Case Report Received: October 24, 2013 Accepted: October 28, 2013 Published online: December 17, 2013
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
Dermoscopic Rosettes as a Clue for Pigmented Incipient Melanoma Tatiana González-Álvarez a Miquel Armengot-Carbó a, d Alicia Barreiro a Ivette Alarcón a Cristina Carrera a, c Adriana García b Josep Malvehy a, c Susana Puig a, c a
Dermatology Department and b Pathology Service, Melanoma Unit, Hospital Clínic and Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona University, and c Centro Investigación Biomédica en Enfermedades Raras, ISCIII, Barcelona; d Dermatology Department, Hospital Arnau de Vilanova, Valencia, Spain
Abstract The rosette structure is a dermoscopic sign visible under polarized light, characterized by 4 white points arranged as a 4-leaf clover. It has been mainly described in facial sundamaged skin and actinic keratosis, although it has also been found in squamous and basal cell carcinomas, and in 2 cases of hypomelanotic melanomas. We describe 2 different cases of pigmented incipient melanomas with the presence of multiple rosettes and shiny white structures on dermoscopy. In the reflectance confocal microscope they exhibit a disarranged epidermal architecture with atypical and dendritic cells. Histological examination showed focal hyperkeratosis and a normal corneal layer presented alternatively. To our knowledge this is the first description of rosette structures in pigmented melanomas. Based on a proper dermoscopicconfocal-histopathological correlation, we hypothesize that rosettes could correspond to optic phenomena due to changes in the superficial epidermal reaction and in the ac© 2013 S. Karger AG, Basel rosyringia.
Introduction
Dermoscopy has been proven to improve accuracy in the diagnosis of melanocytic skin tumours by experienced examiners [1, 2]. Classically dermoscopy was performed with contact non-polarized dermatoscopes [3]; the introduction of non-contact polarized dermoscopy permits the fast evaluation of many lesions in a single patient and facilitates exploration in areas where the immersion liquid would be uncomfortable. But both dermoscopy techniques are not completely equivalent [4]. Contact non-polarized dermoscopy enhances superficial structures such as milialike cysts and makes comedo-like openings brighter; also peppering, lighter colours and blue-white veils are more evident. In contrast, polarized dermoscopy allows the better identification of deeper structures, vessels and red areas, melanin appears darker and blue naevi have more shades of blue [4]. Surprisingly, new dermoscopy criteria appear with the use of polarized dermoscopy, white shiny streaks or chrysalids being the most studied [4–7]. They have been described in lesions with an increased amount of collagen, such as dermatofibroma, scars, melanomas, Spitz naevi and basal cell carcinoma [8–10]. Another new feature only seen using polarized dermoscopy are the so-called ‘ro-
© 2013 S. Karger AG, Basel 1018–8665/13/2281–0031$38.00/0 E-Mail [email protected] www.karger.com/drm
settes’. Rosettes are characterized by 4 white dots arranged as a 4-leaf clover or as leaves radiating out from a central stem [11]. It has been described mainly in facial sun-damaged skin, actinic keratosis and flat seborrhoeic keratosis [9, 11, 12], but has also recently been detected in other skin neoplasias such as squamous and basal cell carcinomas, and in 2 cases of hypomelanotic melanomas [9, 12, 13]. Case 1
A 36-year-old fair-skinned female patient with a personal history of nodular polypoid melanoma at the age of 15 and dysplastic naevus syndrome was under digital follow-up with the 2-step method using total body photography and digital dermoscopy [14]. A 4-mm symmetric, melanocytic lesion on the lateral Wallace line of her foot was detected. On dermoscopy it exhibited asymmetry of colours and structures being a lesion with multiple colours, exhibiting light and dark brown reticulation with mild erythema. Multiple rosettes with shiny white structures were also found (fig. 1). Reflectance confocal microscopy showed an atypical honeycombed pattern, small roundish pagetoid cells and atypical junctional thickenings forming elongated
Susana Puig, MD, PhD Melanoma Unit, Dermatology Department Hospital Clínic de Barcelona, IDIBAPS Villarroel 170, ES–08036 Barcelona (Spain) E-Mail susipuig @ gmail.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
Key Words Dermoscopy · Dermatoscopy · Melanoma · Rosettes · Reflectance confocal microscopy
Fig. 1. A 4-mm symmetric, melanocytic lesion on the lateral Wallace line. Reticular pattern with multiple rosettes and shiny white structures.
Fig. 2. Dermo-epidermal junction disarranged with elongated
Fig. 3. Hyperkeratotic area combined with focal parakeratosis
Fig. 4. A 1-cm pigmented lesion on the right leg. Dermoscopy re-
(‘flag sign’, red arrows).
vealed an atypical pigmented network with multiple rosettes and shiny white structures (red circles).
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
González-Álvarez et al.
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
32
junctional clusters and non-edged papillas, forming an atypical meshwork pattern. Correlation with the junctional proliferation of atypical melanocytes at the histopathological level (inset).
thick cord-like structures. The dermo-epidermal junction was disarranged with elongated junctional clusters and nonedged papillas; atypical nucleated cells were also detected on the basal layer. Histopathology demonstrated a good correlation with confocal findings (fig. 2), with atypical melanocytic hyperplasia and roundish melanocytes invading the whole epidermis and the presence of elongated nests of atypical melanocytes in the dermoepidermal junction. Focal hyperkeratosis and normal corneal layer were presented alternatively. Note the keratin-filled acrosyringeal structure (arrows in fig. 3). An in situ melanoma arising in a naevus was diagnosed.
Dermoscopy was consistent with a clear-cut melanoma with the presence of a multicomponent pattern in a lesion with multiple colours, atypical pigment network, blue whitish veil, irregular distributed streaks at the periphery and blotches. On reflectance confocal microscopy it exhibited a disarranged epidermal architecture with pagetoid spreading of pleomorphic, large, nucleated atypical and dendritic cells. Histological examination confirmed the diagnosis of a superficial spreading melanoma with Breslow 0.7 mm, Clark III, without ulceration. Again a good correlation with confocal findings was demonstrated with features similar to case 1.
Case 2 Discussion
An 88-year-old female patient presented with a 5-year history of a pigmented lesion on her right leg, which had progressively enlarged during the last 2 years. She had a family history of melanoma (her father). A full-body clinical examination revealed a 1-cm pigmented lesion on her right leg, slightly elevated with a black coloration and irregular borders. Dermoscopy revealed an atypical pigment network with pseudopods and a central blue-whitish veil. An interesting finding was the presence of multiple rosettes and shiny white streaks (fig. 4, red circles).
The introduction of non-contact polarized dermoscopy allows the visualization of white shiny structures or chrysalids and rosettes, new dermoscopy criteria that have been described in actinic tumours, malignant and benign neoplasms. As opposed to shiny white streaks (chrysalids), in our experience rosettes do not present angular dependence when the dermoscope is rotated around its central axis; this contrasts with the previously published findings by Liebman et al. [13]; they are probably attributable to an optical effect of the polarized light and its interaction with adnexal
openings that are either narrowed or filled with keratin [13]. We suggest that they correspond to an alternating focal hyperkeratosis and normal corneal layer and keratinfilled adnexal openings. They have been described in non-lesional actinically damaged skin, actinic keratosis, squamous cell carcinoma, basal cell carcinomas and melanomas [13]. Currently, nobody describes rosettes in pigmented melanomas, and we think that they could be important in the diagnosis of incipient melanomas; therefore, further research is required to determine the predictive value of rosettes for any given diagnosis. Conclusion
To our knowledge this is the first description of rosette structures in 2 incipient pigmented melanomas located on an acral site and leg. Based on a proper dermoscopic-confocal-histopathological correlation, we hypothesize that rosettes could correspond to alternating focal hyperkeratosis and a normal corneal layer, and keratinfilled acrosyringeal structures. Disclosure Statement
No conflicts of financial or marketing interest.
References
Dermoscopic Rosettes as a Clue for Pigmented Incipient Melanoma
6
7 8
9
scopic finding in melanomas viewed using contact polarised dermoscopy. Australas J Dermatol 2010;51:295–298. Shitara D, Ishioka P, Alonso-Pinedo Y, Palacios-Bejarano L, Carrera C, Malvehy J, Puig S: Shiny white streaks: a sign of malignancy at dermoscopy of pigmented skin lesions. Acta Derm Venereol 2013, E-pub ahead of print. Marghoob AA, Cowell L, Kopf AW, Scope A: Observation of chrysalis structures with polarized dermoscopy. Arch Dermatol 2009;145:618. Salerni G, Salerni G, Alonso C, Bussy RF: Crystalline structures as the only dermoscopic clue for the diagnosis of basal cell carcinoma. Arch Dermatol 2012;148:776. Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA: White shiny structures: dermoscopic features revealed under polarized light. J Eur Acad Dermatol Venereol 2012;26: 1493–1497.
10 Liebman TN, Rabinovitz HS, Balagula Y, Jaimes-Lopez N, Marghoob AA: White shiny structures in melanoma and BCC. Arch Dermatol 2012;148:146. 11 Cuellar F, Vilalta A, Puig S, Palou J, Salerni G, Malvehy J: New dermoscopic pattern in actinic keratosis and related conditions. Arch Dermatol 2009;145:732. 12 Marques-da-Costa J, Campos-do-Carmo G, Ormiga P, Ishida CE, Cuzzi T, Ramos-e-Silva M: Rosette sign in dermatoscopy: a polarized finding. Skinmed 2011;9:392. 13 Liebman TN, Scope A, Rabinovitz HS, Braun RP, Marghoob AA: Rosettes may be observed in a range of conditions. Arch Dermatol 2011; 147:1468. 14 Malvehy J, Puig S: Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopy: a two-step method. Clin Dermatol 2002;20:297–304.
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
33
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
1 Kittler H, Pehamberger H, Wolff K, Binder M: Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159–165. 2 Bafounta ML, Beauchet A, Aegerter P, Saiag P: Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001;137:1343–1350. 3 Malvehy J, Puig S: Principios de dermatoscopia, ed 2. Barcelona, CEGE, 2009. 4 Venvenuto-Andrade C, Dusza SW, Agero AL, Scope A, Rajadhyaksha M, Halpern AC, Marghoob AA: Differences between polarized light dermoscopy and immersion contact dermoscopy for the evaluation of skin lesions. Arch Dermatol 2007;143:329–338. 5 Di Stefani A, Campbell TM, Malvehy J, Massone C, Soyer HP, Hofmann-Wellenhof R: Shiny white streaks: an additional dermo-
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
Dermoscopic Rosettes as a Clue for Pigmented Incipient Melanoma Tatiana González-Álvarez a Miquel Armengot-Carbó a, d Alicia Barreiro a Ivette Alarcón a Cristina Carrera a, c Adriana García b Josep Malvehy a, c Susana Puig a, c a
Dermatology Department and b Pathology Service, Melanoma Unit, Hospital Clínic and Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona University, and c Centro Investigación Biomédica en Enfermedades Raras, ISCIII, Barcelona; d Dermatology Department, Hospital Arnau de Vilanova, Valencia, Spain
Abstract The rosette structure is a dermoscopic sign visible under polarized light, characterized by 4 white points arranged as a 4-leaf clover. It has been mainly described in facial sundamaged skin and actinic keratosis, although it has also been found in squamous and basal cell carcinomas, and in 2 cases of hypomelanotic melanomas. We describe 2 different cases of pigmented incipient melanomas with the presence of multiple rosettes and shiny white structures on dermoscopy. In the reflectance confocal microscope they exhibit a disarranged epidermal architecture with atypical and dendritic cells. Histological examination showed focal hyperkeratosis and a normal corneal layer presented alternatively. To our knowledge this is the first description of rosette structures in pigmented melanomas. Based on a proper dermoscopicconfocal-histopathological correlation, we hypothesize that rosettes could correspond to optic phenomena due to changes in the superficial epidermal reaction and in the ac© 2013 S. Karger AG, Basel rosyringia.
Introduction
Dermoscopy has been proven to improve accuracy in the diagnosis of melanocytic skin tumours by experienced examiners [1, 2]. Classically dermoscopy was performed with contact non-polarized dermatoscopes [3]; the introduction of non-contact polarized dermoscopy permits the fast evaluation of many lesions in a single patient and facilitates exploration in areas where the immersion liquid would be uncomfortable. But both dermoscopy techniques are not completely equivalent [4]. Contact non-polarized dermoscopy enhances superficial structures such as milialike cysts and makes comedo-like openings brighter; also peppering, lighter colours and blue-white veils are more evident. In contrast, polarized dermoscopy allows the better identification of deeper structures, vessels and red areas, melanin appears darker and blue naevi have more shades of blue [4]. Surprisingly, new dermoscopy criteria appear with the use of polarized dermoscopy, white shiny streaks or chrysalids being the most studied [4–7]. They have been described in lesions with an increased amount of collagen, such as dermatofibroma, scars, melanomas, Spitz naevi and basal cell carcinoma [8–10]. Another new feature only seen using polarized dermoscopy are the so-called ‘ro-
© 2013 S. Karger AG, Basel 1018–8665/13/2281–0031$38.00/0 E-Mail [email protected] www.karger.com/drm
settes’. Rosettes are characterized by 4 white dots arranged as a 4-leaf clover or as leaves radiating out from a central stem [11]. It has been described mainly in facial sun-damaged skin, actinic keratosis and flat seborrhoeic keratosis [9, 11, 12], but has also recently been detected in other skin neoplasias such as squamous and basal cell carcinomas, and in 2 cases of hypomelanotic melanomas [9, 12, 13]. Case 1
A 36-year-old fair-skinned female patient with a personal history of nodular polypoid melanoma at the age of 15 and dysplastic naevus syndrome was under digital follow-up with the 2-step method using total body photography and digital dermoscopy [14]. A 4-mm symmetric, melanocytic lesion on the lateral Wallace line of her foot was detected. On dermoscopy it exhibited asymmetry of colours and structures being a lesion with multiple colours, exhibiting light and dark brown reticulation with mild erythema. Multiple rosettes with shiny white structures were also found (fig. 1). Reflectance confocal microscopy showed an atypical honeycombed pattern, small roundish pagetoid cells and atypical junctional thickenings forming elongated
Susana Puig, MD, PhD Melanoma Unit, Dermatology Department Hospital Clínic de Barcelona, IDIBAPS Villarroel 170, ES–08036 Barcelona (Spain) E-Mail susipuig @ gmail.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
Key Words Dermoscopy · Dermatoscopy · Melanoma · Rosettes · Reflectance confocal microscopy
Fig. 1. A 4-mm symmetric, melanocytic lesion on the lateral Wallace line. Reticular pattern with multiple rosettes and shiny white structures.
Fig. 2. Dermo-epidermal junction disarranged with elongated
Fig. 3. Hyperkeratotic area combined with focal parakeratosis
Fig. 4. A 1-cm pigmented lesion on the right leg. Dermoscopy re-
(‘flag sign’, red arrows).
vealed an atypical pigmented network with multiple rosettes and shiny white structures (red circles).
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
González-Álvarez et al.
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
32
junctional clusters and non-edged papillas, forming an atypical meshwork pattern. Correlation with the junctional proliferation of atypical melanocytes at the histopathological level (inset).
thick cord-like structures. The dermo-epidermal junction was disarranged with elongated junctional clusters and nonedged papillas; atypical nucleated cells were also detected on the basal layer. Histopathology demonstrated a good correlation with confocal findings (fig. 2), with atypical melanocytic hyperplasia and roundish melanocytes invading the whole epidermis and the presence of elongated nests of atypical melanocytes in the dermoepidermal junction. Focal hyperkeratosis and normal corneal layer were presented alternatively. Note the keratin-filled acrosyringeal structure (arrows in fig. 3). An in situ melanoma arising in a naevus was diagnosed.
Dermoscopy was consistent with a clear-cut melanoma with the presence of a multicomponent pattern in a lesion with multiple colours, atypical pigment network, blue whitish veil, irregular distributed streaks at the periphery and blotches. On reflectance confocal microscopy it exhibited a disarranged epidermal architecture with pagetoid spreading of pleomorphic, large, nucleated atypical and dendritic cells. Histological examination confirmed the diagnosis of a superficial spreading melanoma with Breslow 0.7 mm, Clark III, without ulceration. Again a good correlation with confocal findings was demonstrated with features similar to case 1.
Case 2 Discussion
An 88-year-old female patient presented with a 5-year history of a pigmented lesion on her right leg, which had progressively enlarged during the last 2 years. She had a family history of melanoma (her father). A full-body clinical examination revealed a 1-cm pigmented lesion on her right leg, slightly elevated with a black coloration and irregular borders. Dermoscopy revealed an atypical pigment network with pseudopods and a central blue-whitish veil. An interesting finding was the presence of multiple rosettes and shiny white streaks (fig. 4, red circles).
The introduction of non-contact polarized dermoscopy allows the visualization of white shiny structures or chrysalids and rosettes, new dermoscopy criteria that have been described in actinic tumours, malignant and benign neoplasms. As opposed to shiny white streaks (chrysalids), in our experience rosettes do not present angular dependence when the dermoscope is rotated around its central axis; this contrasts with the previously published findings by Liebman et al. [13]; they are probably attributable to an optical effect of the polarized light and its interaction with adnexal
openings that are either narrowed or filled with keratin [13]. We suggest that they correspond to an alternating focal hyperkeratosis and normal corneal layer and keratinfilled adnexal openings. They have been described in non-lesional actinically damaged skin, actinic keratosis, squamous cell carcinoma, basal cell carcinomas and melanomas [13]. Currently, nobody describes rosettes in pigmented melanomas, and we think that they could be important in the diagnosis of incipient melanomas; therefore, further research is required to determine the predictive value of rosettes for any given diagnosis. Conclusion
To our knowledge this is the first description of rosette structures in 2 incipient pigmented melanomas located on an acral site and leg. Based on a proper dermoscopic-confocal-histopathological correlation, we hypothesize that rosettes could correspond to alternating focal hyperkeratosis and a normal corneal layer, and keratinfilled acrosyringeal structures. Disclosure Statement
No conflicts of financial or marketing interest.
References
Dermoscopic Rosettes as a Clue for Pigmented Incipient Melanoma
6
7 8
9
scopic finding in melanomas viewed using contact polarised dermoscopy. Australas J Dermatol 2010;51:295–298. Shitara D, Ishioka P, Alonso-Pinedo Y, Palacios-Bejarano L, Carrera C, Malvehy J, Puig S: Shiny white streaks: a sign of malignancy at dermoscopy of pigmented skin lesions. Acta Derm Venereol 2013, E-pub ahead of print. Marghoob AA, Cowell L, Kopf AW, Scope A: Observation of chrysalis structures with polarized dermoscopy. Arch Dermatol 2009;145:618. Salerni G, Salerni G, Alonso C, Bussy RF: Crystalline structures as the only dermoscopic clue for the diagnosis of basal cell carcinoma. Arch Dermatol 2012;148:776. Liebman TN, Rabinovitz HS, Dusza SW, Marghoob AA: White shiny structures: dermoscopic features revealed under polarized light. J Eur Acad Dermatol Venereol 2012;26: 1493–1497.
10 Liebman TN, Rabinovitz HS, Balagula Y, Jaimes-Lopez N, Marghoob AA: White shiny structures in melanoma and BCC. Arch Dermatol 2012;148:146. 11 Cuellar F, Vilalta A, Puig S, Palou J, Salerni G, Malvehy J: New dermoscopic pattern in actinic keratosis and related conditions. Arch Dermatol 2009;145:732. 12 Marques-da-Costa J, Campos-do-Carmo G, Ormiga P, Ishida CE, Cuzzi T, Ramos-e-Silva M: Rosette sign in dermatoscopy: a polarized finding. Skinmed 2011;9:392. 13 Liebman TN, Scope A, Rabinovitz HS, Braun RP, Marghoob AA: Rosettes may be observed in a range of conditions. Arch Dermatol 2011; 147:1468. 14 Malvehy J, Puig S: Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopy: a two-step method. Clin Dermatol 2002;20:297–304.
Dermatology 2014;228:31–33 DOI: 10.1159/000356822
33
Downloaded by: UCSF Library & CKM 169.230.243.252 - 11/20/2014 8:00:32 AM
1 Kittler H, Pehamberger H, Wolff K, Binder M: Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159–165. 2 Bafounta ML, Beauchet A, Aegerter P, Saiag P: Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol 2001;137:1343–1350. 3 Malvehy J, Puig S: Principios de dermatoscopia, ed 2. Barcelona, CEGE, 2009. 4 Venvenuto-Andrade C, Dusza SW, Agero AL, Scope A, Rajadhyaksha M, Halpern AC, Marghoob AA: Differences between polarized light dermoscopy and immersion contact dermoscopy for the evaluation of skin lesions. Arch Dermatol 2007;143:329–338. 5 Di Stefani A, Campbell TM, Malvehy J, Massone C, Soyer HP, Hofmann-Wellenhof R: Shiny white streaks: an additional dermo-
