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Extrafacial Lentigo Maligna: A Report on 14 Cases and a Review of the Literature
Lentigo maligno extrafacial. Serie de 14 casos y revisión de la literatura
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Martínez-Leboráns, J. Garcías-Ladaria, V. Oliver-Martínez, V. Alegre de Miquel" "autores" => array:4 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Martínez-Leboráns" "email" => array:1 [ …1] "referencia" => array:2 [ …2] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Garcías-Ladaria" "referencia" => array:1 [ …1] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Oliver-Martínez" "referencia" => array:1 [ …1] ] 3 => array:3 [ "nombre" => "V. Alegre de" "apellidos" => "Miquel" "referencia" => array:2 [ …2] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Manacor, Manacor, Mallorca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universidad de Valencia, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lentigo maligno extrafacial. Serie de 14 casos y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1113 "Ancho" => 1500 "Tamanyo" => 587938 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient #4: A 63-year-old man with a pigmented lesion on the scapula. A, A 13-mm pigmented macule on the left scapula. B, Dermoscopic image showing asymmetric follicular pigmentation, rhomboidal structures, and some obliterated follicular openings. Note also the features typically associated with superficial spreading melanoma, such as the atypical network, regression areas, and a blue-white veil. C, Proliferation of solitary and small nests of epithelioid melanocytes in the epidermis, with an accompanying inflammatory infiltrate, involvement of the adnexal epithelium, and solar elastosis (hematoxylin-eosin, original magnification ×100). D, A higher-magnification view shows melanophages in the papillary dermis (hematoxylin-eosin, original magnification ×200).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna</span> (LM) was first described by Hutchinson in 1890.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is used to describe melanoma in situ that develops on chronically sun-exposed skin in elderly individuals.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Approximately 86% of all cases occur in the head and neck region, which is by far the most common site affected.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">lentigo maligna melanoma</span> (LMM) is used to describe the invasive form of LM. In Spain LMM accounts for 8% of all invasive melanomas excised annually.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The majority of studies of LM to date have analyzed lesions on the head and neck, with few series analyzing extrafacial locations.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,5,6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We undertook a descriptive study of the clinical, dermoscopic, and histologic characteristics of extrafacial LM/LMM diagnosed at 2 Spanish hospitals: Hospital General Universitario de Valencia (HGU) and Hospital de Manacor (HMAN).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The main inclusion criterion was that the specimens had been examined by the same dermatopathologist. At the time of the study, the database at HGU contained information on 296 LM and LMM cases diagnosed since 1990, and 44 of these were extrafacial. Following histologic confirmation of extrafacial LM and LMM, only those tumors with a clinical and a dermoscopic image of the lesion were selected for inclusion in the study (n <span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span> 11). At HDM, only lesions diagnosed in 2014 and 2015 and that met the study criteria were included.</p><p id="par0030" class="elsevierStylePara elsevierViewall">For all specimens, sections measuring 4 μm were cut and stained with hematoxylin and eosin. LM was defined as a melanoma in situ formed by a proliferation of atypical, predominantly single, melanocytes along the basal layer of the epidermis and adnexal structures with poorly defined borders, accompanied by epidermal atrophy and solar elastosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> These melanocytes occasionally form small nests at the dermal-epidermal junction and are typically surrounded by a light halo caused by a retraction artifact. There may also be multinucleated giant cells in the epidermis, and upward (pagetoid) spread of melanocytes is not a prominent finding. Melanophages are observed in the papillary dermis. LMM was defined using the same criteria as above in addition to dermal invasion by neoplastic cells. Breslow thickness was measured in all invasive lesions.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Superficial spreading melanoma (SSM) differs from LM in that it does not generally show signs of significant sun damage, the epidermis is acanthotic, and there are solitary or nested epithelioid cells with abundant cytoplasm and clumps of melanin distributed throughout the epidermis. Mitotic activity is also observed, together with pagetoid spread (a common finding) and regression phenomena with an accompanying inflammatory infiltrate. The above criteria were used to differentiate between LM/LMM and SSM.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We studied 8 women and 6 men with a mean age of 75 years (median, 78 years) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Eight lesions were located on the upper limbs, 3 on the trunk (the scapula), and 3 on the lower limbs. The mean maximum diameter was 15.78<span class="elsevierStyleHsp" style=""></span>mm. Clinically, most of the lesions were described as slow-growing, asymmetric macules with poorly defined borders, heterogeneous pigmentation, and colors ranging from light to dark brown with white-grayish areas of regression.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Dermoscopic examination of the lesions showed characteristic findings of both LM and SSM. We searched for the presence of dermoscopic features described for facial LM, namely rhomboidal structures (present in 9/14 lesions), annular-granular pigmentation (5/14), asymmetric perifollicular pigmentation (3/14), obliteration of follicular openings (3/14), increased vascular network (2/14), red rhomboidal structures (2/14), and isobar structures, and darkening at dermoscopic examination (0/14). We also evaluated dermoscopic signs associated with SSM, i.e., regression (12/14), an atypical network (10/14), irregular dots or globules (10/14), pseudopods (4/14), a blue-white veil (4/14), and black lamella (0/14). These findings are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We recorded 17 histologic features, shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Mean Breslow thickness for the 5 invasive lesions was 0.26<span class="elsevierStyleHsp" style=""></span>mm.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">LM has low malignant potential and is characterized by slow progression to the invasive form LMM. Invasive lesions have a similar prognosis to SSM.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical and dermoscopic appearance of lesions are determined by the characteristics of the sun-damaged skin in which they arise (epidermal atrophy and effacement of rete ridges).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Clinically, LM presents as a slow-growing pigmented macule in chronically sun-exposed areas of the skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). It is characterized by asymmetric pigmentation and morphology, and has poorly defined borders.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Extrafacial LM was first described by Hutchinson,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but these lesions account for less than 20% of all LM cases.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Dermoscopic features of facial LM have been extensively described and include dark and red rhomboidal structures, asymmetric perifollicular pigmentation, obliteration of follicular openings, annular-granular pigmentation, isobar structures, and an increased vascular network.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6–9</span></a> These features are largely determined by the structural characteristics of the skin on the face (effaced rete ridges and prominent adnexal structures). These distinctive anatomic characteristics must therefore be borne in mind when interpreting lentigo-like dermoscopic findings in locations other than the face (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the largest series of LM/LMM published to date, Cox et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> described a prevalence of 17.5% for extrafacial lesions; most of the patients were women (49 vs 22 men) and the mean age was 63 years, which is somewhat lower than that in our series (75 years). Similarly to in our patients, the lesions were located predominantly on the trunk (68%) in men and on the limbs (80%) in women. Cox et al. did not report any clinical or dermoscopic features.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some years later, Lau et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> described the dermoscopic findings of LM on the upper limbs of 3 women. They highlighted the presence of structures associated with both SSM (network, dots/globules, pseudopods) and LM (rhomboidal structures and perifollicular pigmentation) and concluded that these 2 patterns coexist and that the presence of rhomboidal structures and asymmetric perifollicular pigmentation would point to a diagnosis of LM.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2014, Keir<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> reported on a series of 20 patients with extrafacial LM in which 90% of lesions had a poorly defined border and a lentigo-like pattern, defined as any combination of fine reticular lines, fingerprint-like structures, and light brown areas. Ten (71%) of the 14 lesions in our series had these features, supporting their potential diagnostic value.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The histologic differences between LMM and SSM were described by Clark et al. in 1969.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> For SSM, the authors described nests of cells with a more monomorphous appearance than in LMM and a greater pagetoid distribution of melanocytes. For LMM, they described a predominance of epidermal atrophy, with proliferation of single melanocytes and a greater degree of cellular pleomorphism, in addition to involvement of adnexal structures and less frequent melanocytic nest formation. In our series, isolated nests were observed in 13 of the 14 cases, while focal pagetoid spread of melanocytes was observed in 11 cases. Cytologically, our findings were consistent with the descriptions by Clark et al., with marked cellular pleomorphism and more epithelioid than spindle cells.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Histologic findings did not differ to those described for facial LM.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">LM progresses very slowly and may therefore be present for years. This slow-growing melanoma, however, has excellent prognosis. Most lesions are in situ and if they acquire invasive potential, they generally have a low Breslow thickness, although with time they can reach the same depth as any melanoma. Dermoscopic features include a mix of patterns seen in facial LM and SSM, although typical features of SSM are dominant in larger lesions. The literature to date contains few reports of extrafacial LM/LMM, and more studies are needed to identify specific criteria to improve the accuracy of clinical diagnosis, as based on the data available so far, extrafacial LM has overlapping dermoscopic features with SSM.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital's protocol on the publication of data concerning patients.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres826683" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ …1] ] ] 1 => array:2 [ "identificador" => "xpalclavsec822977" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres826682" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ …1] ] ] 3 => array:2 [ "identificador" => "xpalclavsec822978" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec822977" "palabras" => array:3 [ 0 => "Lentigo maligno" 1 => "Melanoma" 2 => "Dermoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec822978" "palabras" => array:3 [ 0 => "Lentigo maligno" 1 => "Melanoma" 2 => "Dermatoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lentigo maligna is the most common form of in situ melanoma. It is most often found on the head and neck, and its clinical and dermoscopic features in this location have been extensively described in the literature. We present a series of 14 patients diagnosed with extrafacial lentigo maligna and lentigo maligna melanoma at Hospital General de Valencia and Hospital de Manacor in Spain, and describe the clinical, dermoscopic, and histologic features observed. Most of the melanomas were located on the upper limbs; the next most common locations were the trunk and the lower limbs. The dermoscopic patterns were consistent with facial lentigo maligna and superficial spreading melanoma. Extrafacial lentigo maligna is uncommon. It has similar clinical and histologic features to facial lentigo, but dermoscopy may show a mix of patterns typically seen in lentigo maligna and superficial spreading melanoma. This difference in dermoscopic features is essentially due to anatomical differences between skin on the face and on other parts of the body.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es actualmente la variante más frecuente de melanoma <span class="elsevierStyleItalic">in situ</span>. Se localiza principalmente en la cabeza y el cuello, donde sus características clínicas y dermatoscópicas están descritas ampliamente en la literatura. Presentamos una serie de 14 pacientes diagnosticados de lentigo maligno y lentigo maligno melanoma extrafacial en el Hospital General de Valencia y Hospital de Manacor, describiendo los hallazgos clínicos, dermatoscópicos e histológicos de los mismos. La localización más frecuentemente encontrada fue las extremidades superiores, seguida del tronco y las extremidades inferiores. En la dermatoscopia se hallaron patrones compatibles con lentigo maligno facial y melanoma de extensión superficial. La localización extracefálica de los lentigos malignos es poco frecuente. Clínica e histológicamente muestra características semejantes al de localización facial, aunque en la dermatoscopia podemos encontrar una mezcla de patrones de lentigo maligno y melanoma de extensión superficial, debido principalmente a las diferencias entre las características anatómicas de la piel facial y la extrafacial.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez-Leboráns L, Garcías-Ladaria J, Oliver-Martínez V, Miquel VA. Lentigo maligno extrafacial. Serie de 14 casos y revisión de la literatura. Actas Dermosifiliogr. 2016;107:e57–e63.</p>" ] ] "multimedia" => array:201 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 1502 "Tamanyo" => 362697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient #2: An 88-year-old man with a pigmented macule present on his hand for years. A, Pigmented macule with asymmetric morphology and pigmentation. B, Dermoscopic image showing annular-granular pigmentation at one of the borders, together with rhomboidal structures and areas of regression. C, Histologic image of excised lesion showing proliferation of single melanocytes surrounded by a light halo in sun-damaged skin (marked solar elastosis) in addition to epidermal atrophy (hematoxylin-eosin, original magnification ×20). D, A higher-magnification view shows a proliferation of epithelioid cells with a pagetoid distribution and subepidermal fibrosis (hematoxylin-eosin, original magnification ×200).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1113 "Ancho" => 1500 "Tamanyo" => 587938 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patient #4: A 63-year-old man with a pigmented lesion on the scapula. A, A 13-mm pigmented macule on the left scapula. B, Dermoscopic image showing asymmetric follicular pigmentation, rhomboidal structures, and some obliterated follicular openings. Note also the features typically associated with superficial spreading melanoma, such as the atypical network, regression areas, and a blue-white veil. C, Proliferation of solitary and small nests of epithelioid melanocytes in the epidermis, with an accompanying inflammatory infiltrate, involvement of the adnexal epithelium, and solar elastosis (hematoxylin-eosin, original magnification ×100). D, A higher-magnification view shows melanophages in the papillary dermis (hematoxylin-eosin, original magnification ×200).</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: Max Diam, maximum diameter; HGV: Hospital General Universitario de Valencia; HMAN, Hospital de Manacor; Tis, melanoma in situ.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ …2] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Extrafacial Lentigo Maligna and Tumor Stage in 14 Patients.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AG, annular-granular; APFOs, asymmetric pigmented follicular openings; FOs, follicular openings; Rhom., rhomboidal; VN, vascular network.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ …2] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic Features of Extrafacial Lentigo Maligna in 14 Patients.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: NA, not assessed.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ …2] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Histologic Features of Extrafacial Lentigo Maligna in 14 Patients.</p>" ] ] 5 => array:5 [ "identificador" => "201704100107038711" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 54 "Ancho" => 54 "Tamanyo" => 1230 ] ] ] 6 => array:5 [ "identificador" => "201704100107038712" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 54 "Ancho" => 54 "Tamanyo" => 1230 ] ] ] 7 => array:5 [ "identificador" => "201704100107038713" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 54 "Ancho" => 54 "Tamanyo" => 1230 ] ] ] 8 => array:5 [ 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array:10 [ …10] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000008/v2_201704100057/S1578219016301573/v2_201704100057/en/main.assets" "Apartado" => array:4 [ "identificador" => "34944" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "e- Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000008/v2_201704100057/S1578219016301573/v2_201704100057/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301573?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 7 | 14 |
| 2024 October | 77 | 36 | 113 |
| 2024 September | 93 | 22 | 115 |
| 2024 August | 122 | 65 | 187 |
| 2024 July | 95 | 29 | 124 |
| 2024 June | 93 | 31 | 124 |
| 2024 May | 78 | 32 | 110 |
| 2024 April | 73 | 37 | 110 |
| 2024 March | 83 | 35 | 118 |
| 2024 February | 52 | 35 | 87 |
| 2024 January | 48 | 37 | 85 |
| 2023 December | 49 | 20 | 69 |
| 2023 November | 80 | 31 | 111 |
| 2023 October | 80 | 25 | 105 |
| 2023 September | 72 | 30 | 102 |
| 2023 August | 49 | 32 | 81 |
| 2023 July | 59 | 34 | 93 |
| 2023 June | 52 | 23 | 75 |
| 2023 May | 41 | 27 | 68 |
| 2023 April | 50 | 22 | 72 |
| 2023 March | 52 | 28 | 80 |
| 2023 February | 49 | 24 | 73 |
| 2023 January | 44 | 34 | 78 |
| 2022 December | 67 | 42 | 109 |
| 2022 November | 74 | 23 | 97 |
| 2022 October | 37 | 17 | 54 |
| 2022 September | 43 | 42 | 85 |
| 2022 August | 35 | 29 | 64 |
| 2022 July | 51 | 60 | 111 |
| 2022 June | 39 | 34 | 73 |
| 2022 May | 53 | 35 | 88 |
| 2022 April | 48 | 23 | 71 |
| 2022 March | 43 | 62 | 105 |
| 2022 February | 43 | 18 | 61 |
| 2022 January | 37 | 30 | 67 |
| 2021 December | 58 | 40 | 98 |
| 2021 November | 70 | 40 | 110 |
| 2021 October | 109 | 55 | 164 |
| 2021 September | 60 | 49 | 109 |
| 2021 August | 69 | 48 | 117 |
| 2021 July | 73 | 26 | 99 |
| 2021 June | 51 | 24 | 75 |
| 2021 May | 57 | 46 | 103 |
| 2021 April | 129 | 79 | 208 |
| 2021 March | 94 | 46 | 140 |
| 2021 February | 79 | 24 | 103 |
| 2021 January | 46 | 20 | 66 |
| 2020 December | 52 | 28 | 80 |
| 2020 November | 43 | 23 | 66 |
| 2020 October | 46 | 11 | 57 |
| 2020 September | 62 | 20 | 82 |
| 2020 August | 43 | 14 | 57 |
| 2020 July | 40 | 14 | 54 |
| 2020 June | 37 | 34 | 71 |
| 2020 May | 33 | 20 | 53 |
| 2020 April | 32 | 18 | 50 |
| 2020 March | 26 | 12 | 38 |
| 2020 February | 3 | 1 | 4 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 4 | 1 | 5 |
| 2019 April | 3 | 3 | 6 |
| 2019 February | 2 | 0 | 2 |
| 2018 December | 1 | 0 | 1 |
| 2018 November | 4 | 0 | 4 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 0 | 3 |
| 2018 May | 1 | 0 | 1 |
| 2018 February | 19 | 2 | 21 |
| 2018 January | 37 | 9 | 46 |
| 2017 December | 32 | 16 | 48 |
| 2017 November | 30 | 7 | 37 |
| 2017 October | 38 | 12 | 50 |
| 2017 September | 20 | 8 | 28 |
| 2017 August | 22 | 5 | 27 |
| 2017 July | 24 | 11 | 35 |
| 2017 June | 29 | 7 | 36 |
| 2017 May | 29 | 10 | 39 |
| 2017 April | 21 | 7 | 28 |
| 2017 March | 25 | 7 | 32 |
| 2017 February | 20 | 17 | 37 |
| 2017 January | 13 | 7 | 20 |
| 2016 December | 35 | 18 | 53 |
| 2016 November | 32 | 20 | 52 |
| 2016 October | 179 | 29 | 208 |
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