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The results were positive for Melan-A&#44; human melanoma black &#40;HMB&#41; 45&#44; and S-100&#46; No distant lesions were revealed in the extension study&#44; which included full-body positron emission tomography&#47;computed tomography and fundoscopy&#46; The patient underwent surgery in the ear&#44; nose&#44; and throat department&#46; During the procedure&#44; in addition to the tumor described above&#44; she was observed to have very extensive and vague jet-black pigmentation affecting both the wide lateral margins and the deep margins of the resection &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 1</a>&#41;&#46; The thyroid gland&#44; facial nerve&#44; adjacent cervical muscle fascia&#44; and several lymph nodes were totally pigmented&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histopathology of the surgical specimen revealed 2 very different areas&#46; The portion of the pre-existing peripheral plaque comprised bundles of spindle cells accompanied by abundant melanophages and sclerotic collagen arranged in thick fascicles occupying mainly the subcutaneous fat and&#44; to a lesser extent&#44; the dermis&#44; albeit sparing the dermal&#8211;epidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>B&#41;&#46; The nuclei of these cells were small&#44; with no atypia&#44; pleomorphism&#44; or mitosis &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>B&#44; inset&#41;&#46; The abundant melanin followed a uniform pattern throughout the tumor&#46; The whole lesion was considered to be plaque-type blue nevus&#46; The central portion of the large tumor contained more mixed areas&#44; with mostly dense sheets of epithelioid and pleomorphic cells replacing all the pre-existing structures &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#41;&#46; Large areas of coagulative necrosis in mass were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#44; lower inset&#41;&#44; as was a very irregularly distributed melanin pattern&#44; with areas comprising a high density of melanophages heavily laden with melanin that contrasted with the densely melanocytic areas that did not contain melanin &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#44; upper inset&#41;&#46; The results of immunohistochemistry with Melan-A&#44; HMB45&#44; and S-100 were positive&#46; The findings were interpreted as melanoma arising in plaque-type nevus&#46; Immunohistochemistry also revealed expression of <span class="elsevierStyleItalic">BAP1</span> in the nucleus of cells in the plaque-type blue nevus portion &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>D&#44; upper&#41; and loss of <span class="elsevierStyleItalic">BAP1</span> expression in the melanoma portion &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>D&#44; lower&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The molecular study included somatic analysis of 42 genes based on next-generation sequencing with the Somatic Tumor Genetics kit &#40;Sophia Genetics&#41; in a NextSeq sequencer &#40;Illumina&#41; &#40;analysis of the coding and splicing regions of the genes <span class="elsevierStyleItalic">AKT1&#44; ALK&#44; BRAF&#44;CDK4&#44; CDKN2A&#44; CTNNB1&#44; DDR2&#44; DICER1&#44; EGFR&#44; ERBB2&#44; ERBB4&#44; FBXW7&#44; FGFR1&#44; FGFR2&#44; FGFR3&#44; FOXL2&#44;GNA11&#44; GNAQ&#44; GNAS&#44; H3F3A&#44; H3F3B&#44; HIST1H3B&#44; HRAS&#44; IDH1&#44; IDH2&#44; KIT&#44; KRAS&#44; MAP2K1&#44; MET&#44; MYOD1&#44;NRAS&#44; PDGFRA&#44; PIK3CA&#44; PTPN11&#44; RAC1&#44; RAF1&#44; RET&#44; ROS1&#44; SF3B1&#44; SMAD4&#44; TERT</span>&#44; and its promoter&#44; <span class="elsevierStyleItalic">TP53</span>&#41;&#44; both of the blue nevus portion and of the melanoma portion&#44; with the only finding being that of the pathogenic mutation p&#46;Q209L in <span class="elsevierStyleItalic">GNAQ</span> in both portions&#46; Moreover&#44; CGH revealed the complete absence of chromosomal abnormalities in the plaque-type blue nevus portion but detected several abnormalities in the melanoma portion&#44; including gains of 1q&#44; Cr 2&#44; 5p&#44; 6p&#44; Cr 7 and 8 &#40;4n&#41;&#44; and Cr 13&#44; 14&#44; 17&#44; 19&#44; 20&#44; 21&#44; and 22&#44; as well as a loss of heterozygosity for 1p&#44; Cr 3&#44; and 5q and a loss of 6q and CrX&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Six months after surgery&#44; the patient experienced a locoregional recurrence&#44; with multiple reddish&#44; ulcerated nodules in the left cervical and auricular areas&#44; as well as metastasis to the lymph nodes in the neck&#44; mediastinum&#44; lungs&#44; and liver&#46; She went on to receive systemic treatment with ipilimumab and nivolumab&#46; After a 4-month follow-up&#44; the patient was still alive&#44; with progressive disease&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 53-year-old man was being followed up because of a bluish-gray pigmented plaque measuring 8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm in diameter on the left frontotemporal region that had first appeared many years previously &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 2&#44; Supplementary Material</a>&#41;&#46; The lesion had been biopsied on 2 occasions &#40;2002 and 2004&#41;&#44; leading to a diagnosis of blue nevus&#46; At the most recent visit&#44; a nodule could be felt inside the plaque&#46; Ultrasound showed the nodule to be in the subcutaneous cellular tissue&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Histology revealed the lesion to be part typical discrete dendritic blue nevus and part highly pigmented plaque-type blue nevus below the hypodermis &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 3&#44; Supplementary Material</a>&#41;&#46; A much more cellular expansive nodule with a lower amount of melanin than the adjacent plaque was embedded in the subcutaneous portion of the plaque-type blue nevus &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 4&#44; Supplementary Material</a>&#41;&#46; The cells of the nodular portion had nuclei with loose chromatin and evident nucleoli&#46; Despite the scarce atypia and pleomorphism in most fields&#44; focal areas with moderate atypia and some mitotic figures &#40;2&#47;mm<span class="elsevierStyleSup">2</span>&#41; were observed &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 5&#44; Supplementary Material</a>&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fluorescence in situ hybridization &#40;FISH&#41; of the regions coding for C-MYC&#44; CDKN2A&#44; and CCDN1 revealed no abnormalities in the superficial portion of the dendritic blue nevus or the in portion of the plaque-type blue nevus&#46; Amplification of the 8q region &#40;<span class="elsevierStyleItalic">C-MYC</span>&#41; was observed in the deep nodular portion&#46; In addition&#44; CGH of the lesion revealed chromosomal abnormalities &#40;loss of 6q and 8p and gain of 6p and 8q&#41;&#46; Nuclear expression of <span class="elsevierStyleItalic">BAP1</span> in immunohistochemistry was preserved both in the nodule and in the blue nevus portion&#46; The patient was diagnosed with melanoma in plaque-type blue nevus based on the presence of chromosomal abnormalities in the nodular portion&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patient 3</span><p id="par0055" class="elsevierStylePara elsevierViewall">The third patient was a 58-year-old woman with grayish-blue pigmentation &#40;onset at puberty&#41; that initially affected the right auricular and adjacent regions &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 6&#44; Supplementary Material</a>&#41; before extending progressively to the skin of the submandibular area and the ipsilateral buccal and palatal mucosa &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 7&#44; Supplementary Material</a>&#41;&#46; The ipsilateral sclera was completely white&#46; Over the course of a month&#44; the patient developed a preauricular nodule&#44; which was clinically considered an abscess&#44; although once removed&#44; it was diagnosed as melanoma in situ&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Histopathology of the fast-growing nodule revealed a fragmented and damaged specimen comprising epithelioid cell aggregates with no clear atypia or pleomorphism accompanied at the periphery by abundant melanophages &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 8&#44; Supplementary Material</a>&#41;&#46; Only a single mitotic figure was observed in the nodule&#46; Histology of the pre-existing grayish-blue patch showed scant spindle-cell melanocytes and melanophages scattered through the dermis &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 9&#44; Supplementary Material</a>&#41;&#46; Given the clinical context&#44; this finding was diagnosed as dermal melanocytosis in the form of nevus of Ota&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Somatic molecular testing using next-generation sequencing &#40;see Patient 1&#41; revealed the pathogenic mutation p&#46;Q209P in <span class="elsevierStyleItalic">GNAQ</span>&#44; both in the nodule and in the dermal melanocytosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Immunohistochemistry for <span class="elsevierStyleItalic">BAP1</span> revealed preserved nuclear expression in the nodule that arose in the nevus of Ota &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 8&#44; Supplementary Material</a>&#46; Immunohistochemistry&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The extension study did not reveal distant lesions&#59; therefore&#44; treatment was limited to surgery&#46; The result of the sentinel node biopsy was negative&#44; and the patient has remained recurrence-free during 9 months of follow-up&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patient was eventually diagnosed with cellular blue nevus in dermal melanocytosis&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Plaque-type blue nevus is a generally cellular form of blue nevus that usually develops during early childhood&#46; It is large&#44; measuring 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm and sometimes reaching 10<span class="elsevierStyleHsp" style=""></span>cm or more&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4&#44;5</span></a> It manifests as a speckled plaque&#44; as in patient 2&#44; formed by a confluent cluster of blue nevi&#44; or as a uniformly bluish plaque&#46; The histologic diagnosis must correlate with the clinical diagnosis&#44; since the lesion has no specific histologic characteristics&#46; The proliferation is usually deep and may even reach the fascia&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Plaque-type blue nevus&#44; other dermal melanocytoses&#44; and neurocristic hamartoma share various characteristics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Neurocristic hamartoma results from an abnormal migration of melanocytes from the neural crest to the epidermis&#44; as in blue nevus&#44; although unlike this condition&#44; it is accompanied by a mesenchymal component and&#44; more particularly&#44; a neural component &#40;Schwann cells&#41;&#46; However&#44; the distinction is not clear&#44; and there have been reports of cases described as neurocristic hamartoma that many dermatologists would diagnose as blue nevus&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#44;8</span></a> Plaque-type blue nevus could probably be considered simply as a neurocristic hamartoma with only a melanocytic component&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In clinical practice&#44; the appearance of a cutaneous melanoma on these lesions has mainly been reported in blue nevus and&#44; albeit much less frequently&#44; in nevus of Ota&#44; nevus of Ito&#44; and neurocristic hamartoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The term melanoma arising on blue nevus&#44; melanoma ex blue nevus&#44; or blue nevus-like melanoma includes both melanomas that develop on a pre-existing blue nevus &#40;or a dermal melanocytosis&#41; and melanomas that develop on the scar of a previously resected blue nevus&#44; melanomas with histologic characteristics similar to those of a blue nevus&#44; and melanomas with a blue nevus component&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> Ex blue nevus melanoma is a rare tumor&#44; with fewer than 200 cases reported to date&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#44;13</span></a> although some reports of neurocristic hamartoma with metastasis could be considered melanoma ex blue nevus&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> and fatal melanomas arising on plaque-type blue nevus have been published as &#8220;nodules in plaque-type blue nevus&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> The most common locations for melanoma ex blue nevus are the head and neck&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> although the lesion has also been reported on the buttocks and trunk&#46; The most common age at onset is 45&#8211;55 years&#44; and the most frequent clinical manifestation is as a large&#44; rapidly growing nodule on a previous blue nevus&#44; most frequently a cellular blue nevus&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The classic histopathology criteria for malignancy in melanocytic tumors cannot always be applied in melanoma arising on blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> The asymmetrical or mainly deep silhouette&#44; the absence of maturation&#44; and the expansive growth pattern&#44; as well as the uniform expression of human melanoma black 45 are common features of blue nevus&#46; Criteria that do prove useful for the diagnosis of melanoma include the presence of necrosis&#44; marked pleomorphism&#44; atypia&#44; and a high mitotic index&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> In doubtful cases&#44; the loss of <span class="elsevierStyleItalic">BAP1</span> expression and the demonstration of chromosomal abnormalities using FISH or CGH &#40;gains and losses in chromosomes 6 and 8 and losses in chromosomes 1 and 3&#41; are indicative of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#8211;3</span></a> Furthermore&#44; unlike other cutaneous melanomas&#44; they have a low number of mutations&#44; and the most common driver mutations in melanoma arising on blue nevus are those found in <span class="elsevierStyleItalic">GNAQ</span> or <span class="elsevierStyleItalic">GNA11</span> &#40;which are common in blue nevi&#41; and&#44; albeit much less frequently&#44; mutations in <span class="elsevierStyleItalic">CYSLTR2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">13&#44;16&#8211;18</span></a> All these features lead us to consider the tumor more as uveal melanoma than as cutaneous melanoma&#46; Furthermore&#44; driver mutations appear at onset of the lesion&#44; similar to mutations in <span class="elsevierStyleItalic">BRAF</span> or <span class="elsevierStyleItalic">NRAS</span> in conventional cutaneous melanoma&#46; These are mutually exclusive mutations that are usually acquired somatically&#44; although in early phases of embryonic development&#46; Mutations in <span class="elsevierStyleItalic">GNAQ</span>&#47;<span class="elsevierStyleItalic">GNA11</span> serve somehow as &#8220;type markers&#8221; on the blue nevus&#47;melanoma ex blue nevus spectrum&#46; In fact&#44; the presence of mutations in <span class="elsevierStyleItalic">BRAF</span> or <span class="elsevierStyleItalic">NRAS</span> makes it difficult to maintain a diagnosis of blue nevus or melanoma ex blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> Pathogenic mutations in <span class="elsevierStyleItalic">GNAQ</span> or <span class="elsevierStyleItalic">GNA11</span> lead to constitutive activation of the RAS signaling pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> Their presence is essential for the development of blue nevus&#44; although it is insufficient for causing malignancy&#46; Abnormalities have been described in other genes&#46; These are acquired later in the natural history of melanoma arising on blue nevus and are in fact associated with malignancy and even with a poorer prognosis&#44; for example&#44; loss of <span class="elsevierStyleItalic">BAP1</span> expression&#44; either by mutation or by partial or total loss of the region that encodes it &#40;3p21&#41;&#46; As mentioned above&#44; this loss of <span class="elsevierStyleItalic">BAP1</span> expression within the spectrum of blue nevus-like lesions has both diagnostic and prognostic implications&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;16&#8211;18</span></a> The absence of expression in the nuclei of a blue nevus-like tumor almost enables us to make a diagnosis of melanoma&#44; even in cases with scarce atypia and no mitosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; blue nevus-like melanoma with loss of <span class="elsevierStyleItalic">BAP1</span> expression metastasizes more than those that do not lose expression of <span class="elsevierStyleItalic">BAP1</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;16</span></a> This has also been demonstrated in uveal melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> Other&#44; later-onset mutations that are characteristic of melanoma arising on blue nevus &#40;and of uveal melanoma&#41; but that are not present in blue nevus include those in <span class="elsevierStyleItalic">EIF1AX</span> and <span class="elsevierStyleItalic">SF3B1</span>&#46; The prognostic significance of these mutations is less well established&#46; Data from a recent series show that 3 of the 5 patients with melanoma ex blue nevus and the <span class="elsevierStyleItalic">SF3B1</span> mutation died from metastasis of the melanoma&#46; The authors found this surprising&#44; because this mutation was associated with a better prognosis in uveal melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In this study&#44; we report 3 new cases illustrating the spectrum of blue nevus&#47;melanoma ex blue nevus&#46; Case number 1 clearly involves melanoma&#46; It was characterized clinically by early recurrence and visceral metastasis&#44; histology revealed the presence of large areas of necrosis and marked atypia and pleomorphism&#44; and molecular testing showed loss of <span class="elsevierStyleItalic">BAP1</span> expression and the presence of multiple chromosomal abnormalities&#46; Furthermore&#44; the poor response to immunotherapy parallels findings for uveal melanoma&#44; possibly owing to the low mutational burden&#44; which considerably limits treatment options&#46; Patient 2 was diagnosed with melanoma arising on plaque-type blue nevus owing to the presence of chromosomal abnormalities&#44; although the <span class="elsevierStyleItalic">BAP1</span> expression and much less clear histology findings in Patient 1 could be interpreted as atypical blue nevus&#46; The progress of this case to date has not involved recurrence or metastasis&#46; Lastly&#44; the third case was interpreted as cellular blue nevus in dermal melanocytosis owing to the absence of pleomorphism and necrosis&#44; the finding of a single mitotic figure in all the samples studied&#44; and maintained expression of <span class="elsevierStyleItalic">BAP1</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Dermal melanocytosis"
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            0 => "Melanoma sobre sobre nevus azul"
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            2 => "Melanocitosis d&#233;rmicas"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Melanoma arising in blue nevus&#44; also known as melanoma ex blue nevus&#44; is a specific form of melanoma whose genetic profile is different to that of other cutaneous melanomas and surprisingly similar to that of uveal melanoma&#46; Although melanoma ex blue nevus can appear de novo&#44; it usually arises in a pre-existing blue nevus or dermal melanocytosis&#46; Not all nodular lesions arising in association with blue nevus or dermal melanocytosis are melanomas&#44; however&#44; and because clinical and histologic findings may be insufficient for a definitive diagnosis&#44; additional studies such as comparative genomic hybridization are important&#46; Detection of chromosomal aberrations supports a diagnosis of malignancy&#46; Studies of the <span class="elsevierStyleItalic">BAP1</span> gene are particularly useful in this setting because loss of expression is indicative of melanoma&#46; We present 3 cases on the spectrum of blue nevus to melanoma ex blue nevus that were studied using molecular biology techniques&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El melanoma sobre nevus azul o melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> es una variedad de melanoma peculiar que tiene un perfil gen&#233;tico diferente al del resto de los melanomas cut&#225;neos y sorprendentemente superponible al perfil del melanoma uveal&#46; Aunque puede aparecer <span class="elsevierStyleItalic">de novo</span>&#44; el melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> se suele desarrollar sobre un nevus azul previo o sobre una melanocitosis d&#233;rmica&#46; No todas las lesiones nodulares desarrolladas sobre un nevus azul o una melanocitosis d&#233;rmica son melanomas&#44; y los hallazgos cl&#237;nicos e histol&#243;gicos pueden ser insuficientes para llegar a un diagn&#243;stico de certeza&#46; As&#237;&#44; cobran relevancia estudios adicionales&#44; como la hibridaci&#243;n gen&#243;mica comparada&#44; pues la presencia de aberraciones cromos&#243;micas favorece el diagn&#243;stico de malignidad&#46; Es de especial utilidad el estudio del gen <span class="elsevierStyleItalic">BAP1</span>&#44; cuya p&#233;rdida de expresi&#243;n orienta a melanoma en este espectro de lesiones&#46; Presentamos tres casos del espectro nevus azul a melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> con estudios de biolog&#237;a molecular&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#44; Large mass on the skin of the mastoid area on a blue plaque situated on the skin of the left pinna&#44; preauricular region&#44; and side of the neck&#46; B&#44; Plaque-type blue nevus&#46; Panoramic view with inset showing detail&#58; bundles of spindle cells&#44; abundant melanophages&#44; and sclerotic collagen occupying the subcutaneous fat and&#44; to a lesser extent&#44; the dermis&#44; albeit without involvement of the dermal&#8211;epidermal junction&#46; C&#44; Central area of the tumor&#58; note the predominance of dense sheets of epithelioid and pleomorphic cells replacing the pre-existing structures&#46; The lower half of the inset shows areas of mass coagulative necrosis&#46; The upper half of the inset shows densely melanocytic areas with no melanin content&#46; D&#44; Upper panel&#46; Nuclear expression of <span class="elsevierStyleItalic">BAP1</span> &#40;in red&#41; preserved in the plaque-type blue nevus portion&#46; Lower panel&#46; Loss of <span class="elsevierStyleItalic">BAP1</span> expression in the nuclei of the melanoma portion&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>&#58; TGM&#44; trigeminal nerve&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nevus of Ota&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nevus of Ito&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mongolian spot&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Plaque-type blue nevus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Neurocristic hamartoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">First and second branches of the TGM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shoulder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lumbosacral<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Head<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Scalp<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sclerotic collagen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cell density&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neural component&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Degeneration to melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mutations in <span class="elsevierStyleItalic">GNAQ</span>&#47;<span class="elsevierStyleItalic">GNA11</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Dermal Melanocytoses&#44; Plaque-Type Blue Nevus&#44; and Neurocristic Hamartoma&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0100"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Melanomas associated with blue nevi or mimicking cellular blue nevi&#58; clinical&#44; pathologic&#44; and molecular study of 11 cases displaying a high frequency of GNA11 mutations&#44; BAP1 expression loss&#44; and a predilection for the scalp"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Costa"
                            1 => "M&#46; Byrne"
                            2 => "D&#46; Pissaloux"
                            3 => "V&#46; Haddad"
                            4 => "S&#46; Paindavoine"
                            5 => "L&#46; Thomas"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PAS.0000000000000568"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Surg Pathol"
                        "fecha" => "2016"
                        "volumen" => "40"
                        "paginaInicial" => "368"
                        "paginaFinal" => "377"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26645730"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
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              "identificador" => "bib0105"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Molecular analysis of a case of nevus of Ota showing progressive evolution to melanoma with intermediate stages resembling cellular blue nevus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Brief Communication
Melanoma Arising in Plaque-Type Blue Nevus and Dermal Melanocytosis: Diagnostic and Prognostic Value of BAP1
Melanoma sobre nevus azul en placa o sobre melanocitosis dérmicas: utilidad diagnóstica y pronóstica del BAP1
C. Requenaa,
Autor para correspondencia
celiareq@hotmail.com

Corresponding author.
, V. Travesb, E. Ferrandisc, M. Antón Almeroc, Z. García-Casadod, E. Manrique-Silvaa, Á. Santos Brize, P. Escalonillaf, E. Nagorea
a Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, Spain
b Servicio de Anatomía Patológica, Instituto Valenciano de Oncología, Valencia, Spain
c Servicio de Otorrinolaringología, Instituto Valenciano de Oncología, Valencia, Spain
d Servicio de Biología Molecular, Instituto Valenciano de Oncología, Valencia, Spain
e Servicio de Anatomía Patológica, Hospital Universitario Salamanca, Salamanca, Spain
f Servicio de Dermatología, Hospital Nuestra Señora de Sonsoles, Ávila, Spain
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ranging from benign cellular blue nevus to clinically evident melanoma and including a mixed case lying between atypical blue nevus and melanoma ex blue nevus&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Presentations</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 49-year-old woman was assessed for a large&#44; firm subcutaneous mass measuring some 12<span class="elsevierStyleHsp" style=""></span>cm in diameter in the parotid area&#46; The lesion was located on the lower portion of a grayish-blue plaque that had been present since birth and affected the left pinna&#44; as well as the adjacent side of the neck and preauricular skin &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>A&#41;&#46; The plaque had never been biopsied and was clinically labeled as a &#8220;vascular malformation&#8221;&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The nodule was diagnosed as spindle-cell melanoma based on a cytology study of a sample obtained via fine-needle aspiration&#46; The results were positive for Melan-A&#44; human melanoma black &#40;HMB&#41; 45&#44; and S-100&#46; No distant lesions were revealed in the extension study&#44; which included full-body positron emission tomography&#47;computed tomography and fundoscopy&#46; The patient underwent surgery in the ear&#44; nose&#44; and throat department&#46; During the procedure&#44; in addition to the tumor described above&#44; she was observed to have very extensive and vague jet-black pigmentation affecting both the wide lateral margins and the deep margins of the resection &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 1</a>&#41;&#46; The thyroid gland&#44; facial nerve&#44; adjacent cervical muscle fascia&#44; and several lymph nodes were totally pigmented&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histopathology of the surgical specimen revealed 2 very different areas&#46; The portion of the pre-existing peripheral plaque comprised bundles of spindle cells accompanied by abundant melanophages and sclerotic collagen arranged in thick fascicles occupying mainly the subcutaneous fat and&#44; to a lesser extent&#44; the dermis&#44; albeit sparing the dermal&#8211;epidermal junction &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>B&#41;&#46; The nuclei of these cells were small&#44; with no atypia&#44; pleomorphism&#44; or mitosis &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>B&#44; inset&#41;&#46; The abundant melanin followed a uniform pattern throughout the tumor&#46; The whole lesion was considered to be plaque-type blue nevus&#46; The central portion of the large tumor contained more mixed areas&#44; with mostly dense sheets of epithelioid and pleomorphic cells replacing all the pre-existing structures &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#41;&#46; Large areas of coagulative necrosis in mass were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#44; lower inset&#41;&#44; as was a very irregularly distributed melanin pattern&#44; with areas comprising a high density of melanophages heavily laden with melanin that contrasted with the densely melanocytic areas that did not contain melanin &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>C&#44; upper inset&#41;&#46; The results of immunohistochemistry with Melan-A&#44; HMB45&#44; and S-100 were positive&#46; The findings were interpreted as melanoma arising in plaque-type nevus&#46; Immunohistochemistry also revealed expression of <span class="elsevierStyleItalic">BAP1</span> in the nucleus of cells in the plaque-type blue nevus portion &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>D&#44; upper&#41; and loss of <span class="elsevierStyleItalic">BAP1</span> expression in the melanoma portion &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 1</a>D&#44; lower&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The molecular study included somatic analysis of 42 genes based on next-generation sequencing with the Somatic Tumor Genetics kit &#40;Sophia Genetics&#41; in a NextSeq sequencer &#40;Illumina&#41; &#40;analysis of the coding and splicing regions of the genes <span class="elsevierStyleItalic">AKT1&#44; ALK&#44; BRAF&#44;CDK4&#44; CDKN2A&#44; CTNNB1&#44; DDR2&#44; DICER1&#44; EGFR&#44; ERBB2&#44; ERBB4&#44; FBXW7&#44; FGFR1&#44; FGFR2&#44; FGFR3&#44; FOXL2&#44;GNA11&#44; GNAQ&#44; GNAS&#44; H3F3A&#44; H3F3B&#44; HIST1H3B&#44; HRAS&#44; IDH1&#44; IDH2&#44; KIT&#44; KRAS&#44; MAP2K1&#44; MET&#44; MYOD1&#44;NRAS&#44; PDGFRA&#44; PIK3CA&#44; PTPN11&#44; RAC1&#44; RAF1&#44; RET&#44; ROS1&#44; SF3B1&#44; SMAD4&#44; TERT</span>&#44; and its promoter&#44; <span class="elsevierStyleItalic">TP53</span>&#41;&#44; both of the blue nevus portion and of the melanoma portion&#44; with the only finding being that of the pathogenic mutation p&#46;Q209L in <span class="elsevierStyleItalic">GNAQ</span> in both portions&#46; Moreover&#44; CGH revealed the complete absence of chromosomal abnormalities in the plaque-type blue nevus portion but detected several abnormalities in the melanoma portion&#44; including gains of 1q&#44; Cr 2&#44; 5p&#44; 6p&#44; Cr 7 and 8 &#40;4n&#41;&#44; and Cr 13&#44; 14&#44; 17&#44; 19&#44; 20&#44; 21&#44; and 22&#44; as well as a loss of heterozygosity for 1p&#44; Cr 3&#44; and 5q and a loss of 6q and CrX&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Six months after surgery&#44; the patient experienced a locoregional recurrence&#44; with multiple reddish&#44; ulcerated nodules in the left cervical and auricular areas&#44; as well as metastasis to the lymph nodes in the neck&#44; mediastinum&#44; lungs&#44; and liver&#46; She went on to receive systemic treatment with ipilimumab and nivolumab&#46; After a 4-month follow-up&#44; the patient was still alive&#44; with progressive disease&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0040" class="elsevierStylePara elsevierViewall">A 53-year-old man was being followed up because of a bluish-gray pigmented plaque measuring 8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm in diameter on the left frontotemporal region that had first appeared many years previously &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 2&#44; Supplementary Material</a>&#41;&#46; The lesion had been biopsied on 2 occasions &#40;2002 and 2004&#41;&#44; leading to a diagnosis of blue nevus&#46; At the most recent visit&#44; a nodule could be felt inside the plaque&#46; Ultrasound showed the nodule to be in the subcutaneous cellular tissue&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Histology revealed the lesion to be part typical discrete dendritic blue nevus and part highly pigmented plaque-type blue nevus below the hypodermis &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 3&#44; Supplementary Material</a>&#41;&#46; A much more cellular expansive nodule with a lower amount of melanin than the adjacent plaque was embedded in the subcutaneous portion of the plaque-type blue nevus &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 4&#44; Supplementary Material</a>&#41;&#46; The cells of the nodular portion had nuclei with loose chromatin and evident nucleoli&#46; Despite the scarce atypia and pleomorphism in most fields&#44; focal areas with moderate atypia and some mitotic figures &#40;2&#47;mm<span class="elsevierStyleSup">2</span>&#41; were observed &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 5&#44; Supplementary Material</a>&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Fluorescence in situ hybridization &#40;FISH&#41; of the regions coding for C-MYC&#44; CDKN2A&#44; and CCDN1 revealed no abnormalities in the superficial portion of the dendritic blue nevus or the in portion of the plaque-type blue nevus&#46; Amplification of the 8q region &#40;<span class="elsevierStyleItalic">C-MYC</span>&#41; was observed in the deep nodular portion&#46; In addition&#44; CGH of the lesion revealed chromosomal abnormalities &#40;loss of 6q and 8p and gain of 6p and 8q&#41;&#46; Nuclear expression of <span class="elsevierStyleItalic">BAP1</span> in immunohistochemistry was preserved both in the nodule and in the blue nevus portion&#46; The patient was diagnosed with melanoma in plaque-type blue nevus based on the presence of chromosomal abnormalities in the nodular portion&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patient 3</span><p id="par0055" class="elsevierStylePara elsevierViewall">The third patient was a 58-year-old woman with grayish-blue pigmentation &#40;onset at puberty&#41; that initially affected the right auricular and adjacent regions &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 6&#44; Supplementary Material</a>&#41; before extending progressively to the skin of the submandibular area and the ipsilateral buccal and palatal mucosa &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 7&#44; Supplementary Material</a>&#41;&#46; The ipsilateral sclera was completely white&#46; Over the course of a month&#44; the patient developed a preauricular nodule&#44; which was clinically considered an abscess&#44; although once removed&#44; it was diagnosed as melanoma in situ&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Histopathology of the fast-growing nodule revealed a fragmented and damaged specimen comprising epithelioid cell aggregates with no clear atypia or pleomorphism accompanied at the periphery by abundant melanophages &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 8&#44; Supplementary Material</a>&#41;&#46; Only a single mitotic figure was observed in the nodule&#46; Histology of the pre-existing grayish-blue patch showed scant spindle-cell melanocytes and melanophages scattered through the dermis &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 9&#44; Supplementary Material</a>&#41;&#46; Given the clinical context&#44; this finding was diagnosed as dermal melanocytosis in the form of nevus of Ota&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Somatic molecular testing using next-generation sequencing &#40;see Patient 1&#41; revealed the pathogenic mutation p&#46;Q209P in <span class="elsevierStyleItalic">GNAQ</span>&#44; both in the nodule and in the dermal melanocytosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Immunohistochemistry for <span class="elsevierStyleItalic">BAP1</span> revealed preserved nuclear expression in the nodule that arose in the nevus of Ota &#40;<a class="elsevierStyleCrossRef" href="#sec0035">Fig&#46; 8&#44; Supplementary Material</a>&#46; Immunohistochemistry&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The extension study did not reveal distant lesions&#59; therefore&#44; treatment was limited to surgery&#46; The result of the sentinel node biopsy was negative&#44; and the patient has remained recurrence-free during 9 months of follow-up&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patient was eventually diagnosed with cellular blue nevus in dermal melanocytosis&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Plaque-type blue nevus is a generally cellular form of blue nevus that usually develops during early childhood&#46; It is large&#44; measuring 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm and sometimes reaching 10<span class="elsevierStyleHsp" style=""></span>cm or more&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">4&#44;5</span></a> It manifests as a speckled plaque&#44; as in patient 2&#44; formed by a confluent cluster of blue nevi&#44; or as a uniformly bluish plaque&#46; The histologic diagnosis must correlate with the clinical diagnosis&#44; since the lesion has no specific histologic characteristics&#46; The proliferation is usually deep and may even reach the fascia&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Plaque-type blue nevus&#44; other dermal melanocytoses&#44; and neurocristic hamartoma share various characteristics &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Neurocristic hamartoma results from an abnormal migration of melanocytes from the neural crest to the epidermis&#44; as in blue nevus&#44; although unlike this condition&#44; it is accompanied by a mesenchymal component and&#44; more particularly&#44; a neural component &#40;Schwann cells&#41;&#46; However&#44; the distinction is not clear&#44; and there have been reports of cases described as neurocristic hamartoma that many dermatologists would diagnose as blue nevus&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">7&#44;8</span></a> Plaque-type blue nevus could probably be considered simply as a neurocristic hamartoma with only a melanocytic component&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In clinical practice&#44; the appearance of a cutaneous melanoma on these lesions has mainly been reported in blue nevus and&#44; albeit much less frequently&#44; in nevus of Ota&#44; nevus of Ito&#44; and neurocristic hamartoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The term melanoma arising on blue nevus&#44; melanoma ex blue nevus&#44; or blue nevus-like melanoma includes both melanomas that develop on a pre-existing blue nevus &#40;or a dermal melanocytosis&#41; and melanomas that develop on the scar of a previously resected blue nevus&#44; melanomas with histologic characteristics similar to those of a blue nevus&#44; and melanomas with a blue nevus component&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> Ex blue nevus melanoma is a rare tumor&#44; with fewer than 200 cases reported to date&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">12&#44;13</span></a> although some reports of neurocristic hamartoma with metastasis could be considered melanoma ex blue nevus&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> and fatal melanomas arising on plaque-type blue nevus have been published as &#8220;nodules in plaque-type blue nevus&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> The most common locations for melanoma ex blue nevus are the head and neck&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> although the lesion has also been reported on the buttocks and trunk&#46; The most common age at onset is 45&#8211;55 years&#44; and the most frequent clinical manifestation is as a large&#44; rapidly growing nodule on a previous blue nevus&#44; most frequently a cellular blue nevus&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The classic histopathology criteria for malignancy in melanocytic tumors cannot always be applied in melanoma arising on blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> The asymmetrical or mainly deep silhouette&#44; the absence of maturation&#44; and the expansive growth pattern&#44; as well as the uniform expression of human melanoma black 45 are common features of blue nevus&#46; Criteria that do prove useful for the diagnosis of melanoma include the presence of necrosis&#44; marked pleomorphism&#44; atypia&#44; and a high mitotic index&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> In doubtful cases&#44; the loss of <span class="elsevierStyleItalic">BAP1</span> expression and the demonstration of chromosomal abnormalities using FISH or CGH &#40;gains and losses in chromosomes 6 and 8 and losses in chromosomes 1 and 3&#41; are indicative of malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#8211;3</span></a> Furthermore&#44; unlike other cutaneous melanomas&#44; they have a low number of mutations&#44; and the most common driver mutations in melanoma arising on blue nevus are those found in <span class="elsevierStyleItalic">GNAQ</span> or <span class="elsevierStyleItalic">GNA11</span> &#40;which are common in blue nevi&#41; and&#44; albeit much less frequently&#44; mutations in <span class="elsevierStyleItalic">CYSLTR2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">13&#44;16&#8211;18</span></a> All these features lead us to consider the tumor more as uveal melanoma than as cutaneous melanoma&#46; Furthermore&#44; driver mutations appear at onset of the lesion&#44; similar to mutations in <span class="elsevierStyleItalic">BRAF</span> or <span class="elsevierStyleItalic">NRAS</span> in conventional cutaneous melanoma&#46; These are mutually exclusive mutations that are usually acquired somatically&#44; although in early phases of embryonic development&#46; Mutations in <span class="elsevierStyleItalic">GNAQ</span>&#47;<span class="elsevierStyleItalic">GNA11</span> serve somehow as &#8220;type markers&#8221; on the blue nevus&#47;melanoma ex blue nevus spectrum&#46; In fact&#44; the presence of mutations in <span class="elsevierStyleItalic">BRAF</span> or <span class="elsevierStyleItalic">NRAS</span> makes it difficult to maintain a diagnosis of blue nevus or melanoma ex blue nevus&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> Pathogenic mutations in <span class="elsevierStyleItalic">GNAQ</span> or <span class="elsevierStyleItalic">GNA11</span> lead to constitutive activation of the RAS signaling pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> Their presence is essential for the development of blue nevus&#44; although it is insufficient for causing malignancy&#46; Abnormalities have been described in other genes&#46; These are acquired later in the natural history of melanoma arising on blue nevus and are in fact associated with malignancy and even with a poorer prognosis&#44; for example&#44; loss of <span class="elsevierStyleItalic">BAP1</span> expression&#44; either by mutation or by partial or total loss of the region that encodes it &#40;3p21&#41;&#46; As mentioned above&#44; this loss of <span class="elsevierStyleItalic">BAP1</span> expression within the spectrum of blue nevus-like lesions has both diagnostic and prognostic implications&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;16&#8211;18</span></a> The absence of expression in the nuclei of a blue nevus-like tumor almost enables us to make a diagnosis of melanoma&#44; even in cases with scarce atypia and no mitosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; blue nevus-like melanoma with loss of <span class="elsevierStyleItalic">BAP1</span> expression metastasizes more than those that do not lose expression of <span class="elsevierStyleItalic">BAP1</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1&#44;16</span></a> This has also been demonstrated in uveal melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> Other&#44; later-onset mutations that are characteristic of melanoma arising on blue nevus &#40;and of uveal melanoma&#41; but that are not present in blue nevus include those in <span class="elsevierStyleItalic">EIF1AX</span> and <span class="elsevierStyleItalic">SF3B1</span>&#46; The prognostic significance of these mutations is less well established&#46; Data from a recent series show that 3 of the 5 patients with melanoma ex blue nevus and the <span class="elsevierStyleItalic">SF3B1</span> mutation died from metastasis of the melanoma&#46; The authors found this surprising&#44; because this mutation was associated with a better prognosis in uveal melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In this study&#44; we report 3 new cases illustrating the spectrum of blue nevus&#47;melanoma ex blue nevus&#46; Case number 1 clearly involves melanoma&#46; It was characterized clinically by early recurrence and visceral metastasis&#44; histology revealed the presence of large areas of necrosis and marked atypia and pleomorphism&#44; and molecular testing showed loss of <span class="elsevierStyleItalic">BAP1</span> expression and the presence of multiple chromosomal abnormalities&#46; Furthermore&#44; the poor response to immunotherapy parallels findings for uveal melanoma&#44; possibly owing to the low mutational burden&#44; which considerably limits treatment options&#46; Patient 2 was diagnosed with melanoma arising on plaque-type blue nevus owing to the presence of chromosomal abnormalities&#44; although the <span class="elsevierStyleItalic">BAP1</span> expression and much less clear histology findings in Patient 1 could be interpreted as atypical blue nevus&#46; The progress of this case to date has not involved recurrence or metastasis&#46; Lastly&#44; the third case was interpreted as cellular blue nevus in dermal melanocytosis owing to the absence of pleomorphism and necrosis&#44; the finding of a single mitotic figure in all the samples studied&#44; and maintained expression of <span class="elsevierStyleItalic">BAP1</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Melanoma in blue nevus"
            1 => "Plaque-type blue nevus"
            2 => "Dermal melanocytosis"
            3 => "<span class="elsevierStyleItalic">BAP1</span>"
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            0 => "Melanoma sobre sobre nevus azul"
            1 => "Nevus azul en placa"
            2 => "Melanocitosis d&#233;rmicas"
            3 => "<span class="elsevierStyleItalic">BAP1</span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Melanoma arising in blue nevus&#44; also known as melanoma ex blue nevus&#44; is a specific form of melanoma whose genetic profile is different to that of other cutaneous melanomas and surprisingly similar to that of uveal melanoma&#46; Although melanoma ex blue nevus can appear de novo&#44; it usually arises in a pre-existing blue nevus or dermal melanocytosis&#46; Not all nodular lesions arising in association with blue nevus or dermal melanocytosis are melanomas&#44; however&#44; and because clinical and histologic findings may be insufficient for a definitive diagnosis&#44; additional studies such as comparative genomic hybridization are important&#46; Detection of chromosomal aberrations supports a diagnosis of malignancy&#46; Studies of the <span class="elsevierStyleItalic">BAP1</span> gene are particularly useful in this setting because loss of expression is indicative of melanoma&#46; We present 3 cases on the spectrum of blue nevus to melanoma ex blue nevus that were studied using molecular biology techniques&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El melanoma sobre nevus azul o melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> es una variedad de melanoma peculiar que tiene un perfil gen&#233;tico diferente al del resto de los melanomas cut&#225;neos y sorprendentemente superponible al perfil del melanoma uveal&#46; Aunque puede aparecer <span class="elsevierStyleItalic">de novo</span>&#44; el melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> se suele desarrollar sobre un nevus azul previo o sobre una melanocitosis d&#233;rmica&#46; No todas las lesiones nodulares desarrolladas sobre un nevus azul o una melanocitosis d&#233;rmica son melanomas&#44; y los hallazgos cl&#237;nicos e histol&#243;gicos pueden ser insuficientes para llegar a un diagn&#243;stico de certeza&#46; As&#237;&#44; cobran relevancia estudios adicionales&#44; como la hibridaci&#243;n gen&#243;mica comparada&#44; pues la presencia de aberraciones cromos&#243;micas favorece el diagn&#243;stico de malignidad&#46; Es de especial utilidad el estudio del gen <span class="elsevierStyleItalic">BAP1</span>&#44; cuya p&#233;rdida de expresi&#243;n orienta a melanoma en este espectro de lesiones&#46; Presentamos tres casos del espectro nevus azul a melanoma <span class="elsevierStyleItalic">ex-blue nevus</span> con estudios de biolog&#237;a molecular&#46;</p></span>"
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0125" class="elsevierStylePara elsevierViewall">Supplementary material can be consulted online at <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.ad.2023.06.008">doi&#58;10&#46;1016&#47;j&#46;ad&#46;2023&#46;06&#46;008</span>&#46;<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix"
            "titulo" => "Supplementary Material"
            "identificador" => "sec0035"
          ]
        ]
      ]
    ]
    "multimedia" => array:12 [
      0 => array:7 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#44; Large mass on the skin of the mastoid area on a blue plaque situated on the skin of the left pinna&#44; preauricular region&#44; and side of the neck&#46; B&#44; Plaque-type blue nevus&#46; Panoramic view with inset showing detail&#58; bundles of spindle cells&#44; abundant melanophages&#44; and sclerotic collagen occupying the subcutaneous fat and&#44; to a lesser extent&#44; the dermis&#44; albeit without involvement of the dermal&#8211;epidermal junction&#46; C&#44; Central area of the tumor&#58; note the predominance of dense sheets of epithelioid and pleomorphic cells replacing the pre-existing structures&#46; The lower half of the inset shows areas of mass coagulative necrosis&#46; The upper half of the inset shows densely melanocytic areas with no melanin content&#46; D&#44; Upper panel&#46; Nuclear expression of <span class="elsevierStyleItalic">BAP1</span> &#40;in red&#41; preserved in the plaque-type blue nevus portion&#46; Lower panel&#46; Loss of <span class="elsevierStyleItalic">BAP1</span> expression in the nuclei of the melanoma portion&#46;</p>"
        ]
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      1 => array:8 [
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          0 => array:3 [
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>&#58; TGM&#44; trigeminal nerve&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nevus of Ota&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nevus of Ito&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mongolian spot&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Plaque-type blue nevus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Neurocristic hamartoma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Location&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">First and second branches of the TGM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shoulder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lumbosacral<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Head<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scalp<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sclerotic collagen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cell density&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neural component&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Degeneration to melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mutations in <span class="elsevierStyleItalic">GNAQ</span>&#47;<span class="elsevierStyleItalic">GNA11</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;&#47;&#8722;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  """
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Melanomas associated with blue nevi or mimicking cellular blue nevi&#58; clinical&#44; pathologic&#44; and molecular study of 11 cases displaying a high frequency of GNA11 mutations&#44; BAP1 expression loss&#44; and a predilection for the scalp"
                      "autores" => array:1 [
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        "texto" => "<p id="par0120" class="elsevierStylePara elsevierViewall">We are grateful to Dr&#46; Jos&#233; Luis Rodr&#237;guez Peralto for kindly performing the comparative genomic hybridization studies&#46;</p>"
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Información del artículo
ISSN: 00017310
Idioma original: Inglés
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