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1</a>A and B&#41;&#46; En bloc resection was performed for histological analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Additional immunohistochemical staining showed that the sample was negative for preferentially expressed antigen in melanoma &#40;PRAME&#41;&#46; Ki-67 immunostaining revealed a low proliferation index&#46; A complete sequencing study of exon 5 of <span class="elsevierStyleItalic">GNAQ</span> showed no alterations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Based on these clinical and histological data&#44; diagnosis of agminate blue nevus was established&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This infrequent presentation of blue nevus is of interest given the potential for clinical diagnostic confusion with melanoma metastasis&#46; Genetic alterations potentially shared with uveal melanoma&#44; nevus of Ota&#44; and nevus of Ito are of particular interest&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In blue nevus the most frequently described genetic mutation&#44; which is found in up to 83&#37; of cases and considered a driver mutation&#44; is a somatic mutation in <span class="elsevierStyleItalic">GNAQ</span> and <span class="elsevierStyleItalic">GNA11</span> &#40;which encode the alpha subunits of heterotrimeric G proteins involved in G-protein-coupled receptor-mediated signaling&#41;&#46; This mutation causes the affected genes to act as oncogenes&#44; as it results in constitutive activation of these proteins and continuous activation of the Ras signaling pathway&#44; which is involved in regulation of the cell cycle and proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Consequently&#44; in blue nevi with this mutation there is an increase in the activity of mitogen-activated protein kinase 1 &#40;ERK2&#41;&#44; which is activated by RAS&#47;RAF&#47;MAP kinase kinase &#40;MEK&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is only 1 published report of agminate blue nevus with a proven mutation&#44; located at c&#46;626A&#8239;&#62;&#8239;T &#40;p&#46;Glu209Leu&#41; in <span class="elsevierStyleItalic">GNAQ</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In some reported cases&#44; including ours&#44; in which no <span class="elsevierStyleItalic">GNAQ</span> mutation is detected&#44; activating mutations have been detected in cysteinyl leukotriene receptor 2 &#40;<span class="elsevierStyleItalic">CYSLTR2</span>&#41;&#44; which is involved in a signaling pathway analogous to that of <span class="elsevierStyleItalic">GNAQ</span> and ultimately activates the same intracellular processes&#46; This is yet another driver mutation&#44; mutually exclusive from <span class="elsevierStyleItalic">GNAQ</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Driver mutations affecting <span class="elsevierStyleItalic">GNAQ&#47;GNA11</span> and <span class="elsevierStyleItalic">CYSLTR2</span> can be accompanied by additional mutations in different cellular pathways that favor the progression and malignant transformation of the lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> The most widely known mutation is in the BRCA1-associated protein 1 gene &#40;<span class="elsevierStyleItalic">BAP1</span>&#41;&#46; <span class="elsevierStyleItalic">BAP1</span> acts as a tumor suppressor and is involved in DNA repair processes&#44; the ubiquitin-proteasome system&#44; regulation of transcription&#44; and chromatin modulation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Inactivation of this protein&#44; either by partial deletion of the <span class="elsevierStyleItalic">BAP1</span> locus on chromosome 3 or alteration in the phosphorylation or ubiquitination of its protein chain&#44; results in accelerated progression of cell proliferation that can trigger malignant transformation of blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore&#44; these alterations described for blue nevus and for blue-nevus-like melanoma closely resemble those found in other pathological processes such as uveal melanoma&#46; For example&#44; the <span class="elsevierStyleItalic">GNAQ</span> mutation has been described in 46&#37; of uveal melanomas&#44; where it also acts as a driver mutation and can be associated with other mutations affecting <span class="elsevierStyleItalic">BAP1</span> or other pathways involved in chromosomal instability&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Knowledge of genetic alterations and intracellular signaling pathways in these lesions is not only of diagnostic value&#44; but may also have therapeutic implications&#46; For example&#44; the use of MEK inhibitors&#44; with or without phosphatidyl-inositol 3 kinase &#40;PI3K&#41; or mammalian target of rapamycin &#40;mTOR&#41; inhibitors&#44; has been proposed for the treatment of uveal melanoma and could also prove useful for the treatment of blue nevi with progression to melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; PRAME immunostaining has been recently proposed as a diagnostically useful marker to distinguish between nevi and melanoma&#44; and is a biomarker of metastatic risk in uveal melanoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In our case&#44; the negative PRAME immunostaining is in line with the other histological findings that support a diagnosis of blue nevus in our patient&#46; To our knowledge&#44; this is the first report of PRAME staining of agminate blue nevus&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given the potential diagnostic and therapeutic implications of blue nevus with an atypical clinical presentation&#44; as in the present case of agminate blue nevus&#44; knowledge of the underlying genetics is important&#46; PRAME immunohistochemistry and genetic analyses can increase diagnostic specificity in cases of atypical melanocytic lesions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dr&#46; Llamas has acted as a speaker and consultant for Janssen-Cilag&#44; AbbVie&#44; Celgene&#44; Pfizer&#44; Novartis&#44; Lilly&#44; Almirall&#44; and Leo-Pharma&#44; and has participated in clinical trials&#46; The remaining authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Jim&#233;nez P&#44; Mayor-Sanabria F&#44; R&#252;tten A&#44; Fraga J&#44; Llamas-Velasco M&#46; Nevus azul agminado&#44; mutaciones en <span class="elsevierStyleItalic">GNAQ</span> y m&#225;s all&#225;&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;95&#8211;97&#46;</p>"
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Letter to the Editor
Agminated blue nevus: GNAQ mutations and beyond
Nevus azul agminado, mutaciones en GNAQ y más allá
P. Rodríguez-Jiméneza,b,
Corresponding author
, F. Mayor-Sanabriaa, A. Rüttenc, J. Fragad, M. Llamas-Velascoa,e
a Departamento de Dermatología, Hospital Universitario de La Princesa, Madrid, Spain
b Clínica Dermatológica Internacional, Madrid, Spain
c Friedrichshafen Dermatopathologie, Friedrichshafen, Alemania
d Departamento de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain
e Centro Médico Voth, Madrid, Spain
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1</a>A and B&#41;&#46; En bloc resection was performed for histological analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Additional immunohistochemical staining showed that the sample was negative for preferentially expressed antigen in melanoma &#40;PRAME&#41;&#46; Ki-67 immunostaining revealed a low proliferation index&#46; A complete sequencing study of exon 5 of <span class="elsevierStyleItalic">GNAQ</span> showed no alterations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Based on these clinical and histological data&#44; diagnosis of agminate blue nevus was established&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This infrequent presentation of blue nevus is of interest given the potential for clinical diagnostic confusion with melanoma metastasis&#46; Genetic alterations potentially shared with uveal melanoma&#44; nevus of Ota&#44; and nevus of Ito are of particular interest&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In blue nevus the most frequently described genetic mutation&#44; which is found in up to 83&#37; of cases and considered a driver mutation&#44; is a somatic mutation in <span class="elsevierStyleItalic">GNAQ</span> and <span class="elsevierStyleItalic">GNA11</span> &#40;which encode the alpha subunits of heterotrimeric G proteins involved in G-protein-coupled receptor-mediated signaling&#41;&#46; This mutation causes the affected genes to act as oncogenes&#44; as it results in constitutive activation of these proteins and continuous activation of the Ras signaling pathway&#44; which is involved in regulation of the cell cycle and proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Consequently&#44; in blue nevi with this mutation there is an increase in the activity of mitogen-activated protein kinase 1 &#40;ERK2&#41;&#44; which is activated by RAS&#47;RAF&#47;MAP kinase kinase &#40;MEK&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is only 1 published report of agminate blue nevus with a proven mutation&#44; located at c&#46;626A&#8239;&#62;&#8239;T &#40;p&#46;Glu209Leu&#41; in <span class="elsevierStyleItalic">GNAQ</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In some reported cases&#44; including ours&#44; in which no <span class="elsevierStyleItalic">GNAQ</span> mutation is detected&#44; activating mutations have been detected in cysteinyl leukotriene receptor 2 &#40;<span class="elsevierStyleItalic">CYSLTR2</span>&#41;&#44; which is involved in a signaling pathway analogous to that of <span class="elsevierStyleItalic">GNAQ</span> and ultimately activates the same intracellular processes&#46; This is yet another driver mutation&#44; mutually exclusive from <span class="elsevierStyleItalic">GNAQ</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Driver mutations affecting <span class="elsevierStyleItalic">GNAQ&#47;GNA11</span> and <span class="elsevierStyleItalic">CYSLTR2</span> can be accompanied by additional mutations in different cellular pathways that favor the progression and malignant transformation of the lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> The most widely known mutation is in the BRCA1-associated protein 1 gene &#40;<span class="elsevierStyleItalic">BAP1</span>&#41;&#46; <span class="elsevierStyleItalic">BAP1</span> acts as a tumor suppressor and is involved in DNA repair processes&#44; the ubiquitin-proteasome system&#44; regulation of transcription&#44; and chromatin modulation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Inactivation of this protein&#44; either by partial deletion of the <span class="elsevierStyleItalic">BAP1</span> locus on chromosome 3 or alteration in the phosphorylation or ubiquitination of its protein chain&#44; results in accelerated progression of cell proliferation that can trigger malignant transformation of blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore&#44; these alterations described for blue nevus and for blue-nevus-like melanoma closely resemble those found in other pathological processes such as uveal melanoma&#46; For example&#44; the <span class="elsevierStyleItalic">GNAQ</span> mutation has been described in 46&#37; of uveal melanomas&#44; where it also acts as a driver mutation and can be associated with other mutations affecting <span class="elsevierStyleItalic">BAP1</span> or other pathways involved in chromosomal instability&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Knowledge of genetic alterations and intracellular signaling pathways in these lesions is not only of diagnostic value&#44; but may also have therapeutic implications&#46; For example&#44; the use of MEK inhibitors&#44; with or without phosphatidyl-inositol 3 kinase &#40;PI3K&#41; or mammalian target of rapamycin &#40;mTOR&#41; inhibitors&#44; has been proposed for the treatment of uveal melanoma and could also prove useful for the treatment of blue nevi with progression to melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; PRAME immunostaining has been recently proposed as a diagnostically useful marker to distinguish between nevi and melanoma&#44; and is a biomarker of metastatic risk in uveal melanoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In our case&#44; the negative PRAME immunostaining is in line with the other histological findings that support a diagnosis of blue nevus in our patient&#46; To our knowledge&#44; this is the first report of PRAME staining of agminate blue nevus&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given the potential diagnostic and therapeutic implications of blue nevus with an atypical clinical presentation&#44; as in the present case of agminate blue nevus&#44; knowledge of the underlying genetics is important&#46; PRAME immunohistochemistry and genetic analyses can increase diagnostic specificity in cases of atypical melanocytic lesions&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dr&#46; Llamas has acted as a speaker and consultant for Janssen-Cilag&#44; AbbVie&#44; Celgene&#44; Pfizer&#44; Novartis&#44; Lilly&#44; Almirall&#44; and Leo-Pharma&#44; and has participated in clinical trials&#46; The remaining authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez-Jim&#233;nez P&#44; Mayor-Sanabria F&#44; R&#252;tten A&#44; Fraga J&#44; Llamas-Velasco M&#46; Nevus azul agminado&#44; mutaciones en <span class="elsevierStyleItalic">GNAQ</span> y m&#225;s all&#225;&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;95&#8211;97&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Panoramic image of the lesion in which 2 areas of blue nevus are evident &#40;arrows&#41;&#44; one of about 3&#8239;mm and the other of about 1&#8239;mm&#46; B&#44; Compact nests of spindle-shaped melanocytes located in the papillary and superficial reticular dermis without the presence of nests at the dermoepidermal junction &#40;hematoxylin-eosin &#91;HE&#93;&#44; original magnification &#215;4&#41;&#46; C&#44; Detail of melanin distribution&#44; with denser granules visible in the deepest part of the lesion &#40;HE&#44; original magnification &#215;10&#41;&#46; D&#44; Detail of melanocytes&#44; showing monomorphic nuclei and the absence of mitosis and necrosis &#40;HE&#44; original magnification &#215;20&#41;&#46;</p>"
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        "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">The authors thank the entire Friedrichshafen team for their unconditional support&#44; as well as Dr&#46; Gabriele Palmero&#44; Dr&#46; Maximiliano Arag&#252;es&#44; and Dr&#46; Javier Fraga&#46;</p>"
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