Nipple and areola lesions: review of dermoscopy and reflectance confocal microscopy features.

The differential diagnosis of nipple and areola complex (NAC) lesions encompasses a large spectrum of conditions from benign tumours to inflammatory diseases that could be challenging to recognize on clinical ground. While melanoma (MM) of the NAC is exceedingly rare, benign lesions are more frequent but could be difficult to distinguish from MM. Besides MM, other malignant tumours can affect this area and in particular Paget's disease (PD). For clinically doubtful lesions, biopsy is required, with possible functional and aesthetic consequences in this sensitive area. Dermoscopy and reflectance confocal microscopy (RCM) are widely used techniques for the diagnosis of many skin lesions, but their use for NAC lesions is not well established. The objective of this study was to evaluate current literature on these imaging techniques for NAC lesions. We searched in Medline, PubMed and Cochrane database all studies up to November 2018 dealing with dermoscopy, RCM and this special site. We found that the most described malignant tumour was PD and that only two primary MMs of the NAC have been reported with these imaging techniques. Although there are few data on diagnostic accuracy of non-invasive imaging techniques for NAC lesions, it seems that dermoscopy and RCM can add relevant information to be integrated with clinical examination for the diagnosis of NAC lesions and in particular for the differential diagnosis of PD and eczema.

Differences in clinicopathological features and distribution of risk factors in Italian melanoma patients.

BACKGROUND: No studies are available in the literature on the distribution of different melanoma features and risk factors in the Italian geographical areas. OBJECTIVE: To identify the differences in clinical-pathological features of melanoma, the distribution of risk factors and sun exposure in various Italian macro-areas. METHODS: Multicentric-observational study involving 1,472 melanoma cases (713 north, 345 centre, 414 south) from 26 referral centres belonging to the Italian Multidisciplinary Group for Melanoma. RESULTS: Melanoma patients in northern regions are younger, with thinner melanoma, multiple primaries, lower-intermediate phototype and higher counts of naevi with respect to southern patients; detection of a primary was mostly connected with a physician examination, while relatives were more involved in the south. Northern patients reported a more frequent use of sunbeds and occurrence of sunburns before melanoma despite sunscreen use and a lower sun exposure during the central hours of the day. CONCLUSIONS: The understanding of differences in risk factors distribution could represent the basis for tailored prevention programmes.

Patient perspectives of early detection of melanoma: the experience at the Brescia Melanoma Centre, Italy.

AIM: Skin self-examination is usually recommended for early melanoma diagnosis. Given the current lack of a standardized Skin Self-Examination method, we raised the issue about the suitable approach to explain to patients what can be considered a suspicious lesion. Hereinafter, we report the results of a pilot-study carried out at the Melanoma Centre, University Hospital Spedali Civili Brescia, Italy. METHODS: A consecutive sample of 200 melanoma patients entered into the Melanoma Prevention Project. A detailed survey revealed who had the first suspicion of the melanoma lesion. When melanoma was Self- or Relative-detected, we investigated the signs/symptoms that had alerted patients with reference to the ABCDE rule. The study included also socio-demographic variables, family history of melanoma, skin type, number and type of nevi, and melanoma features. RESULTS: Eighty-seven melanoma had been Self-Detected and 44 Relative-Detected. Patients report most commonly signs/symptoms such as dark colour (58%) and changing in size (47%). Seventy-nine percent of these patients have less than ten nevi and 92% have small and regular moles. CONCLUSION: Sometimes the signs of melanoma seem to be easy to identify. Our patients say that they recognized melanoma on the base of the Colour and the Change in size. Therefore, we propose the short "CC" acronym that could facilitate the melanoma self-diagnosis. The aim is to give a short and effective message that leads patients to have the doubt of a suspicious lesion of melanoma so that they seek medical attention.

The controversial management of giant congenital melanocytic nevi. When would it be better "to wait and see"?

AIM: A giant congenital nevus is a melanocytic nevus present at birth with wide extent on the skin surface. The management of this nevus remains controversial and needs to be personalized for each patient. METHODS: A retrospective multicenter study was carried out in the Dermatological Departments of Brescia, Padua, and Pavia, Italy. The inclusion criterion was the diagnosis of a giant congenital melanocytic nevus on the basis of clinical observation. RESULTS: Nine patients with giant congenital nevus are reported. None developed melanoma, whereas giant congenital nevi have been slowly fading in pigmentation. CONCLUSION: Having regard to the doubts on treatment that persist in the literature, we should consider that decisional management of giant congenital melanocytic nevi can be really complex, because of the size and depth of lesions. Indeed, the ablative surgery or other treatments might cause significant troubles and complete excision of deeper layers of the lesion is almost impossible to achieve. Moreover, the treatment does not reduce the risk of melanoma and might lead to a greater difficulty in clinical and dermoscopic observation due to the scarring occurrence after therapy. In our retrospective study, the pigmentation of giant congenital melanocytic nevi slowly faded on its own and until now none developed melanoma. Therefore, we suggest a close regular follow-up which should be focused on the exclusion of possible complications. Perhaps, it would be better "to wait and see" since other procedures do not decrease the risk of melanoma, but rather might lead the patient to underestimate it.

Association between multiple cutaneous melanoma and other primary neoplasms.

BACKGROUND: The risk of a subsequent cancer is an important issue for patients with melanoma. The development of a second primary cancer in patients with a solitary melanoma has been discussed in several studies. However, to our knowledge, the incidence of second primary cancer (SPC) in patients with multiple primary melanoma (MPM) has not been thoroughly investigated. AIM: To quantify the incidence of SPC in patients with MPM, with the aim of possibly developing further preventive measures. METHODS: In a retrospective study, 76 patients with MPM were identified from 2155 patients being followed up at our unit. RESULTS: Of the 76 patients, 12 (16%) developed another neoplasm, with 59% of them having nonmelanoma skin cancer (NMSC), and 41% other noncutaneous cancers. By contrast, only 8% of those with single primary melanoma had other neoplasms (21% of whom had NMSC). CONCLUSIONS: Patients with MPM, especially men with skin phototype II, have a significantly increased incidence of developing SPC, particularly NMSC. Thus, careful monitoring is essential not only to detect recurrence of the original cancer or development of another primary melanoma, but also development of new malignancies of different types, particularly NMSC.

Familial and sporadic melanoma: different clinical and histopathological features in the Italian population - a multicentre epidemiological study - by GIPMe (Italian Multidisciplinary Group on Melanoma).

BACKGROUND: Having a familial member affected by cutaneous melanoma is a risk factor for this neoplasm. Only a few epidemiological case-control studies have been carried out to investigate whether familial and sporadic melanomas show different clinical and histopathological features. OBJECTIVE: The aim of this study was to evaluate eventual different features and risk factors in subjects affected by familial and sporadic cutaneous melanoma. METHODS: A case-control multicentre study interesting 1407 familial (n = 92) and sporadic (n = 1315) melanomas in the Italian population. The analysis was made using t-test for continuous variables and chi-squared test for categorized ones. The variables which have shown statistically significant differences in the two groups in the univariate analysis were included in a multivariate model. RESULTS: The results showed some main significantly clinical differences between the two groups investigated: earlier age at diagnosis, a greater proportion of sunburns and a higher number of naevi were observed for the familial cases compared with sporadic ones. Nevertheless, we did not find a diagnostic anticipation in familial melanomas, in fact the invasion level and the thickness of melanomas was similar in the two groups. CONCLUSION: Some relevant clinical differences are observed between the two groups examined. The familial melanoma members, although carriers of constitutional risk factors, are not careful enough to primary and secondary prevention.

Dermoscopy of scalp tumours: a multi-centre study conducted by the international dermoscopy society.

BACKGROUND: Little is known about the dermoscopic features of scalp tumours. Objective To determine the dermoscopic features of scalp tumours. METHODS: Retrospective analysis of dermoscopic images of histopathologically diagnosed scalp tumours from International Dermoscopy Society members. RESULTS: A total of 323 tumours of the scalp from 315 patients (mean age: 52 years; range 3-88 years) were analysed. Scalp nevi were significantly associated with young age (<30 years) and exhibited a globular or network pattern with central or perifollicular hypopigmentation. Melanoma and non-melanoma skin cancer were associated with male gender, androgenetic alopecia, age >65 years and sun damage. Atypical network and regression were predictive for thin (≤1 mm) melanomas, whereas advanced melanomas (tumour thickness > 1 mm) revealed blue white veil, unspecific patterns and irregular black blotches or dots. CONCLUSIONS: The data collected provide a new knowledge regarding the clinical and dermoscopy features of pigmented scalp tumours.

Interval sentinel lymph nodes: an unusual localization in patients with cutaneous melanoma.

Background. Recent studies have demonstrated that there exists a great variation in the lymphatic drainage in patients with malignant melanoma. Some patients have drainage to lymph nodes outside of conventional nodal basins. The lymph nodes that exist between a primary melanoma and its regional nodal basin are defined "interval nodes". Interval node occurs in a small minority of patients with forearm melanoma. We report our experience of the Melanoma Unit of University Hospital Spedali Civili Brescia, Italy. Methods. Lymphatic mapping using cutaneous lymphoscintigraphy (LS) has become a standard preoperative diagnostic procedure to locate the sentinel lymph nodes (SLNs) in cutaneous melanoma. We used LS to identify sentinel lymph nodes biopsy (SLNB) in 480 patients. Results. From over 2100 patients affected by cutaneous melanoma, we identified 2 interval nodes in 480 patients with SLNB . The melanomas were both located in the left forearm. The interval nodes were also both located in the left arm. Conclusion. The combination of preoperative LS and intraoperative hand-held gamma detecting probe plays a remarkable role in identifying these uncommon lymph node locations. Knowledge of the unusual drainage patterns will help to ensure the accuracy and the completeness of sentinel nodes identification.

Desmoplastic melanoma: report of 5 cases.

Background. The clinical presentation of desmoplastic melanoma is often challenging. We report the experience of the Melanoma Unit of Spedali Civili University Hospital of Brescia, Italy. Method. Study subjects were drawn from 1770 patients with histologica confirmed melanoma. Within this group, desmoplastic melanoma developed in 5 patients. For each diagnosed melanoma, histological characteristics, treatment, and outcomes were evaluated. Results. Of the 5 patients described in this study, 2 were males and 3 females. The average age was 62.4 years ranging from 56 to 68 years. Breslow thickness ranged from 2.1 to 12 mm with a mean thickness of 5.8 mm. Primary treatment of 5 patients included a wide local excision of their primary lesions. Conclusions. Desmoplastic melanoma is a rare neoplasm which clinically may mimic other tumours or cutaneous infiltrate of uncertain significance. The diagnosis is hiastopathological and radical resection is necessary.

The importance of self-examination in the earliest diagnosis of multiple primary cutaneous melanomas: a report of 47 cases.

BACKGROUND: Development of more than one primary melanoma in a patient is a relatively uncommon but well-recognized phenomenon. Its frequency has ranged from 1.2% to 8.2% in several series. This subgroup of patients with multiple primary lesions has not been characterized sufficiently. We report the experience of the Melanoma Unit of University Hospital Spedali Civili of Brescia, Italy. METHOD: Study subjects were drawn from 1240 patients with histologically confirmed melanoma, including melanoma in situ. From this group, multiple melanomas developed in 47 patients (3.79%). Every one of our patients has been taught to perform self-examination of the skin to detect suspicious pigmented lesions. RESULTS: Of the 47 patients described in this study, 38 had two primary melanomas, 7 had three melanomas and 2 had 5 and 10 melanomas, respectively. Mean age at first diagnosis was 46.2 years. The majority of subsequent melanomas (74.5%) were removed within 5 years of the initial operation. Synchronous lesions were found in 10 patients. In male patients, the lesion appeared most frequently on the trunk; in female patients, melanoma appeared mostly on the lower extremities. The second primary melanomas developed in the same anatomic region from the first in 53.2% of our patients. The proportion of in situ to invasive melanomas was greater for the second melanomas compared with the first melanomas. Regarding invasive melanomas, the mean thickness of the first melanomas was 1.31 mm compared with 0.66 mm for the second ones. Dividing patients into two groups, of more and less than 50, it is highlighted that in older patients synchronous lesions appear more frequently (36.4% vs. 8.0%); the median time interval between sequential melanomas is longer (84 vs. 63.7 months); and the ratio between the primary and secondary melanoma mean thickness is lower (1.21 : 1.08 vs. 1.43 : 0.63 mm). CONCLUSIONS: The study confirms that second primary melanoma is usually thinner than the first lesion, and it is more common in the same region of the body as the initial melanoma. The highest risk for a second melanoma is during the first 5 years, but a much longer time interval of 28 years is possible. Continued medical follow-up with complete skin examinations seems prudent, but it is very important to promote self-skin evaluation in patients to detect not only metastases but also subsequent primary melanomas in their earliest phases.

Chronic urticaria associated with thyroid carcinoma: report of 4 cases.

Chronic urticaria is a common condition that can be very disabling when severe. A variety of causes has been reported to induce urticaria, including food, infections, drugs and other factors. In more than 50% of cases of chronic urticaria, however, the cause remains unknown and cannot be ascribed to allergic, physical, environmental or other factors. Although an association between chronic idiopathic urticaria and malignancy has been occasionally reported, such an association remains controversial because it is difficult to demonstrate it is not just coincidental. Here we report the cases of four female patients with occult papillary carcinoma of the thyroid who developed chronic urticaria. In all of these cases, removal of the tumor led to prompt resolution of the urticarial lesions, thus suggesting a pathogenetic relationship between the two. This is the first report of papillary thyroid carcinomas associated with chronic urticaria and highlights how chronic urticaria may be an important cutaneous marker for patients with thyroid carcinoma.