Practical Dermatology
Reflectance Confocal Microscopy in Lentigo Maligna
La microscopía confocal de reflectancia en el lentigo maligno
Hospital Universitario Fundación de Alcorcón, Madrid, Spain
Read
7137
Timeswas read the article
2250
Total PDF
4887
Total HTML
Share statistics
array:24 [ "pii" => "S1578219016302396" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.09.014" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1480" "copyright" => "Elsevier España, S.L.U. and AEDV" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2016;107:830-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1031 "formatos" => array:3 [ "EPUB" => 42 "HTML" => 732 "PDF" => 257 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731016302770" "issn" => "00017310" "doi" => "10.1016/j.ad.2016.07.012" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1480" "copyright" => "AEDV" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2016;107:830-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 468 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 383 "PDF" => 82 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">DERMATOLOGÍA PRÁCTICA</span>" "titulo" => "La microscopía confocal de reflectancia en el lentigo maligno" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "830" "paginaFinal" => "835" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Reflectance Confocal Microscopy in Lentigo Maligna" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1927 "Ancho" => 1983 "Tamanyo" => 546887 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">a) Imagen clínica en la que se aprecia una lesión pigmentada en un varón de 80 años. b) Imagen dermatoscópica con abundantes estructuras romboidales azul-grisáceas (flechas amarillas) y vascularización (flecha azul). c) Imagen con MCR en el área del recuadro negro por dermatoscopia de 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm que muestra en la unión dermoepidérmica engrosamientos junturales con células atípicas (flechas amarillas); también se observa la disposición de las células dendríticas formando puentes que constituyen estructuras que simulan mitocondrias (flechas azules). d) Imagen por MCR de 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm en la que vemos su disposición alrededor del folículo simulando una cabeza de medusa (recuadro amarillo).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Gamo, A. Pampín, U. Floristán" "autores" => array:3 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Gamo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pampín" ] 2 => array:2 [ "nombre" => "U." "apellidos" => "Floristán" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219016302396" "doi" => "10.1016/j.adengl.2016.09.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302396?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016302770?idApp=UINPBA000044" "url" => "/00017310/0000010700000010/v1_201611260105/S0001731016302770/v1_201611260105/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219016302359" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.09.011" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1469" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2016;107:836-44" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1513 "formatos" => array:3 [ "EPUB" => 59 "HTML" => 1173 "PDF" => 281 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Frontal Fibrosing Alopecia in Men: Presentations in 12 Cases and a Review of the Literature" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "836" "paginaFinal" => "844" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alopecia frontal fibrosante en el varón: presentación de 12 casos y revisión de la literatura" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1339 "Ancho" => 2500 "Tamanyo" => 612349 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A and B, Androgenetic alopecia, Hamilton grade VI. On examination a band of thinner skin without hair follicles was found at both temples. Both erythema and follicular hypererkeratosis were evident at the forehead and top of the head.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Ormaechea-Pérez, A. López-Pestaña, J. Zubizarreta-Salvador, A. Jaka-Moreno, A. Panés-Rodríguez, A. Tuneu-Valls" "autores" => array:6 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Ormaechea-Pérez" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "López-Pestaña" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Zubizarreta-Salvador" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Jaka-Moreno" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Panés-Rodríguez" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Tuneu-Valls" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731016302605" "doi" => "10.1016/j.ad.2016.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016302605?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302359?idApp=UINPBA000044" "url" => "/15782190/0000010700000010/v1_201611260103/S1578219016302359/v1_201611260103/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219016302384" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.05.025" "estado" => "S300" "fechaPublicacion" => "2016-12-01" "aid" => "1445" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Actas Dermosifiliogr. 2016;107:823-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1980 "formatos" => array:3 [ "EPUB" => 56 "HTML" => 1634 "PDF" => 290 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Advances in Dermatology</span>" "titulo" => "Kidney Disease and Psoriasis. A New Comorbidity?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "823" "paginaFinal" => "829" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad renal y psoriasis. ¿Una nueva comorbilidad?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. González-Parra, E. Daudén, J.M. Carrascosa, A. Olveira, R. Botella, C. Bonanad, R. Rivera" "autores" => array:8 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "González-Parra" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Daudén" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Carrascosa" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Olveira" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Botella" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Bonanad" ] 6 => array:2 [ "nombre" => "R." "apellidos" => "Rivera" ] 7 => array:1 [ "colaborador" => "for the Systemic Inflammation in Psoriasis Working Group" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731016301715" "doi" => "10.1016/j.ad.2016.05.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016301715?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302384?idApp=UINPBA000044" "url" => "/15782190/0000010700000010/v1_201611260103/S1578219016302384/v1_201611260103/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Practical Dermatology</span>" "titulo" => "Reflectance Confocal Microscopy in Lentigo Maligna" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "830" "paginaFinal" => "835" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Gamo, A. Pampín, U. Floristán" "autores" => array:3 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Gamo" "email" => array:1 [ 0 => "reyesgamo2000@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pampín" ] 2 => array:2 [ "nombre" => "U." "apellidos" => "Floristán" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Universitario Fundación de Alcorcón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La microscopía confocal de reflectancia en el lentigo maligno" ] ] "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" => 1460 "Ancho" => 1503 "Tamanyo" => 404119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A, Clinical image showing a pigmented lesion on an 80-year-old man. B, Dermoscopic lesion with abundant blue-gray rhomboid structures (yellow arrows) and vascularization (blue arrow). C, CRM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm black box in the dermoscopic image, showing the dermal-epidermal junction broadening with atypical cells (yellow arrows); the localization of the dendritic cells, forming bridges that constitute the structures that simulate mitochondria (blue arrows) can also be seen. D, CRM image of 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm in which their follicular localization can be seen with a tentacle-like appearance (yellow box).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lentigo maligna (LM) is a melanoma in situ that usually presents on sun-exposed skin (head and neck) in elderly individuals. LM accounts for 80% of melanomas in situ and is the most common facial melanoma. If the lesion becomes invasive, it is termed LM melanoma (LMM).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis of LM is difficult because the initial clinical and dermoscopic signs are subtle and not pathognomonic. In addition, differential diagnosis needs to include numerous pigmented lesions, such as solar lentigines (SL), simple lentigines, flat seborrheic keratosis (irritated or not irritated), lichenoid keratosis, actinic keratosis (above all, the pigmented variety), Bowen disease, and pigmented basal cell epitheliomas.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy (RCM) is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology. RCM is an excellent technique for analyzing and establishing diagnosis of facial lesions. This article describes the main features of confocal microscopy images associated with diagnosis of LM.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical, Histological, and Dermoscopic Features of Lentigo Maligna</span><p id="par0020" class="elsevierStylePara elsevierViewall">LM is characterized clinically by the presence of slow-growing pigmented macules. Differential diagnosis with solar lentigines, pigmented actinic keratosis, and flat seborrheic keratosis is sometimes complex. It is much easier to distinguish LM from melanocytic nevi on the face given that, in elderly individuals, these latter lesions often have a papular appearance, with normal skin coloration (Miescher nevus).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologically, differential diagnosis between LM lesions and atypical melanocytic hyperplasia associated with sun-damaged skin may also be difficult, particularly when only small biopsy samples are available. A good pathologic-clinical correlation is essential for avoid wrong diagnosis, particularly in areas of sun-damaged skin such as the face and neck in elderly individuals and in large lesions.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> If LM is suspected on clinical grounds and the pathologic diagnosis is of junctional nevus, dysplastic nevus, or atypical lentiginous nevus, the pathology findings should be reviewed in detail. Furthermore, surgery is usually complicated as these are large lesions with poorly defined borders on the face. With amelanotic forms, recurrence is not uncommon.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Dermoscopy is a technique that increases the sensitivity and specificity of diagnosis of pigmented facial lesions. The classic dermoscopic features associated with LM were described by Schiffner et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> in 2002 and include asymmetric follicular pigmentation, presence of small slate-gray dots and globules irregularly distributed around the follicle (annular-granular pattern), pigmented rhomboidal structures, and homogeneous areas that obliterate the follicles. Actinic pigmented keratosis, SL, and lichenoid keratosis can also present an annular-granular pattern (grey dots/globules). The rhomboidal structures and, above all, the homogeneous areas that obliterate the follicles are more specific to LM and are mainly associated with LM that have become invasive.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2012, Pralong et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> published the characteristics of 125 LM/LMM lesions in white patients, and verified the utility of the classic signs of LM. They also identified additional dermoscopic signs associated with LM. These included increased vascular density in the region of LM compared to surrounding skin, presence of red rhomboidal structures, presence of bullseye structures, and darkening of the lesion on examination with dermoscopy compared to the clinical examination.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The increased vascular density and red rhomboidal structures can also be seen in actinic keratosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The angular or zigzag lines described in LM correspond to the early stages of formation of rhomboidal structures.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> In some extrafacial LM, the only dermoscopic sign may be these zigzag lines.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> The presence of fine dots similar to those seen in the annular-granular pattern, but of brown color and with nonannular distribution, has been associated with failure of radiotherapy or imiquimod treatment.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Confocal Reflectance Microscopy Features of Lentigo Maligna</span><p id="par0050" class="elsevierStylePara elsevierViewall">RCM is a noninvasive imaging technique that permits visualization of the epidermis and papillary dermis with a cellular resolution approaching that of conventional histology. Both clinical and dermoscopic differential diagnosis of macular facial lesions such as SL, seborrheic keratosis, actinic keratosis, Bowen disease, basal cell epithelioma, and LM is sometimes difficult. In these cases, RCM is very useful for establishing the correct diagnosis. Most of the changes in LM are located in the epidermis and the dermal-epidermal junction. RCM permits a precise visualization of the architectural and cytologic features typical of LM because images are obtained from the epidermis to the papillary dermis.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> In addition to diagnosis, RCM can also be used to define the margins of LM prior to treatment<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12–14</span></a> as well as during surgery.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> Furthermore, RCM can detect recurrence after surgery or be used to assess response to nonsurgical treatments.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">10,12,16,17</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A focal or global loss of honeycomb architecture is detected by RCM in the epidermis of LM lesions. Atypical cells corresponding to pagetoid cell infiltration in histology are also observed. The cells present are mainly of dendritic morphology (large and pleomorphic cells with prominent dendrites) and very indicative of LM if they are more than twice the size of keratinocytes, abundant and atypical, and located around follicles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Pagetoid cells can also be round, large, and atypical, with evident nuclei. Round cells occur less frequently than dendritic cells in LM but if they measure more than 20<span class="elsevierStyleHsp" style=""></span>μm they are more specific.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A loss of the annular pattern at the dermal-epidermal junction is a common finding. The presence of poorly delineated papillae with atypical cells is very indicative of LM. It is necessary to differentiate between failure to visualize papillae characteristic of the facial site and the presence of papillae with poorly defined edges. Dendritic cells at the dermal-epidermal junction can form bridges that resemble mitochondria. These structures are frequently observed in melanomas in situ (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> Junctional thickening with atypical cells can also be found in LM. This junctional thickening can be located radially around follicles, giving them a tentacle-like appearance (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d).<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19,20</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Atypical nucleated cells can occasionally be observed in the dermis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">With RCM, we can distinguish between LM and SL, which is the main entity to be included in the differential diagnosis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In SL, the main findings are located in the dermal-epidermal junction, as the changes are observed in the papillary dermis and rete ridges. There is an increase in the density of the dermal papillae that presents as bright contours in a polycyclic shape (papillae with polycyclic outline). These contours are also known as bulbous projections and are formed by monomorphic, brilliant, reflective cells without atypia, which contain melanin and melanosomes. The contours seen by RCM correspond in dermoscopy to the fingerprint. In the granular and spinous layer, SL lesions maintain the honeycomb pattern consisting of monomorphic polygonal cells with a dark nucleus and clear cytoplasm, and melanophages and lymphocytes can be seen in the dermal papillae. The honeycomb pattern is lost focally or globally in LM lesions. LM lesions also often show atypical pagetoid cells with a dendritic appearance with folliculotropism as well as loss of papillae and nonhomogeneous junction thickening with atypical cells.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">RCM also permits diagnosis of lichenoid keratosis. Clinically, this condition presents as macular lesions which, in dermoscopic images, show blue-grey regression distributed throughout the lesion. With RCM, pagetoid cells and cellular atypia are not observed. These are abundant plump bright cells that sometimes cluster together and that correspond to melanophages, usually without a visible nucleus.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In 2010, Guitera et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> published a prospective study analyzing 64 signs observed in RCM in hard-to-diagnose facial lesions (81 LM lesions and 203 benign lesions were included). They described the confocal features of the LM lesions, and identified 6 parameters that were related to diagnosis of LM and established a diagnostic algorithm. This included 2 major criteria, each of which score +2 points, and 4 minor criteria, 3 of which scored +1 point and 1, a negative criterion that protected diagnosis of LM, scored -1. The major criteria included loss of reflectance annular pattern typical of the dermal-epidermal junction and the presence of round pagetoid cells measuring more than 20 microns across. The positive minor criteria were presence of 3 or more atypical cells in 5 quadrants of 0.5 by 0.5<span class="elsevierStyleHsp" style=""></span>mm at the dermal-epidermal junction, follicular localization of atypical cells, and the finding of nucleated cells with the dermal papillae. The negative criterion included presence of broadened epidermal pattern. A score of 2 or more gave a sensitivity of 85% and a specificity of 76% for the diagnosis of LM (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">De Carvalho et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> retrospectively analyzed 60 pigmented macular facial lesions, including LM, LMM, SL/planar seborrheic keratosis, lichenoid keratosis, and pigmented actinic keratosis. Relating the dermoscopic features with RCM findings, they found that the fingerprint pattern was only found in benign lesions and corresponded in RCM to polycyclic papillary contours. The annular-granular pattern was present in both benign lesions and LM lesions. The blue and black rhomboid structures and the blue or black spots were seen almost exclusively in LM/LMM, and above all in nonincipient lesions. In a limited number of cases of benign lesions with spots or homogenous areas, the lesions corresponded to a cobblestone pattern in the epidermis and papillary polycyclic contours consisting of basal hyperpigmented cells located at the dermal-epidermal junction, typical of SL lesions and planar seborrheic keratosis. In LM/LMM, intraepidermal proliferation of dendritic cells was observed (a rare finding in benign lesions) with a tendency towards folliculotropism. In addition, the authors found junctional thickening comprised of atypical cells that were located radially around the follicles, adopting a tentacle-like appearance.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The utility of RCM in the follow-up of noninvasive treatments of LM was studied by Guitera et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> in 99 patients diagnosed with LM who had been treated with radiotherapy or imiquimod. Dermoscopy had a sensitivity of 80% and a specificity of 56%, whereas applying the diagnostic algorithm for LM with RCM, the specificity was 94% and the sensitivity 100%. The 2 dermoscopic signs that were most closely associated with histologic diagnosis of melanoma were asymmetric follicular openings and the presence of fine brown dots (similar to the dotted annular-granular pattern but without the annular distribution). This brown dotted pattern corresponded to the RCM finding of pagetoid cells, unlike the fine greyish points, which appeared as melanophages in RCM.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">RCM is a very effective technique for the diagnosis of LM. The presence of atypical cells in the epidermis (with predominantly perifollicular localization) or the dermal-epidermal junction, as well as loss of normal skin architecture in the epidermal and dermal-epidermal junction are key for diagnosis of LM.</p><p id="par0100" class="elsevierStylePara elsevierViewall">RCM permits us to analyze the entire surface of the lesion, as well as correlate findings with dermoscopic characteristics. RCM is an excellent technique for choosing areas to biopsy. It can delineate the margins of the lesion (even amelanotic lesions) and enable assessment of response to treatment and detection of recurrences in a noninvasive fashion.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We therefore believe that RCM is key not only in the diagnosis but also in the follow-up of LM.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres762923" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec764398" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres762924" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec764397" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical, Histological, and Dermoscopic Features of Lentigo Maligna" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Confocal Reflectance Microscopy Features of Lentigo Maligna" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-28" "fechaAceptado" => "2016-07-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec764398" "palabras" => array:3 [ 0 => "Lentigo maligna" 1 => "Reflectance confocal microscopy" 2 => "Dermoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec764397" "palabras" => array:3 [ 0 => "Lentigo maligno" 1 => "Microscopio confocal de reflectancia" 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 type of facial melanoma. Diagnosis is complicated, however, as it shares clinical and dermoscopic characteristics with other cutaneous lesions of the face. Reflectance confocal microscopy is an imaging technique that permits the visualization of characteristic features of lentigo maligna. These include a disrupted honeycomb pattern and pagetoid cells with a tendency to show folliculotropism. These cells typically have a dendritic morphology, although they may also appear as round cells measuring over 20<span class="elsevierStyleHsp" style=""></span>μm with atypical nuclei. Poorly defined dermal papillae and atypical cells may be seen at the dermal-epidermal junction and can form bridges resembling mitochondrial structures. Other characteristic findings include junctional swelling with atypical cells located around the follicles, resembling caput medusae. Reflectance confocal microscopy is a very useful tool for diagnosing lentigo maligna.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El lentigo maligno es el melanoma más frecuente en la cara.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El diagnóstico del lentigo maligno es complicado porque los signos clínicos y dermatoscópicos asociados a lentigo maligno pueden verse en otras lesiones cutáneas faciales.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es una técnica de imagen que permite detectar hallazgos característicos del lentigo maligno. En la epidermis encontramos la pérdida del patrón en panal de abejas y células pagetoides con tendencia al foliculotropismo. Estas células pagetoides suelen ser de morfología dendrítica, aunque también pueden presentarse como células redondas mayores de 20<span class="elsevierStyleHsp" style=""></span>μm con núcleos atípicos. En la unión dermoepidérmica las papilas dérmicas pueden estar mal delimitadas y haber células atípicas. Estas células pueden formar puentes que parecen estructuras mitocondriales. Además, podemos ver engrosamientos junturales con células atípicas localizados alrededor de los folículos simulando una cabeza de medusa.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La microscopia confocal de reflectancia es muy útil en el diagnóstico del lentigo maligno.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gamo R, Pampín A, Floristán U. La microscopía confocal de reflectancia en el lentigo maligno. Actas Dermosifiliogr. 2016;107:830–835.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1567 "Ancho" => 1503 "Tamanyo" => 391894 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A, Facial polychrome macule of 3 years duration on a 68-year-old man. B, Dermoscopic image with asymmetric follicular openings (yellow arrow), increased vascular density (yellow square), and brown rhomboid structures (blue arrow). C, RCM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>mm black square in the dermoscopic image, showing abundant dendritic cells (yellow square) with follicular localization. To the left of the image, loss of the honeycomb pattern is observed in the spinous cell layer; to the right, the image corresponds to the horny layer.</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" => 1460 "Ancho" => 1503 "Tamanyo" => 404119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A, Clinical image showing a pigmented lesion on an 80-year-old man. B, Dermoscopic lesion with abundant blue-gray rhomboid structures (yellow arrows) and vascularization (blue arrow). C, CRM image corresponding to the area of the 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm black box in the dermoscopic image, showing the dermal-epidermal junction broadening with atypical cells (yellow arrows); the localization of the dendritic cells, forming bridges that constitute the structures that simulate mitochondria (blue arrows) can also be seen. D, CRM image of 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm in which their follicular localization can be seen with a tentacle-like appearance (yellow box).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1143 "Ancho" => 1500 "Tamanyo" => 362356 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A, Dermoscopic image of a lesion of 3 years duration on the cheek of a 72-year-old woman. Dark brown rhomboidal structures are observed on a large part of the lesion (yellow arrows). B, CRM image showing irregular junction broadening with atypical cells (yellow arrows). C, Dermoscopic image of a supraciliary lesion of 10 years duration in a 50-year-old woman. Asymmetric follicular pigmentation (yellow arrows) can be observed. D, CRM image showing areas (yellow boxes) with an increased density of dermal papillae with polycyclic and geometric outlines that are named polycyclic papillary contours (also known as bulbous projections).</p>" ] ] 3 => 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="spar0050" class="elsevierStyleSimplePara elsevierViewall">A score of more than 2 has a sensitivity of 85% and a specificity of 76% for the diagnosis of LM.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Major Features<br>(score +2 points)</td><td class="td" title="table-entry " align="left" valign="top">Nonedged papillae \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pagetoid cells, round and greater than 20<span class="elsevierStyleHsp" style=""></span>μm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Positive minor features<br>(score +1 point)</td><td class="td" title="table-entry " align="left" valign="top">More than 3 atypical cells at the junction in 5 images \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follicular localization of pagetoid cells and/or atypical junctional cells \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nucleated cells within the papilla \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Negative minor feature<br>(score -1 point) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broadened honeycomb pattern \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260349.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Algorithm of Lentigo Maligna of Guitera et al<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lentigo maligna and lentigo maligna melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.M. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1995" "volumen" => "33" "paginaInicial" => "923" "paginaFinal" => "936" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7490362" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermoscopic clues to differentiate facial lentigo maligna from pigmented actinic keratosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Lallas" 1 => "P. Tschandl" 2 => "A. Kyrgidis" 3 => "W. Stolz" 4 => "H. Rabinovitz" 5 => "A. Cameron" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.14355" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2016" "volumen" => "174" "paginaInicial" => "1079" "paginaFinal" => "1085" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26784739" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0130" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spreading pigmented actinic keratosis: A review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.E. Uhlenhake" 1 => "O.P. Sangueza" 2 => "A.D. Lee" 3 => "J.L. Jorizzo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2009.07.026" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2010" "volumen" => "63" "paginaInicial" => "499" "paginaFinal" => "506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20334953" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0135" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Flat pigmented macules on sun-damaged skin of the head/neck: Junctional nevus, atypical lentiginous nevus, or melanoma in situ?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Zalaudek" 1 => "C. Cota" 2 => "G. Ferrara" 3 => "E. Moscarella" 4 => "P. Guitera" 5 => "C. Longo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clindermatol.2013.05.029" "Revista" => array:6 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2014" "volumen" => "32" "paginaInicial" => "88" "paginaFinal" => "93" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24314381" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0140" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improvement of early recognition of lentigo maligna using dermatoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Schiffner" 1 => "J. Schiffner-Rohe" 2 => "T. Vogt" 3 => "M. Landthaler" 4 => "U. Wlotzke" 5 => "A.B. Cognetta" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2000" "volumen" => "42" "paginaInicial" => "25" "paginaFinal" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10607354" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0145" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatoscopy of flat pigmented facial lesions: Diagnostic challenge between pigmented actinic keratosis and lentigo maligna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.N. Akay" 1 => "P. Kocyigit" 2 => "A.O. Heper" 3 => "C. Erdem" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2010.10025.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2010" "volumen" => "163" "paginaInicial" => "1212" "paginaFinal" => "1217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21083845" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0150" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermoscopy of lentigo maligna melanoma: Report of 125 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Pralong" 1 => "E. Bathelier" 2 => "S. Dalle" 3 => "N. Poulalhon" 4 => "S. Debarbieux" 5 => "L. Thomas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2012.10932.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2012" "volumen" => "167" "paginaInicial" => "280" "paginaFinal" => "287" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22404578" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0155" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The zig-zag pattern of lentigo maligna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.B. Slutsky" 1 => "A.A. Marghoob" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2010.307" "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2010" "volumen" => "146" "paginaInicial" => "1444" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21173339" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0160" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A digital dermoscopy follow-up illustration and a histopathologic correlation for angulated lines in extrafacial lentigo maligna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Vanden Daelen" 1 => "I. Ferreira" 2 => "L. Marot" 3 => "I. Tromme" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamadermatol.2015.4132" "Revista" => array:6 [ "tituloSerie" => "JAMA Dermatol" "fecha" => "2016" "volumen" => "152" "paginaInicial" => "200" "paginaFinal" => "203" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26651094" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0165" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surveillance for treatment failure of lentigo maligna with dermoscopy and in vivo confocal microscopy: New descriptors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Guitera" 1 => "L.E. Haydu" 2 => "S.W. Menzies" 3 => "R.A. Scolyer" 4 => "A. Hong" 5 => "G.B. Fogarty" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.12839" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2014" "volumen" => "170" "paginaInicial" => "1305" "paginaFinal" => "1312" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24641247" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0170" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "In vivo examination of lentigo maligna and malignant melanoma in situ, lentigo maligna type by near-infrared reflectance confocal microscopy: Comparison of in vivo confocal images with histologic sections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Z.S. Tannous" 1 => "M.C. Mihm" 2 => "T.J. Flotte" 3 => "S. González" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2002" "volumen" => "46" "paginaInicial" => "260" "paginaFinal" => "263" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11807439" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0175" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of in vivo confocal microscopy in malignant melanoma: An aid in diagnosis and assessment of surgical and nonsurgical therapeutic approaches" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Curiel-Lewandrowski" 1 => "C.M. Williams" 2 => "K.J. Swindells" 3 => "S.R. Tahan" 4 => "S. Astner" 5 => "R.A. Frankenthaler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.140.9.1127" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2004" "volumen" => "140" "paginaInicial" => "1127" "paginaFinal" => "1132" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15381554" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0180" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multimodal in vivo optical imaging, including confocal microscopy, facilitates presurgical margin mapping for clinically complex lentigo maligna melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C-SJ Chen" 1 => "M. Elias" 2 => "K. Busam" 3 => "M. Rajadhyaksha" 4 => "A.A. Marghoob" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2005.06831.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2005" "volumen" => "153" "paginaInicial" => "1031" "paginaFinal" => "1036" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16225620" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0185" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improving management and patient care in lentigo maligna by mapping with in vivo confocal microscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Guitera" 1 => "F.J. Moloney" 2 => "S.W. Menzies" 3 => "J.R. Stretch" 4 => "M.J. Quinn" 5 => "A. Hong" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamadermatol.2013.2301" "Revista" => array:6 [ "tituloSerie" => "JAMA Dermatol" "fecha" => "2013" "volumen" => "149" "paginaInicial" => "692" "paginaFinal" => "698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23553208" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0190" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative real-time reflectance confocal microscopy for guiding surgical margins of lentigo maligna melanoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.P. Hibler" 1 => "M. Cordova" 2 => "R.J. Wong" 3 => "A.M. Rossi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Surg Off Publ Am Soc Dermatol Surg Al" "fecha" => "2015" "volumen" => "41" "paginaInicial" => "980" "paginaFinal" => "983" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0195" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of reflectance confocal microscopy to monitor response of lentigo maligna to nonsurgical treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Nadiminti" 1 => "A. Scope" 2 => "A.A. Marghoob" 3 => "K. Busam" 4 => "K.S. Nehal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Surg Off Publ Am Soc Dermatol Surg Al" "fecha" => "2010" "volumen" => "36" "paginaInicial" => "177" "paginaFinal" => "184" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0200" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reflectance confocal microscopy for recurrent lentigo maligna" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Erfan" 1 => "H.-Y. Kang" 2 => "N. Cardot-Leccia" 3 => "B. Chignon-Sicard" 4 => "T. Passeron" 5 => "J.-P. Ortonne" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatol Surg Off Publ Am Soc Dermatol Surg Al" "fecha" => "2011" "volumen" => "37" "paginaInicial" => "1519" "paginaFinal" => "1524" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0205" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Learning reflectance confocal microscopy of melanocytic skin lesions through histopathologic transversal sections" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C.T. Braga" 1 => "M.P. Macedo" 2 => "C. Pinto" 3 => "J. Duprat" 4 => "M.D. Begnami" 5 => "G. Pellacani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0081205" "Revista" => array:5 [ "tituloSerie" => "PloS One" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "e81205" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24339910" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0210" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Guitera" 1 => "G. Pellacani" 2 => "K.A. Crotty" 3 => "R.A. Scolyer" 4 => "L-X.L. Li" 5 => "S. Bassoli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/jid.2010.84" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "2010" "volumen" => "130" "paginaInicial" => "2080" "paginaFinal" => "2091" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20393481" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0215" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: A preliminary study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Ahlgrimm-Siess" 1 => "C. Massone" 2 => "A. Scope" 3 => "R. Fink-Puches" 4 => "E. Richtig" 5 => "I.H. Wolf" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2009.09289.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2009" "volumen" => "161" "paginaInicial" => "1307" "paginaFinal" => "1316" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19566662" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0220" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "In vivo confocal scanning laser microscopy of benign lentigines: Comparison to conventional histology and in vivo characteristics of lentigo maligna" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.G.B. Langley" 1 => "E. Burton" 2 => "N. Walsh" 3 => "I. Propperova" 4 => "S.J. Murray" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2006.03.009" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2006" "volumen" => "55" "paginaInicial" => "88" "paginaFinal" => "97" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16781299" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0225" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichenoid keratosis: Non-invasive imaging in the setting of diagnostic uncertainty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.K. Ramirez-Fort" 1 => "S. Al Jalbout" 2 => "H. Kittler" 3 => "G. Pellacani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5826/dpc.0302a10" "Revista" => array:6 [ "tituloSerie" => "Dermatol Pract Concept" "fecha" => "2013" "volumen" => "3" "paginaInicial" => "63" "paginaFinal" => "65" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23785648" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0230" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reflectance confocal microscopy correlates of dermoscopic patterns of facial lesions help to discriminate lentigo maligna from pigmented nonmelanocytic macules" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. De Carvalho" 1 => "F. Farnetani" 2 => "S. Ciardo" 3 => "C. Ruini" 4 => "A.M. Witkowski" 5 => "C. Longo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.13546" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2015" "volumen" => "173" "paginaInicial" => "128" "paginaFinal" => "133" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25413382" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000010/v1_201611260103/S1578219016302396/v1_201611260103/en/main.assets" "Apartado" => array:4 [ "identificador" => "6151" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Practical Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000010/v1_201611260103/S1578219016302396/v1_201611260103/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302396?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 14 | 26 |
| 2024 October | 140 | 52 | 192 |
| 2024 September | 111 | 33 | 144 |
| 2024 August | 140 | 66 | 206 |
| 2024 July | 131 | 23 | 154 |
| 2024 June | 144 | 31 | 175 |
| 2024 May | 103 | 29 | 132 |
| 2024 April | 114 | 32 | 146 |
| 2024 March | 119 | 38 | 157 |
| 2024 February | 78 | 38 | 116 |
| 2024 January | 85 | 38 | 123 |
| 2023 December | 145 | 19 | 164 |
| 2023 November | 147 | 40 | 187 |
| 2023 October | 99 | 15 | 114 |
| 2023 September | 120 | 28 | 148 |
| 2023 August | 68 | 23 | 91 |
| 2023 July | 68 | 29 | 97 |
| 2023 June | 69 | 22 | 91 |
| 2023 May | 75 | 26 | 101 |
| 2023 April | 87 | 24 | 111 |
| 2023 March | 81 | 27 | 108 |
| 2023 February | 70 | 31 | 101 |
| 2023 January | 48 | 36 | 84 |
| 2022 December | 69 | 44 | 113 |
| 2022 November | 53 | 34 | 87 |
| 2022 October | 73 | 24 | 97 |
| 2022 September | 51 | 47 | 98 |
| 2022 August | 77 | 37 | 114 |
| 2022 July | 67 | 58 | 125 |
| 2022 June | 33 | 31 | 64 |
| 2022 May | 35 | 45 | 80 |
| 2022 April | 47 | 35 | 82 |
| 2022 March | 42 | 49 | 91 |
| 2022 February | 42 | 32 | 74 |
| 2022 January | 61 | 40 | 101 |
| 2021 December | 37 | 50 | 87 |
| 2021 November | 44 | 48 | 92 |
| 2021 October | 63 | 64 | 127 |
| 2021 September | 49 | 44 | 93 |
| 2021 August | 72 | 50 | 122 |
| 2021 July | 57 | 28 | 85 |
| 2021 June | 72 | 60 | 132 |
| 2021 May | 50 | 54 | 104 |
| 2021 April | 142 | 69 | 211 |
| 2021 March | 60 | 39 | 99 |
| 2021 February | 43 | 31 | 74 |
| 2021 January | 44 | 29 | 73 |
| 2020 December | 24 | 25 | 49 |
| 2020 November | 36 | 22 | 58 |
| 2020 October | 43 | 29 | 72 |
| 2020 September | 37 | 32 | 69 |
| 2020 August | 29 | 18 | 47 |
| 2020 July | 25 | 10 | 35 |
| 2020 June | 41 | 26 | 67 |
| 2020 May | 33 | 27 | 60 |
| 2020 April | 223 | 32 | 255 |
| 2020 March | 25 | 16 | 41 |
| 2020 February | 3 | 0 | 3 |
| 2019 December | 2 | 0 | 2 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 2 | 0 | 2 |
| 2019 May | 1 | 6 | 7 |
| 2019 April | 0 | 6 | 6 |
| 2019 March | 6 | 0 | 6 |
| 2019 February | 5 | 0 | 5 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 63 | 0 | 63 |
| 2018 November | 11 | 0 | 11 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 2 | 0 | 2 |
| 2018 February | 24 | 3 | 27 |
| 2018 January | 42 | 14 | 56 |
| 2017 December | 46 | 14 | 60 |
| 2017 November | 34 | 9 | 43 |
| 2017 October | 44 | 13 | 57 |
| 2017 September | 23 | 7 | 30 |
| 2017 August | 32 | 13 | 45 |
| 2017 July | 24 | 6 | 30 |
| 2017 June | 42 | 16 | 58 |
| 2017 May | 35 | 12 | 47 |
| 2017 April | 43 | 22 | 65 |
| 2017 March | 26 | 21 | 47 |
| 2017 February | 32 | 9 | 41 |
| 2017 January | 35 | 16 | 51 |
| 2016 December | 112 | 37 | 149 |
| 2016 November | 32 | 28 | 60 |
| 2016 October | 4 | 5 | 9 |
Show all
