Papular epidermal nevus with «skyline»: 3 nuevos casos / Papular Epidermal Nevus With "Skyline" Basal Cell Layer: A Report of 3 New Cases

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Virus del papiloma humano y riesgo de desarrollo de carcinoma escamocelular en la hidradenitis supurativa / Human Papilloma Virus and the Risk of Squamous Cell Carcinoma Arising in Hidradenitis Suppurativa

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Utilidad de la ecografía cutánea en la clasificación de subtipos de los carcinomas basocelulares primarios / Usefulness of high-frequency ultrasound in the classification of histologic subtypes of primary basal cell carcinoma

INTRODUCCIÓN: La biopsia incisional puede fallar en la correcta catalogación de subtipos histológicos de carcinoma basocelular (CBC). La ecografía (ECO) cutánea es una herramienta diagnóstica útil en el diagnóstico y manejo de este tumor. OBJETIVOS: El objetivo principal fue evaluar la utilidad diagnóstica de la ECO frente a la biopsia punch en la correcta clasificación del patrón histológico de infiltración de los CBC primarios. Los objetivos secundarios fueron: evaluar si el rendimiento diagnóstico de la ECO frente a la biopsia incisional guardaba relación con el tamaño tumoral y con formas de CBC simples frente a formas mixtas. MÉTODOS: Estudio observacional prospectivo de los casos de CBC primarios atendidos en el Servicio de Dermatología del Hospital Costa del Sol (Marbella) entre octubre de 2013 y mayo de 2014. Previamente a la extirpación quirúrgica se realizó una ECO cutánea (Dermascan C©, sonda lineal, 20 Mhz) y una biopsia punch. Se valoró el porcentaje de acuerdo absoluto y rendimiento diagnóstico (sensibilidad, especificidad, valor predictivo positivo [VPP] y valor predictivo negativo [VPN]) para resultados globales y parciales entre ECO y punch frente al gold estándar (biopsia escisional por cortes seriados). RESULTADOS: Se incluyeron 156 casos. La tasa de concordancia diagnóstica global de la ECO fue del 73,7% (sensibilidad: 74,5%, especificidad: 73%) vs. 79,9% (sensibilidad: 76%, especificidad: 82%) para el punch. En el análisis individual destaca para el CBC superficial un VPP para la ECO del 93,3% frente al 92% para el punch. En el análisis por tamaño tumoral la ECO incrementó el porcentaje de acuerdo absoluto del 70,4 al 77,3% (área 40 mm2 vs. área > 40 mm2) manteniendo el VPN constante para ambos subgrupos (82%). Para la biopsia punch, el porcentaje de acuerdo absoluto pasó del 86,4 al 72,6%. CONCLUSIONES: La ECO cutánea muestra una especial utilidad para descartar la presencia de invasividad, para el diagnóstico de formas superficiales simples y para la correcta catalogación de CBC de área mayor a 40 mm2

INTRODUCTION: Incisional biopsy may not always provide a correct classification of histologic subtypes of basal cell carcinoma (BCC). High-frequency ultrasound (HFUS) imaging of the skin is useful for the diagnosis and management of this tumor. OBJECTIVES: The main aim of this study was to compare the diagnostic value of HFUS compared with punch biopsy for the correct classification of histologic subtypes of primary BCC. We also analyzed the influence of tumor size and histologic subtype (single subtype vs. mixed) on the diagnostic yield of HFUS and punch biopsy. METHODS: Retrospective observational study of primary BCCs treated by the Dermatology Department of Hospital Costa del Sol in Marbella, Spain, between october 2013 and may 2014. Surgical excision was preceded by HFUS imaging (Dermascan C©, 20-MHz linear probe) and a punch biopsy in all cases. We compared the overall diagnostic yield and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of HFUS and punch biopsy against the gold standard (excisional biopsy with serial sections) for overall and subgroup results. RESULTS: We studied 156 cases. The overall diagnostic yield was 73.7% for HFUS (sensitivity, 74.5%; specificity, 73%) and 79.9% for punch biopsy (sensitivity, 76%; specificity, 82%). In the subgroup analyses, HFUS had a PPV of 93.3% for superficial BCC (vs. 92% for punch biopsy). In the analysis by tumor size, HFUS achieved an overall diagnostic yield of 70.4% for tumors measuring 40 mm2 or less and 77.3% for larger tumors; the NPV was 82% in both size groups. Punch biopsy performed better in the diagnosis of small lesions (overall diagnostic yield of 86.4% for lesions 40 mm2 vs. 72.6% for lesions > 40 mm2). CONCLUSIONS: HFUS imaging was particularly useful for ruling out infiltrating BCCs, diagnosing simple, superficial BCCs, and correctly classifying BCCs larger than 40 mm2

Usefulness of High-Frequency Ultrasound in the Classification of Histologic Subtypes of Primary Basal Cell Carcinoma. / Utilidad de la ecografía cutánea en la clasificación de subtipos de los carcinomas basocelulares primarios.

INTRODUCTION: Incisional biopsy may not always provide a correct classification of histologic subtypes of basal cell carcinoma (BCC). High-frequency ultrasound (HFUS) imaging of the skin is useful for the diagnosis and management of this tumor. OBJECTIVES: The main aim of this study was to compare the diagnostic value of HFUS compared with punch biopsy for the correct classification of histologic subtypes of primary BCC. We also analyzed the influence of tumor size and histologic subtype (single subtype vs. mixed) on the diagnostic yield of HFUS and punch biopsy. METHODS: Retrospective observational study of primary BCCs treated by the Dermatology Department of Hospital Costa del Sol in Marbella, Spain, between october 2013 and may 2014. Surgical excision was preceded by HFUS imaging (Dermascan C©, 20-MHz linear probe) and a punch biopsy in all cases. We compared the overall diagnostic yield and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of HFUS and punch biopsy against the gold standard (excisional biopsy with serial sections) for overall and subgroup results. RESULTS: We studied 156 cases. The overall diagnostic yield was 73.7% for HFUS (sensitivity, 74.5%; specificity, 73%) and 79.9% for punch biopsy (sensitivity, 76%; specificity, 82%). In the subgroup analyses, HFUS had a PPV of 93.3% for superficial BCC (vs. 92% for punch biopsy). In the analysis by tumor size, HFUS achieved an overall diagnostic yield of 70.4% for tumors measuring 40mm2 or less and 77.3% for larger tumors; the NPV was 82% in both size groups. Punch biopsy performed better in the diagnosis of small lesions (overall diagnostic yield of 86.4% for lesions ≤40mm2 vs. 72.6% for lesions >40mm2). CONCLUSIONS: HFUS imaging was particularly useful for ruling out infiltrating BCCs, diagnosing simple, superficial BCCs, and correctly classifying BCCs larger than 40mm2.

Pápula eritematosa abdominal / Erythematous Abdominal Papule

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Características clínico patológicas del melanoma en residentes europeos de la Costa del Sol occidental / Clinical and Pathological Features of Melanoma in Europeans Living on the Western Costa del Sol in Southern Spain

OBJETIVO: Estudiar las diferencias clínico-patológicas del melanoma entre grupos de población española y centro-norte europea en el área sanitaria pública de la Costa del Sol occidental. MÉTODOS: Se realizó un estudio descriptivo, transversal, que incluyó todos los casos de melanoma cutáneo primario confirmados histológicamente durante el periodo 2005-2011 en el área sanitaria del Hospital Costa del Sol. Se analizaron las características clínicas y patológicas. Se realizó un análisis descriptivo y un análisis univariado tomando como variable de comparación de subgrupos el país de nacimiento (España vs norte y centro de Europa). RESULTADOS: En comparación con los españoles, los pacientes centro-norte europeos presentaron una edad al diagnóstico 10 años superior (66,2 vs 56,2; p < 0,001) una mayor frecuencia de fototipos bajos (i o ii 90,3% vs. 67,1%; p < 0,001), fotoexposición recreativa (93,7% vs. 66,2%; p < 0,001), antecedentes familiares de melanoma (9,5 vs 2,3; p = 0,01), melanomas múltiples 17,6% vs. 4,4%; p = 0,001) y una mayor asociación con carcinomas cutáneos (47,2% vs 15,7%; p < 0,001). Además, destacó un mayor número de melanomas del tronco (46,3% vs 38,7%) y melanomas in situ (54,7% vs 41,8%; p = 0,03). CONCLUSIÓN: Las diferencias fenotípicas y en los estilos de vida entre la población española y la centro-norte europea parecen determinar patrones diferentes de presentación del melanoma. Conocer estas diferencias permitirá orientar más adecuadamente las estrategias de prevención, así como el seguimiento de los pacientes con melanoma en poblaciones multiculturales como la de la Costa del Sol

OBJECTIVE: To compare clinical and pathological features of melanoma in Spanish patients with those of patients from Central or Northern Europe living in the health district of Costa del Sol Occidental in southern Spain. METHODS: We conducted a descriptive cross-sectional study of all cases of primary cutaneous melanoma histologically confirmed between 2005 and 2011 in the health care district covered by Hospital Costa del Sol in Marbella. We analyzed clinical and pathological features and performed a descriptive analysis of the 2 populations, in addition to univariate analysis with place of birth (Spain vs Central or Northern Europe) as the independent variable. RESULTS: Compared with Spaniards, patients from Central or Northern Europe were 10 years older at the time of melanoma diagnosis (66.2 vs 56.2 years, P < .001), had lighter skin (types I or II) (90.3% vs 67.1%, P < .001), and greater recreational sun exposure (93.7% vs 66.2%, P < .001). In addition, multiple melanomas (17.6% vs 4.4%, P = .001), nonmelanoma skin cancer (47.2% vs 15.7%, P < .001), and a family history of melanoma (9.5% vs 2.3%, P = .01) were more common in these patients. Central and Northern Europeans also had a higher overall frequency of melanoma on the trunk (46.3% vs 38.7%) and melanoma in situ (54.7% vs 41.8%, P = .03). CONCLUSION: Differences in melanoma presentation between Spanish patients and patients from Central or Northern Europe appear to be linked to phenotypic and lifestyle factors. A better understanding of these differences will help to tailor melanoma prevention and follow-up programs for multicultural populations, such as those on Spain's Costa del Sol

Clinical and pathological features of melanoma in europeans living on the Western costa del sol in southern Spain.

OBJECTIVE: To compare clinical and pathological features of melanoma in Spanish patients with those of patients from Central or Northern Europe living in the health district of Costa del Sol Occidental in southern Spain. METHODS: We conducted a descriptive cross-sectional study of all cases of primary cutaneous melanoma histologically confirmed between 2005 and 2011 in the health care district covered by Hospital Costa del Sol in Marbella. We analyzed clinical and pathological features and performed a descriptive analysis of the 2 populations, in addition to univariate analysis with place of birth (Spain vs Central or Northern Europe) as the independent variable. RESULTS: Compared with Spaniards, patients from Central or Northern Europe were 10 years older at the time of melanoma diagnosis (66.2 vs 56.2 years, P<.001), had lighter skin (types I or II) (90.3% vs 67.1%, P<.001), and greater recreational sun exposure (93.7% vs 66.2%, P<.001). In addition, multiple melanomas (17.6% vs 4.4%, P=.001), nonmelanoma skin cancer (47.2% vs 15.7%, P<.001), and a family history of melanoma (9.5% vs 2.3%, P=.01) were more common in these patients. Central and Northern Europeans also had a higher overall frequency of melanoma on the trunk (46.3% vs 38.7%) and melanoma in situ (54.7% vs 41.8%, P=.03). CONCLUSION: Differences in melanoma presentation between Spanish patients and patients from Central or Northern Europe appear to be linked to phenotypic and lifestyle factors. A better understanding of these differences will help to tailor melanoma prevention and follow-up programs for multicultural populations, such as those on Spain's Costa del Sol.

Utilidad de la ecografía cutánea en el diagnóstico de invasividad del carcinoma basocelular recurrente tras tratamiento no quirúrgico / The Usefulness of High-Resolution Ultrasound in Detecting Invasive Disease in Recurrent Basal Cell Carcinoma After Nonsurgical Treatment

INTRODUCCIÓN Y OBJETIVOS: La determinación del subtipo histológico de carcinoma basocelular (CBC) es crucial en el adecuado abordaje del mismo (sobre todo diferenciar variantes agresivas de no agresivas). En ocasiones la biopsia falla en la correcta catalogación del mismo con sus conocidas consecuencias. La ecografía cutánea de alta frecuencia (ECAF) es una técnica reciente que ha mostrado potencialidad en la distinción de variantes de CBC. El objetivo del estudio fue mostrar la posible utilidad de la ECAF en la identificación de la invasividad del CBC recurrente tras tratamientos no quirúrgicos diagnosticados mediante biopsia como no invasivos. MATERIAL Y MÉTODOS: Estudio observacional, prospectivo de casos consecutivos de CBC con sospecha clínica de recurrencia tras tratamiento no quirúrgico y que previamente a dicho tratamiento habían sido diagnosticados por biopsia-punch como variantes superficiales. Previamente a la extirpación quirúrgica de los mismos se realizó una ecografía de la lesión y posteriormente un punch de la zona sospechosa de persistencia. Finalmente se estudió la tasa de concordancia entre los resultados diagnósticos de cada una de las pruebas (ECAF, biopsia-punch y biopsia escisional). RESULTADOS: Se incluyeron 8 casos. De entre los 4 casos en los que la biopsia-punch realizó una mala clasificación de invasividad (eran realmente subtipos invasivos pero la biopsia-punch determinó subtipos superficiales), la ECAF fue capaz de detectar dicha invasividad en 3 de ellos. CONCLUSIÓN: La ECAF podría ser de utilidad en la detección de persistencias tumorales de CBC tras tratamientos no quirúrgicos, permitiendo guiar la biopsia-punch en la detección del área más sospechosa de infiltración

INTRODUCTION AND OBJECTIVES: Accurate subtyping of basal cell carcinoma (BCC) is crucial for the effective management of this disease and it is particularly important to distinguish between aggressive and nonaggressive histologic variants. Histologic subtype is not always accurately identified by biopsy and this can have serious implications. High-resolution ultrasound (HRUS) is a recent technique that has proven to be of value in differentiating between variants of BCC. The aim of this study was to investigate the potential usefulness of HRUS for detecting invasive disease in recurrent BCC treated nonsurgically following an initial diagnosis of noninvasive BCC by biopsy. MATERIAL AND METHODS: This was a prospective observational study of consecutive cases of BCC with clinical suspicion of recurrence following nonsurgical treatment and a pretreatment diagnosis of superficial BCC by punch biopsy. Before surgical excision, the recurrent lesions were evaluated by HRUS followed by a punch biopsy of the site of suspected recurrence. The diagnostic agreement between HRUS, punch biopsy, and excisional biopsy was then evaluated. RESULTS: Eight lesions were studied. HRUS identified invasive disease in 3 of the 4 cases that were incorrectly classified as superficial subtypes by punch biopsy. CONCLUSION: HRUS could be useful for detecting persistent tumor after nonsurgical treatment and for choosing the site most likely to harbor invasive disease for punch biopsy

Mácula equimótica sobre lesión pigmentada tras traumatismo / Ecchymotic Macule on a Pigmented Lesion Following Trauma

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The usefulness of high-resolution ultrasound in detecting invasive disease in recurrent basal cell carcinoma after nonsurgical treatment.

INTRODUCTION AND OBJECTIVES: Accurate subtyping of basal cell carcinoma (BCC) is crucial for the effective management of this disease and it is particularly important to distinguish between aggressive and nonaggressive histologic variants. Histologic subtype is not always accurately identified by biopsy and this can have serious implications. High-resolution ultrasound (HRUS) is a recent technique that has proven to be of value in differentiating between variants of BCC. The aim of this study was to investigate the potential usefulness of HRUS for detecting invasive disease in recurrent BCC treated nonsurgically following an initial diagnosis of noninvasive BCC by biopsy. MATERIAL AND METHODS: This was a prospective observational study of consecutive cases of BCC with clinical suspicion of recurrence following nonsurgical treatment and a pretreatment diagnosis of superficial BCC by punch biopsy. Before surgical excision, the recurrent lesions were evaluated by HRUS followed by a punch biopsy of the site of suspected recurrence. The diagnostic agreement between HRUS, punch biopsy, and excisional biopsy was then evaluated. RESULTS: Eight lesions were studied. HRUS identified invasive disease in 3 of the 4 cases that were incorrectly classified as superficial subtypes by punch biopsy. CONCLUSION: HRUS could be useful for detecting persistent tumor after nonsurgical treatment and for choosing the site most likely to harbor invasive disease for punch biopsy.

Micropápulas generalizadas en una niña de ocho años / Micropapular rash in an 8 year-old girl

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Evaluación de la ecografía cutánea de 15 Mhz en la estimación preoperatoria del espesor tumoral en el melanoma maligno / Preoperative 15-MHz Ultrasound Assessment of Tumor Thickness in Malignant Melanoma

Introducción: El espesor tumoral es una variable de gran trascendencia en el manejo clínico del melanoma maligno cutáneo (MMC), ya que no solo establece el pronóstico, sino que además determina la planificación de márgenes quirúrgicos y selecciona a aquellos pacientes candidatos a biopsia selectiva de ganglio centinela. El índice de Breslow (IB) es el procedimiento histométrico estándar para la determinación del espesor tumoral del melanoma. El desarrollo de técnicas de imagen, como la ecografía cutánea (EC), plantea la posibilidad de realizar una estimación no invasiva que agiliza la instauración del tratamiento definitivo. Objetivos: a) Evaluar la EC como instrumento de medición del espesor tumoral en el MMC, y b) analizar los factores histológicos que influyen en la estimación del espesor ecográfico. Material y métodos: Estudio retrospectivo de una serie consecutiva de 79 melanomas cutáneos primarios. En todos los casos, se practicó un estudio ecográfico preoperatorio con una sonda de 15 Mhz para la determinación del espesor tumoral (EE). Se analizaron los exámenes histológicos, estudiándose el IB, además de la presencia de ulceración, regresión, infiltrado inflamatorio y nevus. Se estudian el grado de correlación y el nivel de concordancia entre los valores de EE e IB. Se estiman la sensibilidad, la especificidad y los valores predictivos de la EC en el diagnóstico de melanomas de espesor >1mm. Se analiza la relación de las variables histológicas en la determinación del EE. Resultados: Se estudian 79 melanomas primarios, IB medio: 0,8mm (DE: 1,4). La EC evidenció un grado de correlación y un nivel de concordancia moderado con respecto al IB (coeficiente de correlación de Pearson: 0,678, coeficiente de correlación intraclase: 0,78, respectivamente). La EC mostró tendencia a sobrestimar el espesor histológico en relación con la presencia de infiltrado inflamatorio moderado-intenso y nevus, sin alcanzar significación estadística (p>0,05). La EC mostró valores de sensibilidad y especificidad, y valores predictivos positivo y negativo para el diagnóstico de melanomas gruesos (>1mm) del 82, el 80, el 54 y el 94%, respectivamente. Conclusión: La EC permite discriminar con bastante precisión melanomas finos y planificar márgenes quirúrgicos adecuados, pero presenta limitaciones para el diagnóstico de melanomas gruesos. Son necesarios más estudios para confirmar si determinadas características histológicas del tumor, como la presencia de infiltrado inflamatorio moderado-intenso y nevus, pueden condicionar una sobrestimación del espesor ecográfico, limitando su aplicabilidad clínica en el manejo del MMC (AU)

Background: Tumor thickness is of great importance in the management of cutaneous malignant melanoma (MM): this variable not only affects prognosis but is also a key factor in planning surgical margins and selecting candidates for sentinel node biopsy. Breslow depth is the standard histologic measure of thickness, but technological advances have provided imaging techniques such as cutaneous ultrasound that can potentially assess tumor thickness and enable prompt initiation of definitive treatment. Objectives: a) To evaluate the utility of ultrasound assessment of tumor thickness in MM, and b) to analyze histologic variables that affect ultrasound assessments of thickness. Materials and methods: Retrospective study of a consecutive series of 79 primary cutaneous MMs in which tumor thickness had been assessed by 15-MHz ultrasound before surgery. We gathered data from histology reports, studying Breslow depth and the presence of ulceration, regression, inflammatory infiltrate, and associated nevi. Correlation coefficients were calculated to evaluate the strength of association between Breslow depth and thickness assessed by ultrasound. We also calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound measurement in the diagnosis of MMs more than 1mm thick. Associations between histologic variables and the overestimation of thickness by ultrasound were also analyzed. Results: The 79 primary MMs studied had a mean (SD) Breslow depth of 0.8 (1.4) mm. There was moderate correlation and agreement between Breslow depth and the ultrasound assessment of thickness (Pearson correlation coefficient, 0.678; intraclass correlation coefficient, 0.78). The tendency of ultrasound to overestimate thickness was non significantly related to the presence of a moderate to intense infiltrate and associated nevi (P>0.05). The sensitivity of ultrasound for the diagnosis of MM over 1mm thick was 82%; specificity was 80%, and positive and negative predictive values were 54% and 94%, respectively. Conclusions: Ultrasound imaging quite correctly identifies thin MMs and can be useful for planning adequate surgical margins; however, there are limitations on its usefulness in the diagnosis of thick MMs. Additional studies are required to confirm whether certain histologic characteristics, such as the presence of a moderate to intense inflammatory infiltrate or associated nevi can lead to overestimation of thickness by ultrasound, limiting the clinical utility of this imaging technique in MM management (AU)

Preoperative 15-MHz ultrasound assessment of tumor thickness in malignant melanoma.

BACKGROUND: Tumor thickness is of great importance in the management of cutaneous malignant melanoma (MM): this variable not only affects prognosis but is also a key factor in planning surgical margins and selecting candidates for sentinel node biopsy. Breslow depth is the standard histologic measure of thickness, but technological advances have provided imaging techniques such as cutaneous ultrasound that can potentially assess tumor thickness and enable prompt initiation of definitive treatment. OBJECTIVES: a) To evaluate the utility of ultrasound assessment of tumor thickness in MM, and b) to analyze histologic variables that affect ultrasound assessments of thickness. MATERIALS AND METHODS: Retrospective study of a consecutive series of 79 primary cutaneous MMs in which tumor thickness had been assessed by 15-MHz ultrasound before surgery. We gathered data from histology reports, studying Breslow depth and the presence of ulceration, regression, inflammatory infiltrate, and associated nevi. Correlation coefficients were calculated to evaluate the strength of association between Breslow depth and thickness assessed by ultrasound. We also calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound measurement in the diagnosis of MMs more than 1mm thick. Associations between histologic variables and the overestimation of thickness by ultrasound were also analyzed. RESULTS: The 79 primary MMs studied had a mean (SD) Breslow depth of 0.8 (1.4) mm. There was moderate correlation and agreement between Breslow depth and the ultrasound assessment of thickness (Pearson correlation coefficient, 0.678; intraclass correlation coefficient, 0.78). The tendency of ultrasound to overestimate thickness was nonsignificantly related to the presence of a moderate to intense infiltrate and associated nevi (P>.05). The sensitivity of ultrasound for the diagnosis of MM over 1mm thick was 82%; specificity was 80%, and positive and negative predictive values were 54% and 94%, respectively. CONCLUSIONS: Ultrasound imaging quite correctly identifies thin MMs and can be useful for planning adequate surgical margins; however, there are limitations on its usefulness in the diagnosis of thick MMs. Additional studies are required to confirm whether certain histologic characteristics, such as the presence of a moderate to intense inflammatory infiltrate or associated nevi can lead to overestimation of thickness by ultrasound, limiting the clinical utility of this imaging technique in MM management.