Case Reports
Clinical Usefulness of Reflectance Confocal Microscopy in the Management of Facial Lentigo Maligna Melanoma
Utilidad clínica de la microscopia confocal de reflectancia en el manejo del lentigo maligno melanoma
I. Alarcón
, C. Carrera, S. Puig, J. Malvehy
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Unidad de Melanoma, Servicio de Dermatología, Hospital Clinic de Barcelona, Barcelona, Spain
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A. Imagen clínica y dermatoscópica donde se observa en la zona 1 pigmentación granular anular gris, en la zona 2 una pápula central y estructuras romboidales rojas incipientes en zona la 3 inferior. B. Submosaico de MCR (1000<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>μm) correspondiente a la zona 1 al nivel de la epidermis, donde se aprecia un patrón en panal de abejas típico con células hiperrefráctiles aisladas sin signos de atipia. C. Submosaico de MCR (350<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>600<span class="elsevierStyleHsp" style=""></span>μm) correspondiente a la zona 2 al nivel de la epidermis que muestra cordones epiteliales compatibles con queratosis seborreica. D. Submosaico de MCR (800<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>900<span class="elsevierStyleHsp" style=""></span>μm) correspondiente a la zona 3 al nivel de la epidermis que muestra panal de abejas desestructurado, (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx9"></elsevierMultimedia></span>) refuerzo perifolicular, (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx10"></elsevierMultimedia></span>) así como múltiples células dendríticas (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx11"></elsevierMultimedia></span>) y pagetoides dendríticas (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx12"></elsevierMultimedia></span>) cerca de las salidas foliculares. E. Imagen histológica (H-E y HMB 45<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10 de magnificación) que muestra epidermis de estructura lentiginosa, con nidos de melanocitos atípicos en la capa basal epidérmica y en los folículos (↓).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Alarcón, C. Carrera, S. Puig, J. Malvehy" "autores" => array:4 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Alarcón" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Carrera" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Puig" ] 3 => array:2 [ "nombre" => "J." 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Lesions before (top) and after (bottom) treatment.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Albarrán-Planelles, D. Jiménez-Gallo, M. Linares-Barrios, A. Martínez-Rodríguez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Albarrán-Planelles" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Jiménez-Gallo" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Linares-Barrios" ] 3 => array:2 [ "nombre" => "A." 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Zaragozá-Ninet, C. Sierra-Talamantes, V. Alegre de Miquel" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "de la Cuadra-Oyanguren" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Zaragozá-Ninet" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Sierra-Talamantes" ] 3 => array:2 [ "nombre" => "V." 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Alarcón, C. Carrera, S. Puig, J. Malvehy" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Alarcón" "email" => array:1 [ 0 => "ivette.alarcon13@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Carrera" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Puig" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Malvehy" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Melanoma, Servicio de Dermatología, Hospital Clinic de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad clínica de la microscopia confocal de reflectancia en el manejo del lentigo maligno melanoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1246 "Ancho" => 1752 "Tamanyo" => 438425 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Case 3. A, Photograph and dermoscopic image showing pigmentation with a gray annular-granular pigmentation in area 1, a central papule in area 2, and incipient red rhomboidal structures at the bottom of area 3. B, Confocal submosaic (1000<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 1 showing a typical honeycomb pattern with isolated highly refractile cells without signs of atypia. C, Confocal submosaic (350<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>600<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 2 showing epithelial cords compatible with seborrheic keratosis. D, Confocal submosaic (800<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>900<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 3 showing a destructured honeycomb pattern (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx9"></elsevierMultimedia></span>), perifollicular hyperpigmentation (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx10"></elsevierMultimedia></span>), and multiple dendritic cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx11"></elsevierMultimedia></span>) and dendritic pagetoid cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx12"></elsevierMultimedia></span>) near the follicular openings. E, Histologic image (hematoxylin-eosin and HMB-45, original magnification ×<span class="elsevierStyleMonospace">1</span>0) showing a lentiginous epidermal pattern, with nests of atypical melanocytes in the basal layer of the epidermis and in the follicles (↓). HMB indicates human melanoma black.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Reflectance confocal microscopy is a noninvasive technique that uses a low-power laser system to produce in vivo cellular-resolution images of the skin to the depth of the papillary dermis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It has been shown to improve diagnostic accuracy in melanoma and nonmelanoma skin cancer, particularly in the case of difficult-to-diagnose lesions.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Facial skin has particular histologic characteristics related to the prominence of adnexal structures, flattening of rete ridges, and a varying degree of elastosis in the dermis. Dermoscopic examination of pigmented lesions on the face rarely shows the pigment network seen in lesions in other parts of the body. What is generally observed is a wide-meshed pseudonetwork formed by numerous hair follicles and sweat gland openings.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This pseudonetwork can be seen in all types of pigmented facial lesions, whether melanocytic or nonmelanocytic.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> Diagnosis of facial lentigo maligna (LM) and facial lentigo maligna melanoma (LMM) can often be a challenge as the clinical and dermoscopic features overlap with those of other lesions such as solar lentigines and pigmented actinic keratoses.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Similarly, it is not uncommon for lesions with equivocal clinical and dermoscopic features, or even benign lesions, to be diagnosed as LM/LMM. Tools with improved diagnostic accuracy are therefore essential to enable the early detection of malignant lesions and avoid the unnecessary excision of benign lesions.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">The first patient was a 37-year-old woman with a history of multiple melanoma and familial melanoma. She was a carrier of the high-risk <span class="elsevierStyleItalic">CDKN2A</span> mutation, 358delG. At a check-up visit, we observed a 7<span class="elsevierStyleHsp" style=""></span> x<span class="elsevierStyleHsp" style=""></span>5-mm pigmented lesion on the right cheek that had been present for less than 6 months. Dermoscopy showed a polychromatic (light brown, dark brown, and gray) lesion with asymmetric pigmentation, a gray annular-granular pattern, and a pigmented pseudonetwork. The lesion therefore had dermoscopic features of both LM/LMM and pigmented actinic keratosis. Examination of the lesion with confocal microscopy showed stratum corneum disruption, disturbance of epidermal architecture (atypical honeycomb pattern), and atypical keratinocytes in the suprabasal layer, with several small dendritic cells (<<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>μm); there were no signs of perifollicular distribution or pagetoid invasion. The superficial dermis showed a moderately refractile stroma with thickened bundles, consistent with solar elastosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These findings were strongly suggestive of actinic keratosis and confocal microscopy was used to identify the optimal site for biopsy, which confirmed the diagnosis. The lesion was treated with adapalene 0.1% daily for a month and the follow-up results have been favorable.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 56-year-old woman with no relevant past history was referred to our center for presurgical evaluation of a lesion on the left cheek; a histology report from another center indicated a diagnosis of in situ melanoma, LM type. Physical examination revealed a brown plaque measuring 21<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>mm, with a 6-mm central scar, poorly circumscribed borders, areas of brown pigment and obliteration of follicular openings, and sparsely pigmented areas at the periphery; there were no clear dermoscopic signs of LMM (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Because accurate identification of margins is crucial for the presurgical evaluation of LMM, and the edges of the lesion were not clearly visible on dermoscopy, we used confocal microscopy to map the adjacent areas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>E). The microscopic findings showed signs compatible with LMM in both the pigmented area and an achromic area adjacent to the lesion. Using this information, we mapped the presurgical margins and excised the tumor, which finally measured 28<span class="elsevierStyleHsp" style=""></span>x<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm. Histologic examination showed the margins to be clear and the surgical defect was repaired with a rotation flap. Focal recurrence was observed 6 months later and cleared with simple excision. There were no signs of recurrence at the 2-year follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 62-year-old man with no relevant history consulted for an erythematous lesion measuring 10<span class="elsevierStyleHsp" style=""></span>x<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mm in the right malar region. Dermoscopy revealed 3 distinct areas: an upper pigmented area with a gray annular-granular pattern; a central papule; and a sparsely pigmented lower area with red rhomboidal structures, a recently described dermoscopic feature of LM.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The dermoscopic findings in our patient were not conclusive, and the differential diagnosis included LM/LMM, pigmented actinic keratosis, and solar lentigo. We therefore decided to examine the lesion by confocal microscopy. The findings are described in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. The examination ruled out malignancy in area 1, showed signs of seborrheic keratosis in area 2, and signs of LM in area 3. A punch biopsy of area 3 confirmed the diagnosis of LM, which was corroborated by immunohistochemistry. The lesion was completely excised. Histologic examination confirmed the presence of foci of melanocytic hyperplasia, with no evidence of LM. This diagnosis was also corroborated by immunohistochemistry.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Confocal microscopy is an emerging technique for clinical research in skin cancer. Its main advantage is that it offers a unique opportunity to evaluate skin morphology in vivo. This “virtual biopsy” avoids unnecessary excisions, and while biopsies and excisions are not complex procedures, the associated morbidity and cost of histologic examination are important aspects from the perspective of both the patient and the health care system.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Dermoscopy has a sensitivity of 83.2% and a specificity of 85.5% for melanoma.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>Confocal microscopy has been found to have higher sensitivity (97.3%) and similar specificity (83%).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Nonetheless, because the technique requires special training and is more time-consuming than dermoscopy, it is not indicated for initial evaluation but rather for further analysis of lesions with equivocal findings on dermoscopy. One limitation of confocal microscopy is that it is not a reliable method for analyzing depth of invasion or lesions involving the reticular dermis as its maximum penetration depth is between 350<span class="elsevierStyleHsp" style=""></span>μm and 500<span class="elsevierStyleHsp" style=""></span>μm, which corresponds to the papillary dermis. Also, as with any imaging technique, interpretation of results depends on the observer's training, although automated diagnostic imaging systems are currently being developed.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Multiple studies have demonstrated that confocal microscopy improves diagnostic accuracy for melanocytic lesions that are difficult to diagnose and manage,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,12–15</span></a> adding to the body of evidence that supports the use of confocal microscopy in clinical practice to, among other applications, avoid unnecessary biopsies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">While we recognize the limitations of this case series, we believe that our findings show that reflectance confocal microscopy can be a useful tool for evaluating lesions with equivocal features, even on dermoscopy. In all 3 cases, confocal microscopy not only helped to establish and confirm a diagnosis, but also led to changes in the final treatment decision.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital's protocol on the publication of data concerning patients and that all patients included in the study have received sufficient information and have given their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres327193" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec308863" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres327194" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec308864" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 3" ] ] ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of humans and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec308863" "palabras" => array:3 [ 0 => "Lentigo maligna" 1 => "Confocal microscopy" 2 => "Noninvasive technique" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec308864" "palabras" => array:3 [ 0 => "Lentigo maligno" 1 => "Microscopia confocal" 2 => "Técnica no invasiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facial lentigo maligna melanoma can be a diagnostic challenge in daily clinical practice as it has similar clinical and morphological features to other lesions such as solar lentigines and pigmented actinic keratoses. Confocal microscopy is a noninvasive technique that provides real-time images of the epidermis and superficial dermis with cellular-level resolution. We describe 3 cases of suspected facial lentigo maligna that were assessed using dermoscopy and confocal microscopy before histopathology study. In the first case, diagnosed as lentigo maligna melanoma, presurgical mapping by confocal microscopy was performed to define the margins more accurately. In the second and third cases, with a clinical and dermoscopic suspicion of lentigo maligna melanoma, confocal microscopy was used to identify the optimal site for biopsy.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El diagnóstico del lentigo maligno melanoma facial constituye un reto en la práctica clínica habitual debido al solapamiento de ciertas características clínicas y morfológicas con lesiones como lentigos solares o queratosis actínicas pigmentadas. La microscopia confocal es una técnica no invasiva que permite obtener imágenes en tiempo real de la epidermis y la dermis superficial con resolución a nivel celular. En esta serie se describen 3 casos de lesiones faciales sospechosas de lentigo maligno, evaluadas por dermatoscopia y microscopia confocal antes de realizar el análisis histopatológico. En el primer caso, con diagnóstico de lentigo maligno melanoma, se realizó un mapeo prequirúrgico mediante microscopia confocal, para delimitar los márgenes con mayor precisión, y en el segundo y el tercer caso con sospecha clínica y dermatoscópica de lentigo maligno melanoma se identificó la zona óptima para realizar la biopsia.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alarcón I, Carrera C, Puig S, Malvehy J. Utilidad clínica de la microscopia confocal de reflectancia en el manejo del lentigo maligno melanoma. Actas Dermosifiliogr. 2014;105:e13–e17.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1942 "Ancho" => 1890 "Tamanyo" => 807438 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Case 1. A, Photograph. B, Dermoscopic image showing a pseudonetwork with gray dots and a more intensely pigmented eccentric area with focal perifollicular hyperpigmentation. C, Confocal submosaic (1300<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>800<span class="elsevierStyleHsp" style=""></span>μm) showing an irregular refractile amorphous material (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx1"></elsevierMultimedia></span>) corresponding to hyperkeratosis; loose corneocytes showing disruption of the stratum corneum (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx2"></elsevierMultimedia></span>); a destructured honeycomb pattern with cells and nuclei of different shapes and sizes, consistent with atypia (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx3"></elsevierMultimedia></span>); several small (<<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>μm) isolated dendritic cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx4"></elsevierMultimedia></span>); and no involvement of the follicular openings (↓). D, Confocal submosaic (1100<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>900<span class="elsevierStyleHsp" style=""></span>μm) showing moderately refractile thickened parallel bundles suggestive of elastosis in the superficial dermis (↓). E, Histologic image showing atypical keratinocytes confined to the lower layers of the epidermis (↓) (hematoxylin-eosin, original magnification ×10), without proliferation of atypical melanocytes (Melan-A, original magnification ×10).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1895 "Ancho" => 1001 "Tamanyo" => 501680 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Case 2. A, Photograph showing a pigmented lesion (21<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>17<span class="elsevierStyleHsp" style=""></span>mm) with irregular borders and a central scar on the left cheek. B, Clockwise mapping of the periphery of the lesion, showing the limits seen by dermoscopy (white line) and confocal microscopy (blue line). Microscopic examination revealed an achromic area with signs compatible with LM. C, Dermoscopic image showing perifollicular pigment and obliteration of the follicular openings (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx5"></elsevierMultimedia></span>) in the pigmented region. D, Slight erythema without dermoscopic signs of LM in the achromatic area. E, Confocal submosaic (1000<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1000<span class="elsevierStyleHsp" style=""></span>μm) of the pigmented area showing a destructured honeycomb pattern (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx6"></elsevierMultimedia></span>), perifollicular hyperpigmentation (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx7"></elsevierMultimedia></span>), and multiple dendritic cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx8"></elsevierMultimedia></span>) in the epidermis. F, Confocal submosaic (1000<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1000<span class="elsevierStyleHsp" style=""></span>μm) of the achromatic area showing multiple dendritic cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx8"></elsevierMultimedia></span>) in the upper layers and atypical cells in a perifollicular distribution. (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx7"></elsevierMultimedia></span>). G and H, Histologic image of the pigmented area (hematoxylin-eosin, original magnification ×20) showing nests of atypical melanocytes at the dermal-epidermal junction, with immunohistochemical staining showing follicular involvement (HMB 45, original magnification ×10), and underlying elastosis (*). H, Histologic image of the achromatic area (hematoxylin-eosin, original magnification ×20) showing nests of atypical melanocytes at the dermal-epidermal junction that stained positively with HMB-45 (original magnification ×10) and elastosis in the dermis (*). HMB indicates human melanoma black.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1246 "Ancho" => 1752 "Tamanyo" => 438425 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Case 3. A, Photograph and dermoscopic image showing pigmentation with a gray annular-granular pigmentation in area 1, a central papule in area 2, and incipient red rhomboidal structures at the bottom of area 3. B, Confocal submosaic (1000<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 1 showing a typical honeycomb pattern with isolated highly refractile cells without signs of atypia. C, Confocal submosaic (350<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>600<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 2 showing epithelial cords compatible with seborrheic keratosis. D, Confocal submosaic (800<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>900<span class="elsevierStyleHsp" style=""></span>μm) of the epidermis in area 3 showing a destructured honeycomb pattern (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx9"></elsevierMultimedia></span>), perifollicular hyperpigmentation (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx10"></elsevierMultimedia></span>), and multiple dendritic cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx11"></elsevierMultimedia></span>) and dendritic pagetoid cells (<span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx12"></elsevierMultimedia></span>) near the follicular openings. E, Histologic image (hematoxylin-eosin and HMB-45, original magnification ×<span class="elsevierStyleMonospace">1</span>0) showing a lentiginous epidermal pattern, with nests of atypical melanocytes in the basal layer of the epidermis and in the follicles (↓). HMB indicates human melanoma black.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "In vivo confocal scanning laser microscopy of human skin <span class="elsevierStyleSmallCaps">ii</span>: advances in instrumentation and comparison with histology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Rajadhyaksha" 1 => "S. González" 2 => "J.M. Zavislan" 3 => "R.R. Anderson" 4 => "R.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 4 | 8 | 12 |
| 2024 Octubre | 97 | 43 | 140 |
| 2024 Septiembre | 98 | 33 | 131 |
| 2024 Agosto | 108 | 64 | 172 |
| 2024 Julio | 93 | 40 | 133 |
| 2024 Junio | 111 | 28 | 139 |
| 2024 Mayo | 83 | 28 | 111 |
| 2024 Abril | 74 | 27 | 101 |
| 2024 Marzo | 78 | 32 | 110 |
| 2024 Febrero | 71 | 34 | 105 |
| 2024 Enero | 81 | 34 | 115 |
| 2023 Diciembre | 72 | 21 | 93 |
| 2023 Noviembre | 112 | 25 | 137 |
| 2023 Octubre | 75 | 18 | 93 |
| 2023 Septiembre | 83 | 28 | 111 |
| 2023 Agosto | 53 | 18 | 71 |
| 2023 Julio | 58 | 34 | 92 |
| 2023 Junio | 66 | 24 | 90 |
| 2023 Mayo | 61 | 17 | 78 |
| 2023 Abril | 33 | 23 | 56 |
| 2023 Marzo | 53 | 22 | 75 |
| 2023 Febrero | 51 | 27 | 78 |
| 2023 Enero | 45 | 39 | 84 |
| 2022 Diciembre | 68 | 48 | 116 |
| 2022 Noviembre | 42 | 28 | 70 |
| 2022 Octubre | 36 | 27 | 63 |
| 2022 Septiembre | 32 | 45 | 77 |
| 2022 Agosto | 39 | 35 | 74 |
| 2022 Julio | 32 | 40 | 72 |
| 2022 Junio | 31 | 36 | 67 |
| 2022 Mayo | 35 | 46 | 81 |
| 2022 Abril | 63 | 46 | 109 |
| 2022 Marzo | 65 | 46 | 111 |
| 2022 Febrero | 40 | 37 | 77 |
| 2022 Enero | 69 | 40 | 109 |
| 2021 Diciembre | 53 | 46 | 99 |
| 2021 Noviembre | 45 | 55 | 100 |
| 2021 Octubre | 46 | 47 | 93 |
| 2021 Septiembre | 30 | 36 | 66 |
| 2021 Agosto | 28 | 39 | 67 |
| 2021 Julio | 29 | 29 | 58 |
| 2021 Junio | 24 | 33 | 57 |
| 2021 Mayo | 27 | 33 | 60 |
| 2021 Abril | 48 | 53 | 101 |
| 2021 Marzo | 58 | 32 | 90 |
| 2021 Febrero | 58 | 23 | 81 |
| 2021 Enero | 36 | 28 | 64 |
| 2020 Diciembre | 27 | 17 | 44 |
| 2020 Noviembre | 32 | 12 | 44 |
| 2020 Octubre | 21 | 10 | 31 |
| 2020 Septiembre | 37 | 24 | 61 |
| 2020 Agosto | 21 | 6 | 27 |
| 2020 Julio | 25 | 12 | 37 |
| 2020 Junio | 36 | 27 | 63 |
| 2020 Mayo | 34 | 20 | 54 |
| 2020 Abril | 36 | 18 | 54 |
| 2020 Marzo | 28 | 21 | 49 |
| 2020 Febrero | 6 | 11 | 17 |
| 2020 Enero | 6 | 3 | 9 |
| 2019 Diciembre | 8 | 9 | 17 |
| 2019 Noviembre | 4 | 14 | 18 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 4 | 6 | 10 |
| 2019 Agosto | 4 | 12 | 16 |
| 2019 Julio | 4 | 8 | 12 |
| 2019 Junio | 4 | 7 | 11 |
| 2019 Mayo | 7 | 21 | 28 |
| 2019 Abril | 2 | 12 | 14 |
| 2019 Marzo | 4 | 7 | 11 |
| 2019 Febrero | 0 | 5 | 5 |
| 2019 Enero | 3 | 0 | 3 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 5 | 0 | 5 |
| 2018 Marzo | 2 | 0 | 2 |
| 2018 Febrero | 36 | 2 | 38 |
| 2018 Enero | 38 | 5 | 43 |
| 2017 Diciembre | 48 | 12 | 60 |
| 2017 Noviembre | 46 | 5 | 51 |
| 2017 Octubre | 41 | 9 | 50 |
| 2017 Septiembre | 40 | 8 | 48 |
| 2017 Agosto | 45 | 15 | 60 |
| 2017 Julio | 37 | 12 | 49 |
| 2017 Junio | 56 | 12 | 68 |
| 2017 Mayo | 44 | 9 | 53 |
| 2017 Abril | 47 | 7 | 54 |
| 2017 Marzo | 36 | 27 | 63 |
| 2017 Febrero | 34 | 15 | 49 |
| 2017 Enero | 27 | 9 | 36 |
| 2016 Diciembre | 39 | 5 | 44 |
| 2016 Noviembre | 57 | 5 | 62 |
| 2016 Octubre | 77 | 8 | 85 |
| 2016 Septiembre | 90 | 10 | 100 |
| 2016 Agosto | 61 | 8 | 69 |
| 2016 Julio | 32 | 9 | 41 |
| 2016 Junio | 12 | 4 | 16 |
| 2016 Mayo | 4 | 15 | 19 |
| 2016 Abril | 3 | 1 | 4 |
| 2016 Marzo | 7 | 3 | 10 |
| 2016 Febrero | 8 | 1 | 9 |
| 2016 Enero | 6 | 1 | 7 |
| 2015 Diciembre | 7 | 4 | 11 |
| 2015 Noviembre | 10 | 6 | 16 |
| 2015 Octubre | 6 | 11 | 17 |
| 2015 Septiembre | 7 | 6 | 13 |
| 2015 Agosto | 10 | 2 | 12 |
| 2015 Julio | 35 | 5 | 40 |
| 2015 Junio | 34 | 7 | 41 |
| 2015 Mayo | 56 | 5 | 61 |
| 2015 Abril | 27 | 6 | 33 |
| 2015 Marzo | 26 | 4 | 30 |
| 2015 Febrero | 24 | 3 | 27 |
| 2015 Enero | 30 | 15 | 45 |
| 2014 Diciembre | 75 | 9 | 84 |
| 2014 Noviembre | 34 | 10 | 44 |
| 2014 Octubre | 58 | 4 | 62 |
| 2014 Septiembre | 107 | 8 | 115 |
| 2014 Agosto | 88 | 13 | 101 |
| 2014 Julio | 89 | 15 | 104 |
| 2014 Junio | 67 | 7 | 74 |
| 2014 Mayo | 47 | 12 | 59 |
| 2014 Abril | 19 | 8 | 27 |
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