentinel lymph node positivity. From a diagnostic point of view, our series identified a typical dermoscopic picture for amelanotic ASTs, with a glomerular vascular pattern throughout the lesion in the absence of other dermoscopic parameters, making the correct diagnosis possible.

Melanoma in children, adolescents and young adults: anatomo-clinical features and prognostic study on 426 cases.

PURPOSE: This study was conducted to determine the difference in anatomo-pathological and prognostic features of cutaneous melanoma in children, adolescents and young adults. METHODS: This is a retrospective review on 383 young patients ≤ 39 years of age with cutaneous melanoma, in a period from 2006 to 2016 in Area Vasta Nord Ovest, Tuscany, Italy. We subdivided patients in three groups (children ≤ 14 years, adolescents 15-21 years, young adults 22-39 years). We correlated all the anatomo-pathological parameters with age groups. RESULTS: We identified a total of 426 cases of cutaneous melanoma on an overall total of 383 patients. Mean age at diagnosis for all the patients ≤ 39 years of age was 31.2 years: in group A was 11.2 years, in group B 19.2 years and in group C 32.5 years. Incidence, in the subjects between 0 and 14 years, is 14 cases per million inhabitants, between 15 and 21 years of 145, and between 22 and 39 years of 394. Global incidence was 1.6 case per million for group A, 8.9 cases per million for group B, 105 cases per million for group C. No statistically significative correlation could be described for clinical parameters and age groups. CONCLUSIONS: Incidence of melanoma in our casuistry results as the highest in the world. These data open new study for this kind of cancer.

Treatment of psoriasis with topical agents: Recommendations from a Tuscany Consensus.

Psoriasis is a chronic and relapsing inflammatory skin disease, clinically characterized by erythematous and scaly plaques. Treatment approach is mainly driven by disease severity, though several factors should be considered in order to identify the optimal therapeutic choice. Mild psoriasis may be treated with a wide array of topical agents including corticosteroids, vitamin D analogs, keratolytics, and calcipotriol/betamethasone propionate compound. Because guidelines may not provide practical indications regarding the therapeutic approach, the use of topical agents in psoriasis is more individually tailored. In order to homogenize the standard of care, at least in a local setting, we collected the real-life-based recommendations for the use of topical therapies from an expert panel, the Tuscany Consensus Group on Psoriasis, representing all leading centers for psoriasis established in Tuscany. With this document, this consensus group sought to define principles guiding the selection of therapeutic agents with straightforward recommendations derived from a real-life setting.

Artificial Intelligence Algorithms for Benign vs. Malignant Dermoscopic Skin Lesion Image Classification.

In recent decades, the incidence of melanoma has grown rapidly. Hence, early diagnosis is crucial to improving clinical outcomes. Here, we propose and compare a classical image analysis-based machine learning method with a deep learning one to automatically classify benign vs. malignant dermoscopic skin lesion images. The same dataset of 25,122 publicly available dermoscopic images was used to train both models, while a disjointed test set of 200 images was used for the evaluation phase. The training dataset was randomly divided into 10 datasets of 19,932 images to obtain an equal distribution between the two classes. By testing both models on the disjoint set, the deep learning-based method returned accuracy of 85.4 ± 3.2% and specificity of 75.5 ± 7.6%, while the machine learning one showed accuracy and specificity of 73.8 ± 1.1% and 44.5 ± 4.7%, respectively. Although both approaches performed well in the validation phase, the convolutional neural network outperformed the ensemble boosted tree classifier on the disjoint test set, showing better generalization ability. The integration of new melanoma detection algorithms with digital dermoscopic devices could enable a faster screening of the population, improve patient management, and achieve better survival rates.

Mitotic rate as a predictive factor for positive sentinel lymph nodes in pT1 and pT2 melanomas.

Sentinel lymph node biopsy is a crucial step in the management of patients affected by melanoma. The decision whether to perform it or not is based on different histological parameters, but the mitotic rate is no longer considered a prognostic variable after the release of the 8th edition of the American Joint Committee on Cancer (AJCC) guidelines. Our objective was to investigate the risk factors that increase the chance for sentinel lymph node positivity in melanomas with a Breslow thickness of less than 2.00 mm, including the mitotic count. A retrospective single-center study was performed on a homogenous cohort of 408 patients treated for cutaneous melanoma. Histological and clinical features were gathered and correlated with the increased risk for sentinel lymph node positivity by means of univariate and multivariate analyses. A statistically significant correlation between a high mitotic index and a positive sentinel lymph node was found in pT1 and pT2 patients, suggesting that in the case of pT1a melanoma with a high number of mitoses, a discussion about whether a sentinel lymph node biopsy is required should be done.

Epidemiology of Merkel cell carcinoma in Tuscany (Italy), 2006-2021.

Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer that still has a poor prognosis. MCC incidence has increased in recent years worldwide. The aim of our study was to perform an epidemiological retrospective study and to evaluate the impact of MCC clinical and pathological features on overall survival (OS) in a specific geographical area. We retrospectively collected 94 pathology reports from 2006 to 2021 that were present in the pathology archives of the University Hospital of Pisa and of the Hospital of Livorno. Laterality was different according to the site, and almost half of the lesions were T1 and nearly half of the patients had a clinical stage III. We reported a dramatic increase in MCC diagnoses in the last 5 years compared with the previous years, with a crude incidence rate of 1,15/100000 inhabitants, almost doubling the last reported data in Italy. Surgical margins status and ulceration were not related to OS. We have noticed some patients with a rapidly progressing disease and others showing a slow disease progression which should prompt the investigation of specific biomarkers or other features that could elucidate this striking difference in progression-free survival and could potentially identify different subtypes of MCC. Considering the generally low incidence of MCC worldwide, larger cohorts would be necessary to validate our data and to obtain a better prognostic stratification.

Atypical ulcer arising on stasis dermatitis: achromic melanoma.

INTRODUCTION: Due to venous insufficiency, a vascular ulcer frequently occurs with the progression of stasis dermatitis. Achromic melanoma, a rare form of pigmentless melanoma frequently located on the sole of the foot, is often and easily confused with a typical wound. Diagnosis of ulcerated achromic melanoma is thus often delayed and associated with a poor prognosis. CASE REPORT: The authors report a very rare case of malignant melanoma in a 70-year-old female with stasis dermatitis. The painless ulcer was present for 1 year before the first visit. Upon clinical examination, a 2-cm diameter hypergranulating ulcer with irregular and pigmented borders was present. Dermoscopy revealed the presence of red globules, a gray-to-blue veil, irregular vessels, and the remains of a pigmented ridge pattern. Histological analysis showed infiltration of atypical melanocytes in the dermis, 2 mitoses, and ulceration. Diagnosis of melanoma was confirmed by positive MART-1 immunochemistry. After removal of the melanoma, the area was covered with an autologous skin graft excised from the inner thigh. In accordance with the guidelines, sentinel lymph node biopsy was performed, and the result was negative for lymph node involvement. A comprehensive clinical dermoscopic evaluation led to the correct diagnosis. CONCLUSIONS: The current case highlights the importance of evaluating a chronic, atypical, nonhealing ulcer clinically and dermoscopically as well as through a biopsy procedure.

Epidemiology of melanoma: the importance of correctly reporting to the cancer registries.

In Italy, few epidemiologic studies have been conducted by tracing melanoma reports directly in the electronic registers of the operating units of pathologic anatomy. The Cancer Registers of the Italian regions receive only partial and incomplete data on the diagnoses of melanoma, for this reason, the incidences are usually underestimated. Our work offers a precise picture of the epidemiologic situation of melanoma in a homogenous sample of patients residing in a geographic area traditionally considered to have a high incidence of melanoma.

Pigmentary mammary Paget disease: Clinical, dermoscopical and histological challenge.

A very rare variant of mammary Paget disease (MPD) is the pigmented MPD, first described in 1956. It is very difficult to distinguish this variant from melanoma both clinically and dermoscopically. The diagnosis is confirmed by histopathology and immunohistochemistry. Correct diagnosis is crucial for surgical treatment, which is different for these two diseases. We report the case of a 92-year-old woman, who presented an asymptomatic pigmented lesion of the right nipple and areola. The lesion was arisen for about 6 months and was suspected for melanoma because of clinical and dersmoscopic characteristics. Incisional biopsy revealed tumor cells, that proliferate in the major mammary ducts, and tumor cells in the overlying epidermis of the nipple, thus diagnosing pigmented mammary Paget disease. The patient underwent radical mastectomy.

Dupilumab in Elderly Patients With Severe Atopic Dermatitis.

BACKGROUND: Atopic dermatitis (AD) in the elderly has been poorly investigated, although its incidence is gradually increasing mainly in industrialized countries. Age-specific factors in older patients must be considered when selecting treatment options. OBJECTIVES: To evaluate the efficacy and tolerability of dupilumab in treating elderly patients with severe AD. METHODS: This was a retrospective, multicenter study involving 26 elderly patients (age, ≥65 years) with severe AD who were treated with dupilumab for at least 16 weeks. Absolute and percentage frequencies were used to evaluate qualitative variables and mean and SD for quantitative ones. For Eczema Area and Severity Index (EASI), Pruritus Numeric Rating Scale (NRS), and Dermatology Life Quality Index (DLQI), the median was also calculated. Wilcoxon test was used to evaluate the variations in EASI, Pruritus NRS, and DLQI observed between the 2 examinations. RESULTS: After 4 months of therapy, the majority of patients showed a significant improvement in EASI (64.4%), Pruritus NRS (58.2%), and DLQI (44.9%). Only 11% of patients reported mild or moderate conjunctivitis. CONCLUSIONS: To the best of our knowledge, this is the first study concerning the use of dupilumab in the elderly with severe AD. Our data show the effectiveness of dupilumab in this particular population with a lower percentage of conjunctivitis than observed in studies on adults and also excellent control of itching. Only larger, controlled case studies will be able to clarify whether the dosage or frequency of administration of dupilumab in these patients should be different from the protocol used for adults.

Risk factors in pediatric melanoma: a retrospective study of 39 cases.

Pediatric melanoma is a rare form of the tumor whose epidemiology is widely increasing thanks to the improvement of dermoscopic and anatomopathologic diagnostic techniques. Although it is a tumor of considerable interest in adults, little has been described about the pediatric field. The objective of our study was then to identify the possible risk factors for the development of melanoma in the pediatric population. We performed a retrospective study conducted in the Melanoma and Skin Cancer Unit and Unit of Dermatology (Livorno, Italy). We analyzed a population of 38 children under 21 years with a diagnosis of melanoma. This population was compared with a control population of 114 children followed up in our dermatologic clinic. From our combined univariate-multivariate statistics analysis, the number of nevi [regression coefficient (RC) of 1.04 and odds ratio (OR) of 2.8 confidence interval (Cl, 1.2-6.6)], and family history of melanoma [RC of 1.99 and OR of 7.3 (Cl, 2.3-22.7)] emerged as possible risk factors for the development of melanoma. The identification of these elements would allow the physician to carry out a more targeted preliminary assessment of the patient, potentially decisive in cases of diagnostic doubt of the lesion. Our study also lays the foundations for identifying those children who, despite not having received a diagnosis of melanoma on histologic examination, should be considered as patients susceptible to a focused follow-up, because of the presence of the risk factors that emerged from our research.

Tuscan Consensus on the diagnosis, treatment and follow up of adult atopic dermatitis.

Atopic dermatitis (AD) is an inflammatory disease with a chronic-relapsing course that is intensely itchy. A correct diagnosis of AD in adults and consequently appropriate clinical therapeutic management is a critical issue for extreme clinical expression heterogeneity and various grades of disease severity. In order to ensure high levels of care and standardization of clinical therapeutic management of Adult AD, the decision was taken to create an AD Tuscan Consensus Group (the Group), to work on and validate a consensus based regional clinical-therapeutic management model. The aims of the Group were to find agreement on the criteria for diagnosis, scoring of severity, multidisciplinary approach and treatment of adult atopic dermatitis and to create an easier way for patients to access specialized dermatology outpatient services and importantly to reduce waiting lists and costs related to the management of AD. The Tuscan Consensus Group adopted a simplified Delphi method, in three principal steps: 1) literature metanalysis and critical review of patient's clinical experience to identify the main areas considered questionable or uncertain; 2) discussion of those areas requiring consensus and statement definition through four different sub-committees (diagnosis, severity evaluation, scoring and comorbidities); 3) a consensus based simplified process with final approval of each statement by plenary vote with approval >80% of the participants. The Group here presents and discusses the consensus based recommendation statements on adult atopic dermatitis.